From the Guidelines
Pyelonephritis should be treated with a 5-7 day course of fluoroquinolones, such as ciprofloxacin 500mg twice daily, or a 14-day course of trimethoprim-sulfamethoxazole, depending on local resistance patterns and patient susceptibility 1.
Treatment Options
- Fluoroquinolones (ciprofloxacin 500mg twice daily for 5-7 days) are a recommended empiric option for pyelonephritis, especially in areas with low fluoroquinolone resistance 1.
- Trimethoprim-sulfamethoxazole (160/800mg twice daily for 14 days) is an alternative option, but its use should be guided by susceptibility testing due to high resistance rates 1.
- Third-generation cephalosporins may also be considered, depending on local resistance patterns and patient factors 1.
Severe Cases
- For severe cases requiring hospitalization, intravenous antibiotics such as ceftriaxone 1-2g daily or ampicillin plus gentamicin may be necessary until clinical improvement, followed by oral therapy to complete 7-14 days total 1.
Important Considerations
- Adequate hydration is essential during treatment to help flush bacteria from the urinary system 1.
- Patients should complete the full antibiotic course even if symptoms improve quickly to prevent recurrence 1.
- Untreated pyelonephritis can lead to serious complications, including sepsis, renal abscess, or permanent kidney damage 1.
- Those with recurrent infections may need imaging studies to identify structural abnormalities and might benefit from prophylactic antibiotics or urologic evaluation 1.
From the FDA Drug Label
11 Acute Pyelonephritis: 5 or 10 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia [see Clinical Studies (14.7,14.8)].
7 Complicated Urinary Tract Infections and Acute Pyelonephritis: 5 Day Treatment Regimen To evaluate the safety and efficacy of the higher dose and shorter course of levofloxacin, 1109 patients with cUTI and AP were enrolled in a randomized, double-blind, multicenter clinical trial conducted in the U.S. from November 2004 to April 2006 comparing levofloxacin 750 mg I. V. or orally once daily for 5 days (546 patients) with ciprofloxacin 400 mg I. V. or 500 mg orally twice daily for 10 days (563 patients).
8 Complicated Urinary Tract Infections and Acute Pyelonephritis: 10 Day Treatment Regimen To evaluate the safety and efficacy of the 250 mg dose, 10 day regimen of levofloxacin, 567 patients with uncomplicated UTI, mild-to-moderate cUTI, and mild-to-moderate AP were enrolled in a randomized, double-blind, multicenter clinical trial conducted in the U. S. from June 1993 to January 1995 comparing levofloxacin 250 mg orally once daily for 10 days (285 patients) with ciprofloxacin 500 mg orally twice daily for 10 days (282 patients).
Levofloxacin is indicated for the treatment of acute pyelonephritis. The recommended treatment regimens are 5 or 10 days. The drug is effective against Escherichia coli, including cases with concurrent bacteremia 2.
From the Research
Definition and Treatment of Pyelonephritis
- Pyelonephritis is among the most common bacterial infections, with options for initial treatment including an extended-spectrum cephalosporin or a fluoroquinolone 3.
- The choice of treatment regimen should be based on susceptibility testing results to decrease the spread of antibiotic resistance worldwide 3.
Comparison of Treatment Options
- A study comparing ceftriaxone and levofloxacin for the treatment of acute pyelonephritis found that ceftriaxone was more effective than levofloxacin in terms of microbiological response, but there were no statistically significant differences between the treatment groups in the rates of clinical cure 3.
- Another study found that oral antibiotics, including amoxicillin, amoxicillin-clavulanic acid, and cephalexin, have potential to be effective for a proportion of patients with pyelonephritis, and ciprofloxacin may be effective at lower doses than currently prescribed 4.
- A prospective, open-label, randomized, controlled, multicenter, non-inferiority clinical trial found that short-course intravenous levofloxacin (750 mg/day) was non-inferior to conventional intravenous/oral levofloxacin (500 mg/day) in patients with complicated urinary tract infections and acute pyelonephritis 5.
Cephalosporins as a Treatment Option
- A systematic review found that cephalosporins, including cefazolin, cephalexin, cefuroxime, cefotaxime, cefdinir, cefditoren, and ceftriaxone, may be viable treatment options for the management of uncomplicated acute pyelonephritis, with no trials reporting inferiority of clinical treatment outcomes compared with a fluoroquinolone or sulfamethoxazole-trimethoprim 6.
- Cephalosporins displayed effectiveness for the treatment of acute uncomplicated pyelonephritis regardless of study design or the presence of a comparison group 6.
Antibiotic Resistance
- High resistance rates were detected for cotrimoxazole, ciprofloxacin, and ceftriaxone in isolated E. coli, and all K. pneumoniae isolates were resistant to ciprofloxacin 3.
- The resistance of uropathogens to the most used antibiotics is relatively high, highlighting the need for susceptibility testing and tailored treatment regimens 3.