What is the recommended treatment for pyelonephritis?

Treatment of Pyelonephritis

For acute pyelonephritis, fluoroquinolones (such as levofloxacin) are the recommended first-line treatment for 5-7 days in uncomplicated cases, while patients with complicated infections or who cannot tolerate oral medications should receive initial parenteral therapy. 1

Initial Assessment and Treatment Selection

Outpatient Management

• Appropriate for patients with uncomplicated disease who can tolerate oral therapy 2
• First-line oral therapy options:
  • Fluoroquinolones (e.g., levofloxacin) for 5-7 days 1, 3
  • Levofloxacin is specifically FDA-approved for acute pyelonephritis with 5 or 10-day treatment regimens 3

When to Consider Inpatient Treatment

• Severe illness or suspected complications
• Immunocompromised patients
• Pregnancy (due to elevated risk for severe complications)
• Inability to tolerate oral medications
• Concurrent urinary tract obstruction (requires urgent decompression) 1, 2

Antibiotic Selection Considerations

Empiric Therapy Guidelines

• In communities where fluoroquinolone resistance is ≤10%: Start with oral fluoroquinolones 2
• In communities where fluoroquinolone resistance is >10%: Give one dose of a long-acting broad-spectrum parenteral antibiotic (e.g., ceftriaxone) followed by oral fluoroquinolones 1, 2

Specific Antibiotic Options

1. Fluoroquinolones:

   • Levofloxacin 750 mg daily for 5-7 days 1, 3
   • Contraindicated in pregnancy, patients with tendon disorders, myasthenia gravis, or QT prolongation 1

2. Alternative options when fluoroquinolones cannot be used:

   • Trimethoprim-sulfamethoxazole for 14 days
   • β-lactams for 10-14 days 1

3. For inpatient treatment:

   • Parenteral therapy options include fluoroquinolones, aminoglycosides, and cephalosporins 4
   • For suspected sepsis or risk of multidrug-resistant organisms: Use antibiotics with activity against extended-spectrum beta-lactamase (ESBL) producing organisms 2

Special Considerations

Escherichia coli Infections

• E. coli is the most common pathogen in acute pyelonephritis 4, 2
• Levofloxacin is specifically indicated for treatment of acute pyelonephritis caused by E. coli, including cases with concurrent bacteremia 3
• Extended treatment duration of up to 21 days may be necessary when Enterobacteriaceae are isolated from blood 1

Monitoring and Follow-up

• Obtain urine culture before initiating therapy to guide treatment 1
• Clinical improvement should be seen within 48-72 hours 1
• If no improvement occurs, reassess diagnosis, consider imaging, and review antibiotic choice based on culture results 1, 2

Important Caveats

• Increasing resistance rates: There is increasing resistance to extended-spectrum beta-lactam antibiotics and fluoroquinolones in many regions 4, 5
• Pregnancy: Fluoroquinolones are contraindicated; pregnant patients should be admitted for initial parenteral therapy 1, 2
• Duration of therapy: Recent evidence suggests 7-day courses may be as effective as 14-day courses for fluoroquinolones in uncomplicated cases 6
• Areas with high ESBL prevalence: Consider consulting an infectious disease specialist 1

Treatment Algorithm

1. Obtain urine culture before starting antibiotics
2. Assess for criteria requiring inpatient treatment
3. For outpatient treatment:
   • If local fluoroquinolone resistance ≤10%: Levofloxacin 750 mg daily for 5-7 days
   • If local fluoroquinolone resistance >10%: One dose of ceftriaxone followed by oral levofloxacin
4. For inpatient treatment: Start with parenteral antibiotics (fluoroquinolones, aminoglycosides, or cephalosporins)
5. Reassess in 48-72 hours; if not improving, consider imaging and antibiotic adjustment