What is the recommended treatment for pyelonephritis?

From the Guidelines

The recommended treatment for pyelonephritis typically involves antibiotics, with the specific regimen depending on severity and patient factors, and according to the most recent guidelines from the European Association of Urology in 2024 1, fluoroquinolones and cephalosporins are the only antimicrobial agents that can be recommended for oral empiric treatment of uncomplicated pyelonephritis. For uncomplicated cases, oral fluoroquinolones like ciprofloxacin (500mg twice daily for 7 days) or levofloxacin (750mg once daily for 5-7 days) are commonly prescribed, as suggested by the European Association of Urology guidelines in 2024 1 and the American College of Physicians in 2021 1. Alternatively, trimethoprim-sulfamethoxazole (160/800mg twice daily for 14 days) may be used if the pathogen is susceptible, as noted in the guidelines from the American College of Physicians in 2021 1. For more severe cases requiring hospitalization, initial intravenous antibiotics such as ceftriaxone (1-2g daily), ampicillin plus gentamicin, or piperacillin-tazobactam are recommended, followed by oral therapy once the patient improves, as suggested by the European Association of Urology guidelines in 2024 1. Treatment duration typically ranges from 7-14 days, with longer courses for complicated cases, and adequate hydration is essential during treatment to help flush bacteria from the urinary tract, as emphasized by the American College of Physicians in 2021 1. Patients should complete the full course of antibiotics even if symptoms improve quickly, and follow-up urine cultures may be necessary to confirm resolution, as recommended by the European Association of Urology guidelines in 2024 1. Pyelonephritis requires prompt treatment because the infection can spread to the bloodstream and cause serious complications if left untreated, highlighting the importance of timely and appropriate antibiotic therapy, as noted in the guidelines from the American College of Physicians in 2021 1.

Some key points to consider in the treatment of pyelonephritis include:

• The use of fluoroquinolones and cephalosporins as first-line oral empiric treatment for uncomplicated pyelonephritis, as recommended by the European Association of Urology guidelines in 2024 1.
• The importance of adequate hydration and completion of the full course of antibiotics, as emphasized by the American College of Physicians in 2021 1.
• The need for prompt treatment to prevent complications, as highlighted by the European Association of Urology guidelines in 2024 1.
• The consideration of local resistance patterns and patient factors in selecting the most appropriate antibiotic regimen, as noted in the guidelines from the American College of Physicians in 2021 1.

Overall, the treatment of pyelonephritis requires a thoughtful and individualized approach, taking into account the severity of the infection, patient factors, and local resistance patterns, with the goal of achieving prompt and effective resolution of the infection while minimizing the risk of complications, as recommended by the European Association of Urology guidelines in 2024 1 and the American College of Physicians in 2021 1.

From the FDA Drug Label

ZERBAXA (ceftolozane and tazobactam) is a combination of ceftolozane, a cephalosporin antibacterial, and tazobactam, a beta-lactamase inhibitor, indicated for the treatment of the following infections caused by designated susceptible microorganisms: ... Complicated Urinary Tract Infections (cUTI), Including Pyelonephritis, in adult and pediatric patients (birth to less than 18 years old). Recommended Dosage of ZERBAXA by Infection in Adult Patients (18 years or older) with Creatinine Clearance (CrCl) Greater than 50 mL/min ... Complicated Urinary Tract Infections (cUTI), Including Pyelonephritis: 1.5 g, 7 days

• Treatment for Pyelonephritis: The recommended treatment for pyelonephritis is 1.5 g of ceftolozane-tazobactam administered every 8 hours by intravenous infusion over 1 hour for 7 days in adult patients with creatinine clearance greater than 50 mL/min 2.

  Levofloxacin tablets are indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia

• Alternative Treatment: Levofloxacin is also indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia, for 5 or 10 days 3.

From the Research

Treatment Options for Pyelonephritis

The recommended treatment for pyelonephritis typically involves antibiotics, with the choice of antibiotic depending on various factors such as the severity of the infection, the causative organism, and local resistance patterns.

• Fluoroquinolones: Studies have shown that fluoroquinolones, such as ciprofloxacin and levofloxacin, are effective in treating pyelonephritis 4, 5. A 7-day course of ciprofloxacin has been found to be non-inferior to a 14-day course in women with acute pyelonephritis 4.
• Cephalosporins: Injectable third-generation cephalosporins, such as ceftriaxone, are also effective against enterobacteria, including E. coli, and have good kidney penetration 6, 7. However, the prevalence of E. coli resistance to third-generation cephalosporins is rising rapidly in some countries.
• Aminoglycosides: Monotherapy with an aminoglycoside is an alternative that has not been evaluated in this clinical situation, but due to the serious irreversible adverse effects of aminoglycosides, they should only be used when the other options are unacceptable 8, 7.

Considerations for Treatment

When choosing an antibiotic for pyelonephritis, it is essential to consider the local resistance patterns and the patient's medical history, including any recent antibiotic use or hospitalization.

• Resistance Patterns: The prevalence of resistance to fluoroquinolones and cephalosporins is rising in some countries, making it crucial to adjust the empirical treatment based on antimicrobial susceptibility testing results 6, 7.
• Antibiotic Stewardship: To preserve the efficacy of broader-spectrum antibiotics, they should not be used as empirical therapy for non-serious infections, and fluoroquinolones and third-generation cephalosporins should be avoided whenever possible in non-serious infections 7.