Managing Antibiotic Allergy in Renal Infection and Diabetic Ketoacidosis

A medical case report presented at the University of Texas Rio Grande Valley (UTRGV) School of Medicine Research Colloquium 2025 highlights the clinical complexities involved in treating renal infections when patients present with concurrent antibiotic allergies and diabetic complications.

The report, titled A Delicate Balance: Antibiotic Allergy, Renal Infection, and Diabetic Ketoacidosis, details the management of a patient who developed euglycemic diabetic ketoacidosis (eDKA) while suffering from acute pyelonephritis.

Understanding Acute Pyelonephritis

Acute pyelonephritis is a bacterial infection of the renal parenchyma, most commonly caused by Escherichia coli. The condition typically presents with genitourinary and systemic symptoms, including flank pain, fever, and urinary abnormalities such as a burning sensation during urination and increased urinary frequency.

Medical professionals emphasize that timely antibiotic therapy is critical to prevent severe complications, such as urosepsis or the development of renal abscesses.

The Challenge of Antibiotic Allergies

Empiric treatment for renal infections often involves the use of third-generation cephalosporins, such as ceftriaxone, due to their broad-spectrum activity and ability to penetrate renal tissue.

However, approximately 1% to 2% of patients are allergic to ceftriaxone, necessitating the use of alternative antimicrobial regimens. In the case presented at the UTRGV colloquium, the patient’s allergy to ceftriaxone required a shift in the treatment strategy.

Levofloxacin, a fluoroquinolone, was utilized as an alternative. This medication is available in both oral and intravenous forms and is noted for its broad-spectrum activity against uropathogens and effective renal tissue penetration, making it a viable option for outpatient settings or step-down therapy.

Euglycemic Diabetic Ketoacidosis

The patient in the report developed euglycemic diabetic ketoacidosis, a rare and serious metabolic complication. Unlike typical diabetic ketoacidosis, eDKA is characterized by ketosis and anion gap metabolic acidosis without significant hyperglycemia.

According to the research presented by Aun Ali Bangash, Muhammad Ali Bangash, and Ruben Meza Martinez, the contributing factors in this specific case included the patient’s poorly controlled diabetes and the presence of an underlying infection.

Broader Clinical Context for DKA and Renal Impairment

The management of diabetic ketoacidosis varies depending on the patient’s overall health and comorbidities. For patients where DKA is complicated by sepsis and acute kidney injury (AKI), different first-line antibiotic agents are recommended.

Recommended options for these severe cases include:

• Piperacillin-tazobactam (2.25g IV every 6-8 hours, adjusted for renal function)
• Ceftolozane-tazobactam (1.5g IV every 8 hours)

Clinical guidance for patients with DKA and AKI strictly advises against the use of amphotericin B and aminoglycosides.

the management of DKA can become more complex in patients with chronic kidney disease who are undergoing maintenance hemodialysis, as standard population-based management protocols may not be directly applicable.