What are the treatment options for pyelonephritis (infection of the kidney) on an outpatient basis?

From the Guidelines

Outpatient treatment of pyelonephritis is appropriate for patients with uncomplicated infection who can tolerate oral medications and don't have severe illness or complicating factors, with first-line antibiotic therapy typically including fluoroquinolones such as ciprofloxacin (500mg twice daily for 7 days) or levofloxacin (750mg once daily for 5-7 days) as recommended by the European Association of Urology guidelines 1. The choice of antibiotic should be based on the susceptibility of the pathogen, and fluoroquinolone resistance should be less than 10% 1.

• Alternative options include trimethoprim-sulfamethoxazole (160/800mg twice daily for 14 days) if the pathogen is known to be susceptible, or an oral beta-lactam such as cefpodoxime (200mg twice daily for 10 days) or ceftibuten (400mg once daily for 10 days) 1.
• For patients requiring initial parenteral therapy but suitable for outpatient management, options include a single dose of ceftriaxone (1-2g IV) or an aminoglycoside, followed by oral therapy 1.
• Patients should increase fluid intake, take analgesics for pain/fever as needed, and complete the full antibiotic course even if symptoms improve quickly.
• Close follow-up is essential, with instructions to return immediately if symptoms worsen, fever persists beyond 48-72 hours, or if unable to maintain oral hydration. The American College of Physicians also recommends short-course antibiotics for uncomplicated pyelonephritis, with fluoroquinolones being a suitable option for 5-7 days 1. However, the most recent and highest quality study from the European Association of Urology guidelines 1 should be prioritized for treatment recommendations.

From the FDA Drug Label

Levofloxacin tablets are indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia [see Clinical Studies (14.7,14.8)]. The treatment option for pyelonephritis (infection of the kidney) on an outpatient basis is levofloxacin tablets, which can be used to treat acute pyelonephritis caused by Escherichia coli. Key points to consider:

• The treatment regimen may be 5 or 10 days.
• Levofloxacin tablets can be used for cases with concurrent bacteremia. 2

From the Research

Treatment Options for Pyelonephritis on an Outpatient Basis

• Outpatient oral antibiotic therapy with a fluoroquinolone is successful in most patients with mild uncomplicated pyelonephritis 3
• Other effective alternatives include extended-spectrum penicillins, amoxicillin-clavulanate potassium, cephalosporins, and trimethoprim-sulfamethoxazole 3
• Fluoroquinolones and trimethoprim/sulfamethoxazole are effective oral antibiotics in most cases, but increasing resistance makes empiric use problematic 4
• When local resistance to a chosen oral antibiotic likely exceeds 10%, one dose of a long-acting broad-spectrum parenteral antibiotic should also be given while awaiting susceptibility data 4
• Oral cephalosporins can be considered as an alternative to first-line agents, with no significant difference in UTI recurrence rates 5
• High-dose (750 mg) orally administered levofloxacin over a short 5-day course is a reasonable option for patients eligible for outpatient management 6

Considerations for Outpatient Treatment

• Urine culture with antimicrobial susceptibility testing should be performed in all patients and used to direct therapy 4
• Imaging, blood cultures, and measurement of serum inflammatory markers should not be performed in uncomplicated cases 4
• Patients with uncomplicated disease and can tolerate oral therapy are suitable for outpatient management 4
• Patients with sepsis or risk of infection with a multidrug-resistant organism should receive antibiotics with activity against extended-spectrum beta-lactamase-producing organisms 4

Antibiotic Resistance and Treatment Failure

• Increasing resistance to fluoroquinolones and other antibiotics makes empiric use problematic 4, 7, 6
• Treatment failure may be caused by resistant organisms, underlying anatomic/functional abnormalities, or immunosuppressed states 3
• Lack of response should prompt repeat blood and urine cultures and, possibly, imaging studies 3
• A change in antibiotics or surgical intervention may be required in cases of treatment failure 3