From the Guidelines
For uncomplicated pyelonephritis, oral fluoroquinolones, such as ciprofloxacin 500 mg twice daily for 7 days, are the first-line treatment, as recommended by the most recent guidelines 1. The choice of antibiotic should be guided by local resistance patterns, with fluoroquinolone resistance being less than 10% for empirical use 1. Some key points to consider when treating uncomplicated pyelonephritis include:
- The patient should be stable enough for outpatient management, with no complicating factors like obstruction or abscess, and able to tolerate oral medications.
- Patients should complete the full course of antibiotics, even if symptoms improve quickly, and drink plenty of fluids.
- Immediate medical attention should be sought if symptoms worsen or don't improve within 48-72 hours. Alternative treatments, such as trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 14 days, can be considered if the pathogen is known to be susceptible 1. It's essential to note that the increasing prevalence of fluoroquinolone resistance in Enterobacteriaceae requires reevaluation of the efficacy of shorter courses of antibiotic classes other than fluoroquinolones as targeted therapy for pyelonephritis when susceptibility is known 1. The most recent guidelines from the European Association of Urology provide suggested regimens for empirical oral antimicrobial therapy for uncomplicated pyelonephritis, including ciprofloxacin, levofloxacin, trimethoprim-sulfamethoxazole, cefpodoxime, and ceftibuten 1.
From the FDA Drug Label
11 Acute Pyelonephritis: 5 or 10 Day Treatment Regimen 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)].
7 Complicated Urinary Tract Infections and Acute Pyelonephritis: 5 Day Treatment Regimen To evaluate the safety and efficacy of the higher dose and shorter course of levofloxacin, 1109 patients with cUTI and AP were enrolled in a randomized, double-blind, multicenter clinical trial conducted in the U.S. from November 2004 to April 2006 comparing levofloxacin 750 mg I. V. or orally once daily for 5 days (546 patients) with ciprofloxacin 400 mg I. V. or 500 mg orally twice daily for 10 days (563 patients).
8 Complicated Urinary Tract Infections and Acute Pyelonephritis: 10 Day Treatment Regimen To evaluate the safety and efficacy of the 250 mg dose, 10 day regimen of levofloxacin, 567 patients with uncomplicated UTI, mild-to-moderate cUTI, and mild-to-moderate AP were enrolled in a randomized, double-blind, multicenter clinical trial conducted in the U. S. from June 1993 to January 1995 comparing levofloxacin 250 mg orally once daily for 10 days (285 patients) with ciprofloxacin 500 mg orally twice daily for 10 days (282 patients).
The oral antibiotics for acute pyelonephritis (infection of the kidney) are:
- Levofloxacin: 750 mg orally once daily for 5 days or 250 mg orally once daily for 10 days 2
- Ciprofloxacin: 500 mg orally twice daily for 10 days 3
From the Research
Oral Antibiotics for Acute Pyelonephritis
The following oral antibiotics are effective for the treatment of acute pyelonephritis:
- Fluoroquinolones, such as ciprofloxacin and levofloxacin 4, 5, 6, 7
- Extended-spectrum penicillins 4
- Amoxicillin-clavulanate potassium 4
- Cephalosporins 4, 5, 7
- Trimethoprim-sulfamethoxazole (TMP-SMX) 4, 5, 7, 8
Duration of Therapy
The standard duration of therapy for acute pyelonephritis is 7 to 14 days 4, 6, 8. However, some studies suggest that a 7-day course of antibiotic therapy may be as effective as a 14-day course for the treatment of pyelonephritis 6, 8.
Considerations for Antibiotic Selection
When selecting an antibiotic for the treatment of acute pyelonephritis, it is essential to consider the patient's susceptibility to the antibiotic, as well as the potential for antibiotic resistance 4, 5, 7. The use of broad-spectrum antibiotics should be reserved for severe or complicated infections, and narrower-spectrum antibiotics should be used whenever possible to preserve their efficacy in serious infections 7.