What is the recommended treatment for pyelonephritis?

From the Guidelines

The recommended treatment for pyelonephritis is oral ciprofloxacin (500–750 mg twice daily) for 7 days, or levofloxacin (750 mg once daily) for 5 days, as suggested by the most recent guidelines 1.

Treatment Overview

The treatment of pyelonephritis typically involves antibiotics, with the specific regimen depending on the severity of the disease and patient factors.

• For uncomplicated cases, oral fluoroquinolones are commonly used.
• Alternatively, trimethoprim-sulfamethoxazole may be prescribed if the pathogen is susceptible.
• For more severe cases requiring hospitalization, initial intravenous therapy with ceftriaxone, an aminoglycoside plus ampicillin, or a fluoroquinolone is recommended until clinical improvement, followed by oral therapy to complete 7-14 days total.

Key Considerations

• Patients should increase fluid intake, take medications for the full prescribed duration even if symptoms improve, and seek follow-up care to ensure resolution.
• Pain relievers like acetaminophen may help manage discomfort.
• The choice of antibiotic should be based on local resistance patterns and optimized.
• A urine culture and antimicrobial susceptibility testing should be performed in all cases of pyelonephritis.
• Evaluation of the upper urinary tract via ultrasound should be performed to rule out urinary tract obstruction or renal stone disease.

Recent Guidelines

The European Association of Urology guidelines on urological infections suggest that fluoroquinolones and cephalosporins are the only antimicrobial agents that can be recommended for oral empiric treatment of uncomplicated pyelonephritis 1.

• A short outpatient course of antibiotic treatment for acute pyelonephritis is equivalent to longer therapy durations in terms of clinical and microbiological success.
• However, this approach is associated with a higher recurrence rate within 4–6 weeks and needs to be tailored to local policies and resistance patterns.

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 recommended treatment for pyelonephritis is levofloxacin.

• The treatment regimen is 5 or 10 days.
• It is effective against Escherichia coli, including cases with concurrent bacteremia 2.

From the Research

Treatment Options for Pyelonephritis

The recommended treatment for pyelonephritis depends on the severity of the illness and the presence of complications.

• Outpatient treatment is appropriate for most patients with mild to moderate symptoms 3.
• Inpatient therapy is recommended for patients who have severe illness or in whom a complication is suspected 3.

Antibiotic Regimens

Several antibiotic regimens can be used for the treatment of pyelonephritis, including:

• Oral fluoroquinolones, such as ciprofloxacin or levofloxacin, which are recommended as initial outpatient therapy if the rate of fluoroquinolone resistance in the community is 10 percent or less 3, 4.
• Trimethoprim-sulfamethoxazole (TMP-SMX), which may be as effective as ciprofloxacin for the treatment of pyelonephritis, but has higher resistance rates 5, 6.
• Cephalosporins, which may be used as an alternative to first-line agents, with similar efficacy and lower resistance rates 6, 7.
• Aminoglycosides and cephalosporins, which can be used for inpatient treatment 3.

Duration of Antibiotic Therapy

The duration of antibiotic therapy for pyelonephritis is typically 7-14 days, depending on the severity of the illness and the response to treatment.

• A 7-day course of TMP-SMX may be as effective as a 7-day course of ciprofloxacin for the treatment of pyelonephritis 5.
• A 5-day course of high-dose levofloxacin may be a reasonable option for patients eligible for outpatient management 4.

Resistance and Adverse Effects

The emergence of widespread fluoroquinolone resistance and the risks of antibiotic resistance and associated toxicities should be considered when selecting an antibiotic regimen for pyelonephritis 3, 4.

• Efforts to promote fluoroquinolone-sparing agents should be encouraged, and prescription should be performed in compliance with antimicrobial guidelines 4.