What are the recommended antibiotics for inpatient pyelonephritis?

From the Guidelines

For inpatient pyelonephritis, recommended antibiotics include intravenous fluoroquinolones, such as ciprofloxacin 400mg IV q12h or levofloxacin 750mg IV daily, extended-spectrum cephalosporins, such as ceftriaxone 1-2g IV q24h or cefepime 2g IV q12h, or piperacillin-tazobactam 3.375g IV q6h, as stated in the 2024 European Association of Urology guidelines 1.

Key Considerations

• Initial empiric therapy should cover common uropathogens, particularly E. coli, which causes approximately 80% of cases.
• Treatment should be tailored based on local resistance patterns and patient-specific factors such as allergies, pregnancy status, and renal function.
• Once culture results are available (typically in 48-72 hours), therapy should be narrowed to the most appropriate agent.
• The total duration of treatment is typically 7-14 days, with transition to oral antibiotics when the patient shows clinical improvement (decreased fever, pain, and improved vital signs).

Additional Recommendations

• Patients should be monitored for resolution of symptoms, potential drug toxicities, and complications such as renal abscess or sepsis.
• Adequate hydration and pain management are important adjunctive measures during treatment.
• The choice of antibiotic should be based on local resistance patterns, as recommended by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases 1.

Empiric Therapy Options

• Intravenous fluoroquinolones: ciprofloxacin 400mg IV q12h or levofloxacin 750mg IV daily
• Extended-spectrum cephalosporins: ceftriaxone 1-2g IV q24h or cefepime 2g IV q12h
• Piperacillin-tazobactam 3.375g IV q6h

Oral Antibiotic Options

• Ciprofloxacin 500-750 mg b.i.d. for 7 days
• Levofloxacin 750 mg q.d. for 5 days
• Trimethoprim sulfamethoxazole 160/800 mg b.i.d. for 14 days
• Cefpodoxime 200 mg b.i.d. for 10 days
• Ceftibuten 400 mg q.d. for 10 days, as suggested in the 2024 European Association of Urology guidelines 1.

From the FDA Drug Label

1.3 Uncomplicated and Complicated Urinary Tract Infections (including pyelonephritis) Cefepime Injection is indicated for uncomplicated and complicated urinary tract infections (including pyelonephritis) caused by Escherichia coli or Klebsiella pneumoniae, when the infection is severe, or caused by Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis, when the infection is mild to moderate, including cases associated with concurrent bacteremia with these microorganisms.

Table 1: Recommended Dosage Schedule for Cefepime Injection in Adult Patients with Creatinine Clearance (CrCL) Greater Than 60 mL/min ... Mild to Moderate Uncomplicated or Complicated Urinary Tract Infections, including pyelonephritis, due to E. coli, K. pneumoniae, or P. mirabilis 0.5-1 g IV Every 12 hours 7-10 Severe Uncomplicated or Complicated Urinary Tract Infections, including pyelonephritis, due to E. coli or K. pneumoniae 2 g IV Every 12 hours 10

Recommended antibiotics for inpatient pyelonephritis include Cefepime Injection. The dosage for mild to moderate uncomplicated or complicated urinary tract infections, including pyelonephritis, is 0.5-1 g IV every 12 hours for 7-10 days, and for severe uncomplicated or complicated urinary tract infections, including pyelonephritis, the dosage is 2 g IV every 12 hours for 10 days 2.

From the Research

Recommended Antibiotics for Inpatient Pyelonephritis

The choice of antibiotics for inpatient pyelonephritis depends on various factors, including the severity of the infection, the presence of complications, and the susceptibility of the causative organism to different antibiotics.

• Extended-spectrum cephalosporins, such as ceftriaxone, are effective options for the treatment of acute pyelonephritis, as shown in a study comparing ceftriaxone to levofloxacin 3.
• Fluoroquinolones, such as levofloxacin, may also be used, but their effectiveness can be limited by high resistance rates, as seen in a study where the resistance rate to ciprofloxacin was 48% in isolated E. coli 3.
• For patients admitted to the hospital, parenteral antibiotic therapy is recommended, and those with sepsis or risk of infection with a multidrug-resistant organism should receive antibiotics with activity against extended-spectrum beta-lactamase-producing organisms 4.

Treatment Duration and Switching to Oral Antibiotics

• A short 7-day treatment with third-generation cephalosporins, such as ceftriaxone, may be effective in uncomplicated acute pyelonephritis, as shown in a study where all 37 patients had negative urine cultures on day 9 5.
• Early switch to oral antibiotics may be an acceptable option in the treatment of patients with acute pyelonephritis, as it can reduce the economic burden associated with pyelonephritis without compromising outcomes 6.
• Antibiotic de-escalation should be considered if permitted by the clinical evolution and the antibiogram, in favor of amoxicillin in women and ciprofloxacin in men 7.

Special Considerations

• Urine culture with antimicrobial susceptibility testing should be performed in all patients and used to direct therapy 4.
• Pregnant patients with pyelonephritis are at significantly elevated risk of severe complications and should be admitted and treated initially with parenteral therapy 4.
• In cases of concurrent urinary tract obstruction, referral for urgent decompression should be pursued 4.
• The treatment regimen should be chosen based on susceptibility testing results, and the duration of therapy should be shortened to decrease the spread of antibiotic resistance worldwide 3.