What is the recommended treatment for uncomplicated pyelonephritis?

Treatment of Uncomplicated Pyelonephritis

For uncomplicated pyelonephritis, oral ciprofloxacin (500 mg twice daily) for 7 days is the recommended first-line treatment when local fluoroquinolone resistance is less than 10%. 1, 2

First-Line Treatment Options

Fluoroquinolones

• Ciprofloxacin: 500 mg orally twice daily for 7 days 1
• Extended-release ciprofloxacin: 1000 mg orally once daily for 7 days 1
• Levofloxacin: 750 mg orally once daily for 5 days 2, 3
  • Levofloxacin has demonstrated similar efficacy to ciprofloxacin with the advantage of shorter treatment duration 4

Important Considerations for Fluoroquinolones

• Only use when local resistance rates are <10% 1, 2
• If fluoroquinolone resistance exceeds 10%, administer an initial intravenous dose of:
  • Ceftriaxone 1g IV 1, 2 OR
  • A consolidated 24-hour dose of an aminoglycoside 1

Alternative Treatment Options

Trimethoprim-Sulfamethoxazole

• 160/800 mg (double-strength) orally twice daily for 14 days 1, 2
• Only use when the pathogen is known to be susceptible
• If susceptibility is unknown, administer an initial IV dose of ceftriaxone 1g 1

Oral β-lactams

• Less effective than fluoroquinolones for pyelonephritis 1, 2
• If used, should be preceded by an initial IV dose of ceftriaxone 1g 1
• Longer treatment duration (10-14 days) is recommended 1

Inpatient Treatment

For patients requiring hospitalization (severe illness, inability to tolerate oral medications, failed outpatient treatment):

• Initial IV antimicrobial regimen options:
  • Fluoroquinolone (ciprofloxacin 400 mg IV twice daily or levofloxacin 750 mg IV once daily) 2
  • Ceftriaxone 1-2g IV once daily 2
  • Aminoglycoside with or without ampicillin 1
  • Extended-spectrum cephalosporin or penicillin 1

Diagnostic Approach

• Urine culture and susceptibility testing should always be performed before initiating therapy 1, 2
• Empiric therapy should be adjusted based on culture results 2

Treatment Duration

• Fluoroquinolones: 5-7 days 1, 2, 4
• Trimethoprim-sulfamethoxazole: 14 days 1, 2
• β-lactams: 10-14 days 1

Common Pitfalls to Avoid

• Delaying antibiotic administration beyond one hour after diagnosis 2
• Not obtaining cultures before starting antibiotics 2
• Using fluoroquinolones empirically in areas with high resistance without an initial parenteral dose 2
• Using oral β-lactams as monotherapy without an initial parenteral dose 1

Follow-up

• Consider repeat urine culture 1-2 weeks after completion of therapy, especially in cases with risk factors for recurrence 2
• If symptoms do not improve within 48-72 hours, consider imaging and repeat cultures 5

The treatment of uncomplicated pyelonephritis requires prompt initiation of appropriate antibiotics to prevent complications. While fluoroquinolones remain first-line therapy in areas with low resistance rates, local antimicrobial susceptibility patterns should guide empiric treatment choices.