From the Guidelines
For uncomplicated pyelonephritis, oral fluoroquinolones like ciprofloxacin (500mg twice daily for 7 days) or levofloxacin (750mg once daily for 5 days) are the preferred treatments, as recommended by the European Association of Urology guidelines 1. When choosing an antibiotic, it is essential to consider local resistance patterns and adjust the treatment based on urine culture results.
- The European Association of Urology guidelines suggest that fluoroquinolone resistance should be <10% for empirical use 1.
- If fluoroquinolone resistance exceeds 10%, an initial intravenous dose of a long-acting parenteral antimicrobial, such as ceftriaxone, should be administered 1.
- Alternative treatments, such as trimethoprim-sulfamethoxazole (160/800mg twice daily for 14 days) or oral beta-lactams like cefpodoxime (200mg twice daily for 10 days) or ceftibuten (400mg once daily for 10 days), may be considered in areas with high resistance or when the pathogen is known to be susceptible 1. The choice of antibiotic should prioritize the patient's quality of life, morbidity, and mortality outcomes, and patients should complete the full course of antibiotics even if symptoms improve, drink plenty of fluids, and take pain relievers as needed.
- Fluoroquinolones are preferred due to their excellent tissue penetration into the kidneys and high urinary concentrations, which helps eradicate the infection effectively 1.
From the FDA Drug Label
Dosing and initial route of therapy (i.e., I.V. or oral) for complicated urinary tract infection or pyelonephritis should be determined by the severity of the infection. In the clinical trial, pediatric patients with moderate to severe infection were initiated on 6 to 10 mg/kg I. V. every 8 hours and allowed to switch to oral therapy (10 to 20 mg/kg every 12 hours), at the discretion of the physician.
The best PO medication for pyelonephritis is ciprofloxacin (PO), with a dose of 10 mg/kg to 20 mg/kg (maximum 750 mg per dose) every 12 hours, as determined by the severity of the infection 2.
- Key points:
- The dose should be determined by the severity of the infection.
- The duration of therapy is typically 10-21 days.
- Ciprofloxacin is not a drug of first choice in the pediatric population due to an increased incidence of adverse events compared to controls, including events related to joints and/or surrounding tissues 2.
From the Research
Treatment Options for Pyelonephritis
- Ciprofloxacin is a commonly used antibiotic for the treatment of pyelonephritis, with studies showing its efficacy in both 7-day and 14-day regimens 3, 4, 5.
- A study comparing ciprofloxacin to trimethoprim-sulfamethoxazole found that ciprofloxacin had higher bacteriologic and clinical cure rates, especially in patients infected with trimethoprim-sulfamethoxazole-resistant strains 4.
- Levofloxacin is another antibiotic that has been studied for the treatment of pyelonephritis, with one study showing that a 5-day course of levofloxacin 750 mg once daily was as effective as a 10-day course of ciprofloxacin 400 mg and/or 500 mg twice daily 6.
- However, another study found that ceftriaxone was more effective than levofloxacin in the treatment of acute pyelonephritis, based on microbiological response 7.
Duration of Treatment
- The optimal duration of treatment for pyelonephritis is not well established, but studies suggest that shorter courses of antibiotics (7-10 days) may be as effective as longer courses (14 days) 3, 5, 6.
- A study comparing 7-day and 14-day regimens of ciprofloxacin found that the shorter course was non-inferior to the longer course in terms of clinical and bacteriological outcomes 3.
Choice of Antibiotic
- The choice of antibiotic for the treatment of pyelonephritis should be based on susceptibility testing results and local resistance patterns 7, 4.
- Ciprofloxacin and levofloxacin are both effective options, but resistance rates to these antibiotics are increasing, highlighting the need for careful selection and monitoring of antibiotic use 7, 4.