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, oral fluoroquinolones like ciprofloxacin (500mg twice daily for 7 days) or levofloxacin (750mg once daily for 5-7 days) are commonly used for uncomplicated cases. For uncomplicated cases, the choice of antibiotic should be based on local resistance patterns and the severity of the infection.

• Oral fluoroquinolones like ciprofloxacin or levofloxacin are commonly used for uncomplicated cases, with a treatment duration of 5-7 days.
• Alternatively, trimethoprim-sulfamethoxazole may be prescribed if the pathogen is susceptible, with a treatment duration of 14 days. 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, as suggested by the European Association of Urology guidelines in 2024 1. Adequate hydration is essential during treatment, and patients should complete the full antibiotic course even if symptoms improve quickly. Pain management with acetaminophen or NSAIDs may be needed. These treatments target the bacterial infection (most commonly E. coli) that has ascended from the lower urinary tract to the kidney, causing inflammation of the renal pelvis and parenchyma. Follow-up urine cultures are recommended to ensure complete resolution of the infection, as emphasized by the American College of Physicians in 2021 1. It is also important to note that the choice of antibiotic should be based on local resistance patterns and the severity of the infection, as highlighted by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases in 2011 1.

From the FDA Drug Label

1.11 Acute Pyelonephritis: 5 or 10-day Treatment Regimen Levofloxacin tablets are indicated in adult patients for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia [see Clinical Studies (14.7,14.8)]. 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 (mean age of 6 ± 4 years).

The recommended treatment for pyelonephritis is levofloxacin or ciprofloxacin.

• For adults, levofloxacin can be used for 5 or 10 days.
• For pediatric patients, ciprofloxacin can be administered orally or intravenously, with the dosage and duration depending on the severity of the infection and the patient's age and weight. Key considerations include:
• Dosage: The dosage for ciprofloxacin in pediatric patients is 10 mg/kg to 20 mg/kg (maximum 750 mg per dose) every 12 hours for oral administration, and 6 to 10 mg/kg (maximum 400 mg per dose) every 8 hours for intravenous administration.
• Duration: The total duration of therapy for complicated urinary tract infection and pyelonephritis in pediatric patients can range from 10 to 21 days.
• Renal function: Patients with severe renal impairment may require dosage adjustments. 2 3 3

From the Research

Treatment Options for Pyelonephritis

The recommended treatment for pyelonephritis typically involves antibiotic therapy, with the choice of antibiotic depending on various factors such as the severity of the infection, the presence of underlying medical conditions, and the susceptibility of the causative organism to different antibiotics.

• Empirical antibiotic therapy should be initiated promptly to prevent serious complications, with options including oral fluoroquinolones (e.g., ciprofloxacin, levofloxacin) or injectable third-generation cephalosporins (e.g., ceftriaxone) 4.
• The choice of antibiotic should take into account the potential for resistance, with fluoroquinolone resistance rates varying by region and increasing over time 4, 5.
• Other antibiotic options for the treatment of pyelonephritis include aminoglycosides, beta-lactams, and trimethoprim/sulfamethoxazole, although their use may be limited by potential side effects and resistance patterns 6, 7.

Duration of Treatment

The optimal duration of antibiotic treatment for pyelonephritis has not been well established, but studies suggest that shorter courses of treatment may be effective in certain cases.

• A randomized, open-label and double-blind, placebo-controlled trial found that ciprofloxacin for 7 days was non-inferior to 14 days in women with community-acquired acute pyelonephritis 8.
• Shorter courses of antibiotics may help reduce the risk of antibiotic resistance and minimize side effects, although the specific duration of treatment should be individualized based on the patient's response and the severity of the infection 8.

Considerations for Specific Patient Populations

Certain patient populations, such as pregnant women and those with underlying medical conditions, may require special consideration when selecting antibiotic therapy for pyelonephritis.

• Pregnant women with pyelonephritis may require hospitalization and treatment with antibiotics that are safe for use during pregnancy 7.
• Patients with underlying medical conditions, such as urinary tract obstruction or immunocompromised status, may require more aggressive or prolonged antibiotic treatment 7.