From the Guidelines
Ciprofloxacin is recommended for the treatment of uncomplicated pyelonephritis at a dose of 500-750 mg orally twice daily for 7 days, provided the fluoroquinolone resistance rate is less than 10%. This recommendation is based on the most recent guidelines from the European Association of Urology, published in 2024 1. The guidelines suggest that ciprofloxacin is an appropriate choice for empirical oral antimicrobial therapy for uncomplicated pyelonephritis, with a daily dose of 500-750 mg twice daily and a therapy duration of 7 days.
Some key points to consider when prescribing ciprofloxacin for pyelonephritis include:
- Obtaining a urine culture and susceptibility test to confirm the infecting uropathogen and its susceptibility to ciprofloxacin 1
- Ensuring the patient is not hospitalized and the prevalence of fluoroquinolone resistance in the community is not known to exceed 10% 1
- Administering an initial intravenous dose of a long-acting parenteral antimicrobial, such as ceftriaxone, if fluoroquinolone resistance is a concern 1
- Advising patients to drink plenty of fluids and managing pain with acetaminophen or NSAIDs as needed
- Warning patients about potential side effects, including tendon inflammation, CNS effects, and QT prolongation, and advising them to avoid antacids, dairy products, and multivitamins within 2 hours of taking ciprofloxacin.
It is essential to note that the guidelines emphasize the importance of considering fluoroquinolone resistance rates when selecting empirical therapy for pyelonephritis. If the resistance rate is unknown or exceeds 10%, alternative agents or initial intravenous therapy with a long-acting parenteral antimicrobial may be necessary 1.
From the FDA Drug Label
CLINICAL STUDIES Complicated Urinary Tract Infection and Pyelonephritis – Efficacy in Pediatric Patients: Ciprofloxacin, administered I. V. and/or orally, was compared to a cephalosporin for treatment of complicated urinary tract infections (cUTI) and pyelonephritis in pediatric patients 1 to 17 years of age The duration of therapy was 10 to 21 days (mean duration of treatment was 11 days with a range of 1 to 88 days).
The recommended treatment for pyelonephritis using ciprofloxacin is 10 to 21 days of therapy, with a mean duration of treatment of 11 days 2.
- The treatment can be administered orally and/or intravenously.
- The clinical success rate at 5 to 9 days post-treatment is 95.7%.
- The bacteriologic eradication rate at 5 to 9 days post-treatment is 84.4%.
From the Research
Treatment of Pyelonephritis with Ciprofloxacin
- Ciprofloxacin is a fluoroquinolone antibiotic that can be used to treat pyelonephritis, a common infection in adult women 3.
- A study published in 2012 found that a 7-day course of ciprofloxacin was non-inferior to a 14-day course in women with acute pyelonephritis, with a clinical cure rate of 97% in the 7-day group and 96% in the 14-day group 3.
- However, another study published in 2021 found that ceftriaxone was more effective than levofloxacin (a fluoroquinolone antibiotic similar to ciprofloxacin) in the treatment of acute pyelonephritis, with a microbiological response rate of 68.7% in the ceftriaxone group and 21.4% in the levofloxacin group 4.
Recommended Treatment Duration and Dosage
- The recommended treatment duration for pyelonephritis with ciprofloxacin is 7 days, with a dosage of 500 mg twice daily 3.
- A study published in 2019 found that ciprofloxacin may be effective at lower doses than currently prescribed, with a probability of target attainment (PTA) of ≥ 0.85 at a dose of 100 mg 12 hourly for 71% of the E. coli population 5.
Considerations and Precautions
- The use of ciprofloxacin for pyelonephritis should take into account the increasing resistance rates of E. coli to fluoroquinolones, which can range from 10% to 48% depending on the region and population 4, 6.
- Ciprofloxacin can cause adverse effects such as neuropsychiatric disorders, photosensitivity, tendon disorders, arrhythmia, and cardiac conduction disorders, as well as Clostridium difficile infection 6.
- Alternative treatments, such as trimethoprim-sulfamethoxazole (TMP-SMX), may be considered for the treatment of pyelonephritis, with a 7-day course of TMP-SMX potentially being as effective as a 7-day course of ciprofloxacin 7.