What is the recommended treatment for pyelonephritis?

Treatment of Pyelonephritis

Fluoroquinolones or trimethoprim-sulfamethoxazole are the first-line treatments for pyelonephritis, with ciprofloxacin 500 mg orally twice daily for 7 days being the preferred option when local resistance rates are below 10%. 1

First-Line Treatment Options

Outpatient Management

For patients with uncomplicated pyelonephritis who can be managed as outpatients:

• Fluoroquinolones:

  • Ciprofloxacin 500 mg orally twice daily for 7 days 1
  • Levofloxacin 750 mg orally once daily for 5 days 2
  • Consider an initial IV dose of ciprofloxacin 400 mg for severe presentations 1

• Trimethoprim-sulfamethoxazole (TMP-SMX):

  • 160/800 mg (double-strength) orally twice daily for 14 days 1
  • Only if pathogen susceptibility is known or with initial IV aminoglycoside dose 1
  • Recent evidence suggests 7-day TMP-SMX courses may be as effective as 7-day ciprofloxacin courses 3

When to Add Initial Parenteral Dose

• When local resistance to chosen oral antibiotic likely exceeds 10%, add one dose of a long-acting parenteral antimicrobial 4:
  • Ceftriaxone 1g IV once 1
  • Consolidated 24-hour dose of an aminoglycoside 1

Inpatient Management

Indications for Hospitalization

• Severe illness/sepsis
• Inability to tolerate oral medications
• Failed outpatient treatment
• Extremes of age
• Pregnancy
• Immunocompromised status
• Suspected anatomical abnormalities or obstruction 1

Parenteral Therapy Options

• Fluoroquinolones:

  • Ciprofloxacin 400 mg IV twice daily 1
  • Levofloxacin 750 mg IV once daily 1

• Cephalosporins:

  • Ceftriaxone 1-2 g IV once daily 1
  • Cefepime 1-2 g IV twice daily 1

• Other options:

  • Piperacillin/tazobactam 2.5-4.5 g IV three times daily 1
  • Gentamicin 5 mg/kg IV once daily (monitor renal function) 1
  • Amikacin 15 mg/kg IV once daily 1

Special Considerations

Beta-lactams

• Amoxicillin-clavulanate 875/125 mg orally every 12 hours for 10-14 days 1
• Generally inferior efficacy compared to fluoroquinolones and TMP-SMX 1
• Amoxicillin or ampicillin alone should not be used due to poor efficacy and high resistance 1
• When using oral β-lactams, an initial IV dose of a long-acting parenteral antimicrobial is strongly recommended 1

Pregnancy

• Requires inpatient management, especially with fever, severe flank pain, nausea/vomiting, signs of sepsis, inability to tolerate oral medications, or in second/third trimester 1
• Avoid fluoroquinolones and TMP-SMX due to potential fetal risks

Antimicrobial Resistance Considerations

• Avoid fluoroquinolones as first-line therapy in areas with high resistance (>10%) 1
• E. coli resistance to fluoroquinolones was about 10% in community settings and 18% in hospital settings in France in 2011-2012 5
• Resistance to third-generation cephalosporins is rising rapidly, particularly in hospitals 5

Monitoring and Follow-up

• Always obtain urine culture before starting therapy 1
• Monitor clinical response within 48-72 hours 1
• If no improvement within 48-72 hours, consider imaging, repeat cultures, and alternative diagnoses 4
• Consider repeat urine culture 1-2 weeks after completion of therapy for complicated UTIs 1

Treatment Duration

• Fluoroquinolones: 5-7 days 1
• TMP-SMX: 14 days (traditional recommendation) 1
• β-lactams: 10-14 days 1
• Avoid insufficient treatment duration, especially for complicated UTIs 1

Common Pitfalls to Avoid

• Using fluoroquinolones in areas with high resistance without an initial parenteral dose
• Prescribing amoxicillin or ampicillin alone for empirical treatment
• Treating for insufficient duration
• Failing to obtain urine culture before starting therapy
• Not considering imaging in patients who fail to respond to appropriate therapy
• Using broad-spectrum antibiotics unnecessarily, which contributes to resistance