What is the recommended treatment for pyelonephritis?

Treatment of Pyelonephritis

For acute pyelonephritis, levofloxacin 750 mg once daily for 5-7 days is the recommended first-line treatment regimen. 1, 2

Initial Assessment and Management

• Diagnosis: Obtain urine culture before initiating therapy to guide treatment 1
• Treatment setting:
  • Outpatient: For uncomplicated cases in patients who can tolerate oral therapy
  • Inpatient: For patients with severe illness, suspected complications, immunocompromised state, pregnancy, or inability to tolerate oral medications 1

Antibiotic Therapy

First-line Treatment Options:

• Levofloxacin 750 mg once daily for 5-7 days (oral or IV) 1, 2
• Ciprofloxacin 500 mg twice daily for 7 days (oral) 3

Alternative Treatment Options:

• Trimethoprim-sulfamethoxazole for 14 days 1
• β-lactams for 10-14 days 1
• Ceftriaxone 1g IV every 12 hours (especially in areas with high fluoroquinolone resistance) 4

Special Considerations

Antimicrobial Resistance

• If local fluoroquinolone resistance exceeds 10%, consider initial dose of a long-acting broad-spectrum parenteral antibiotic while awaiting culture results 5
• For areas with high ESBL prevalence, consult an infectious disease specialist 1

Pregnancy

• Fluoroquinolones are contraindicated in pregnancy due to teratogenic effects 1
• Pregnant patients should be admitted for initial parenteral therapy due to elevated risk for severe complications 1, 5

Concurrent Urinary Tract Obstruction

• Requires urgent decompression to prevent further complications 1, 5

Monitoring and Follow-up

• Clinical improvement should be seen within 48-72 hours 1
• If no improvement is observed:
  1. Reassess diagnosis
  2. Consider imaging
  3. Review antibiotic choice based on culture results 1
• For patients with severe infections requiring prolonged therapy, consider outpatient parenteral antibiotic management 1

Duration of Treatment

• Fluoroquinolones: 5-7 days 1, 2
• Trimethoprim-sulfamethoxazole: 14 days 1
• β-lactams: 10-14 days 1
• Extended treatment duration of up to 21 days may be necessary when Enterobacteriaceae are isolated from blood in cases of urosepsis secondary to pyelonephritis 1

Common Pathogens

• Escherichia coli (most common) 4, 6
• Klebsiella pneumoniae 4
• Other Enterobacteriaceae 1

The treatment approach should be adjusted once culture and susceptibility results are available, as resistance patterns vary by region and are increasing for commonly used antibiotics like fluoroquinolones and cephalosporins 6, 5.