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 1, fluoroquinolones and cephalosporins are the only antimicrobial agents that can be recommended for oral empiric treatment of uncomplicated pyelonephritis.

Key Considerations

• 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 supported by recent studies 1.
• Alternatively, trimethoprim-sulfamethoxazole (160/800mg twice daily for 14 days) may be used if the pathogen is susceptible, although its use is limited by increasing resistance rates 1.
• For more severe cases requiring hospitalization, initial intravenous therapy with ceftriaxone (1-2g daily), an aminoglycoside plus ampicillin, or a fluoroquinolone is recommended until clinical improvement, followed by oral therapy to complete 7-14 days of treatment, as outlined in the guidelines 1.
• Adequate hydration is essential during treatment, and fever and flank pain should begin to resolve within 48-72 hours of starting antibiotics, with further evaluation for complications like abscess or obstruction if symptoms persist beyond this timeframe 1.

Treatment Effectiveness

• Treatment effectiveness relies on antibiotics reaching therapeutic concentrations in the kidney tissue to eliminate the bacterial infection, typically caused by organisms like E. coli that have ascended from the lower urinary tract, as noted in the studies 1.
• The choice of antibiotic should be based on local resistance patterns and optimized, with carbapenems and novel broad-spectrum antimicrobial agents reserved for patients with multidrug-resistant organisms 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 mean duration of treatment was 11 days (range 10 to 21 days).

The recommended treatment for pyelonephritis is determined by the severity of the infection, with pediatric patients with moderate to severe infection 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, for a mean duration of 11 days 2.

Key points:

• Severity of infection determines treatment
• Pediatric patients with moderate to severe infection: 6 to 10 mg/kg I.V. every 8 hours
• Oral therapy: 10 to 20 mg/kg every 12 hours
• Mean duration of treatment: 11 days 2

From the Research

Treatment Options for Pyelonephritis

• The recommended treatment for pyelonephritis typically involves empirical antibiotic therapy, with the choice of antibiotic depending on various factors such as the severity of the infection, patient demographics, and local resistance patterns 3.
• Commonly used antibiotics for the treatment of pyelonephritis include fluoroquinolones (e.g., ciprofloxacin, levofloxacin) and third-generation cephalosporins (e.g., ceftriaxone) 3, 4.
• A study comparing levofloxacin and ceftriaxone for the treatment of acute pyelonephritis found that ceftriaxone was more effective in terms of microbiological response, although there was no significant difference in clinical cure rates 4.
• Another study found that the use of long-acting IV antibiotics, such as ceftriaxone, was associated with a decreased rate of initial inactive therapy in patients with pyelonephritis 5.

Antibiotic Resistance and Treatment Duration

• The increasing prevalence of antibiotic resistance is a concern in the treatment of pyelonephritis, with high resistance rates reported for certain antibiotics such as ciprofloxacin and ceftriaxone 3, 4.
• A systematic review of randomized controlled trials found that early switch to oral antibiotic treatment was as effective and safe as intravenous treatment for hospitalized patients with acute pyelonephritis, and may help reduce the duration of intravenous treatment 6.
• The choice of empirical antibiotic therapy should take into account local resistance patterns and be adjusted based on the results of antimicrobial susceptibility testing 3, 4.

Special Considerations

• In patients with acute obstructive pyelonephritis, percutaneous nephrostomy and ureteral stenting are options for urinary drainage, and fluoroquinolones and third-generation cephalosporins are recommended for empirical antibacterial treatment 7.
• A study found that ceftazidime was more effective than ciprofloxacin in the treatment of acute obstructive pyelonephritis, and that percutaneous nephrostomy was associated with better clinical cure rates than ureteral stenting 7.