What is the best antibiotic for pyelonephritis (pyelo) in pregnancy?

From the Guidelines

For pregnant women with pyelonephritis, intravenous ceftriaxone (1-2g daily) is typically the first-line antibiotic treatment, as recommended by the most recent guidelines 1. This should be administered until the patient is afebrile for 24-48 hours, followed by oral cephalexin (500mg four times daily) or amoxicillin-clavulanate (875/125mg twice daily) to complete a 10-14 day total course. Hospitalization is usually necessary initially. These antibiotics are preferred because they effectively target common urinary pathogens like E. coli while having good safety profiles in pregnancy. Some key points to consider in the treatment of pyelonephritis in pregnancy include:

• The use of fluoroquinolones and tetracyclines should be avoided due to potential fetal risks 1.
• Alternatives for penicillin-allergic patients include aztreonam or gentamicin with close monitoring.
• Treatment should be guided by urine culture results when available, and follow-up cultures are recommended after completing therapy to ensure resolution.
• Adequate hydration and antipyretics for fever management are important supportive measures.
• Untreated pyelonephritis in pregnancy can lead to serious complications including preterm labor and sepsis, making prompt treatment essential. The choice of antibiotic should be based on local resistance patterns and susceptibility results, as outlined in the European Association of Urology guidelines 1. In general, the treatment of pyelonephritis in pregnancy should prioritize the use of safe and effective antibiotics, with careful consideration of potential risks and benefits.

From the FDA Drug Label

1. 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)]. CLINICAL STUDIES Complicated Urinary Tract Infection and Pyelonephritis – Efficacy in Pediatric Patients:

The best antibiotic for pyelonephritis in pregnancy is not explicitly stated in the provided drug labels. Levofloxacin and ciprofloxacin are indicated for the treatment of acute pyelonephritis, but the labels do not provide information on their use during pregnancy.

• Key considerations:
  • The safety of levofloxacin and ciprofloxacin in pregnant women has not been established.
  • The use of fluoroquinolones, including levofloxacin and ciprofloxacin, during pregnancy is generally not recommended due to the potential risk of cartilage damage to the developing fetus 2 3. Therefore, a conservative clinical decision would be to avoid using levofloxacin and ciprofloxacin in pregnant women with pyelonephritis, and instead consider alternative antibiotics that are safer for use during pregnancy.

From the Research

Treatment Options for Pyelonephritis in Pregnancy

• The choice of antibiotic for pyelonephritis in pregnancy should consider antimicrobial resistance patterns in the local community 4.
• Studies have compared the efficacy of different antibiotics, including cefazolin, ceftriaxone, and oral cephalexin 5, 6.
• Ceftriaxone has been shown to be effective in the treatment of pyelonephritis in pregnancy, with a single daily dose being as effective as multiple doses of cefazolin 6.
• The use of fluoroquinolones, such as ciprofloxacin, is generally not recommended in pregnancy due to potential risks to the fetus 7.
• In cases where the susceptibility of E. coli to ciprofloxacin is high, it may be considered as an option, but this is not typically the case in pregnancy 8.

Antibiotic Resistance and Treatment

• Antibiotic resistance is a growing concern, and the choice of antibiotic should take into account local resistance patterns 4, 7.
• The use of broad-spectrum antibiotics should be avoided whenever possible to preserve their efficacy in serious infections 7.
• Antibiotic de-escalation should be considered if permitted by the clinical evolution and the antibiogram, with options including amoxicillin and ciprofloxacin 8.
• In cases of history of ESBL infection or carriage, the empirical treatment should be adapted 8.

Clinical Considerations

• Pyelonephritis in pregnancy is a serious condition that requires prompt treatment to prevent complications 4.
• The choice of antibiotic should be individualized based on the patient's clinical presentation, medical history, and local resistance patterns 4, 8.
• Urine culture and susceptibility testing should be performed to guide antibiotic therapy 5, 8.