What is the treatment for Pyelonephritis (infection of the kidney)

From the Guidelines

Pyelonephritis treatment should typically involve antibiotics, with fluoroquinolones like ciprofloxacin (500mg twice daily for 7 days) or levofloxacin (750mg once daily for 5-7 days) being commonly prescribed for uncomplicated cases, as recommended by the most recent guidelines 1.

Treatment Overview

The treatment of pyelonephritis aims to eliminate the bacterial infection in the kidneys, with the choice of antibiotic depending on the severity of the illness, local resistance patterns, and specific host factors.

• For uncomplicated cases, oral fluoroquinolones are preferred due to their efficacy and the high prevalence of Escherichia coli, which causes about 80% of cases.
• Alternatively, trimethoprim-sulfamethoxazole can be used if the pathogen is susceptible, but its use is limited by high resistance rates in some areas.
• For more severe cases requiring hospitalization, intravenous antibiotics such as ceftriaxone, an aminoglycoside with or without ampicillin, or an extended-spectrum cephalosporin or penicillin may be administered until clinical improvement, followed by oral antibiotics to complete a 7-14 day course.

Key Considerations

• Patients should increase fluid intake to help flush bacteria from the urinary tract and may take pain relievers like acetaminophen or ibuprofen for fever and discomfort.
• It's crucial to complete the full antibiotic course even if symptoms improve quickly.
• Pregnant women, elderly patients, and those with comorbidities often require more aggressive treatment and monitoring.
• The treatment should be tailored to local policies and resistance patterns, with a short outpatient course of antibiotic treatment being equivalent to longer therapy durations in terms of clinical and microbiological success, but associated with a higher recurrence rate within 4-6 weeks 1.

Recent Guidelines

The European Association of Urology guidelines on urological infections recommend fluoroquinolones and cephalosporins for oral empiric treatment of uncomplicated pyelonephritis, with other agents like nitrofurantoin, oral fosfomycin, and pivmecillinam being avoided due to insufficient data on their efficacy 1.

• The choice of antibiotic should be based on local resistance patterns and optimized, with carbapenems and novel broad-spectrum antimicrobial agents being considered only in patients with early culture results indicating the presence of multidrug-resistant organisms.

From the FDA Drug Label

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)].

The treatment for pyelonephritis with levofloxacin (PO) is indicated for acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia 2.

• The treatment regimen for acute pyelonephritis is either 5 or 10 days.
• Levofloxacin is effective against Escherichia coli.

From the Research

Treatment Options for Pyelonephritis

• The treatment for pyelonephritis typically involves antibiotic therapy, with the choice of antibiotic depending on various factors such as the severity of the infection, patient's medical history, and resistance patterns of the causative bacteria 3.
• Empirical antibiotic therapy should be initiated promptly to prevent serious complications, and the treatment should be adjusted as soon as the results of antimicrobial susceptibility testing are known 3.
• Oral fluoroquinolones, such as ciprofloxacin and levofloxacin, are effective in treating pyelonephritis, with symptoms resolving within 5 to 7 days in about 96% of women 3.
• However, the use of fluoroquinolones is associated with risks such as neuropsychiatric disorders, photosensitivity, tendon disorders, arrhythmia, and cardiac conduction disorders, as well as Clostridium difficile infection 3.

Comparison of Antibiotic Regimens

• Studies have compared the effectiveness of different antibiotic regimens for the treatment of pyelonephritis, including oral cephalosporins, fluoroquinolones, and trimethoprim/sulfamethoxazole (TMP-SMX) 4, 5, 6.
• The results of these studies suggest that oral cephalosporins are associated with similar treatment failure rates compared to fluoroquinolones and TMP-SMX 4, 5, 6.
• However, the use of cephalosporins is also associated with risks such as hypersensitivity reactions and C. difficile infection 3.

Duration of Antibiotic Therapy

• The optimal duration of antibiotic therapy for pyelonephritis is a topic of debate, with some studies suggesting that short-course therapy may be as effective as longer courses 7.
• A systematic review of randomized controlled trials found that short-course antibiotic treatment was associated with a higher rate of clinical cure and no significant difference in microbiological failure compared to longer courses 7.
• However, more research is needed to confirm these findings and to determine the optimal duration of antibiotic therapy for pyelonephritis.

Resistance Patterns and Treatment Failure

• The increasing resistance of bacteria to antibiotics is a major concern in the treatment of pyelonephritis, with studies showing that resistance rates to fluoroquinolones and TMP-SMX are rising 3, 6.
• Treatment failure is more likely to occur in patients with underlying medical conditions, such as chronic kidney disease, and in those with infections caused by resistant bacteria 4, 6.
• Therefore, it is essential to consider the local resistance patterns and the patient's medical history when selecting an antibiotic regimen for the treatment of pyelonephritis 3, 4, 5, 6.