What is the recommended treatment for pyelonephritis?

Treatment of Pyelonephritis

For uncomplicated pyelonephritis in adults, fluoroquinolones (such as levofloxacin 750 mg once daily for 5-7 days) are recommended as first-line therapy when local resistance rates are below 10%; otherwise, initial parenteral therapy with ceftriaxone followed by oral antibiotics based on susceptibility testing is recommended. 1, 2

Treatment Algorithm

Initial Assessment

• Determine severity: presence of fever, flank pain, nausea/vomiting, signs of sepsis
• Obtain urinalysis and urine culture with antimicrobial susceptibility testing
• Assess for risk factors for complicated infection: pregnancy, immunocompromise, anatomical abnormalities

Outpatient Management (Uncomplicated Cases)

1. First-line options (when local E. coli resistance <10%):

   • Levofloxacin 750 mg orally once daily for 5-7 days 2, 3
   • Ciprofloxacin 500 mg orally twice daily for 7 days 1, 3

2. When local fluoroquinolone resistance >10%:

   • Initial dose of ceftriaxone 1-2 g IV/IM, followed by oral therapy based on susceptibility 1, 4
   • Oral cephalosporins may be considered as alternatives with similar efficacy to fluoroquinolones 5

Inpatient Management (Required For)

• Severe illness/sepsis
• Inability to tolerate oral medications
• Pregnancy (especially 2nd/3rd trimester)
• Suspected complications

Parenteral options:

• Ceftriaxone 1-2 g IV once daily
• Cefepime 1-2 g IV twice daily
• Piperacillin/tazobactam 3.375-4.5 g IV every 6-8 hours
• Levofloxacin 750 mg IV once daily 1, 2

Special Populations

Pregnancy

• Avoid fluoroquinolones and aminoglycosides due to potential fetal risks
• Recommended treatment: Ceftriaxone or other extended-spectrum cephalosporins
• Requires inpatient management, especially with fever or in 2nd/3rd trimester
• Total treatment duration: 10-14 days 1
• Monthly urine cultures until delivery to monitor for recurrence

Elderly Patients

• May present with atypical symptoms
• Higher risk of complicated infections (up to 30%)
• Consider broader initial coverage and thorough evaluation for anatomical abnormalities 1

Treatment Duration and Follow-up

• Uncomplicated pyelonephritis: 5-7 days of appropriate therapy is sufficient 3, 6
• Complicated cases: 10-14 days 1
• Clinical response should be evaluated within 48-72 hours
• Follow-up urine culture 1-2 weeks after completing therapy to confirm clearance 1

Important Considerations

• Local resistance patterns should guide empiric therapy selection
• When Pseudomonas aeruginosa is suspected, combination therapy with an anti-pseudomonal β-lactam is recommended 2
• Short-course therapy (7 days) has shown similar efficacy to longer courses (14 days) for ciprofloxacin in uncomplicated cases 3
• Increasing rates of fluoroquinolone resistance globally may limit their empiric use 6
• Imaging (typically contrast-enhanced CT) is not necessary for uncomplicated cases but should be considered if symptoms don't improve within 48-72 hours or recur after initial improvement 7, 4

Common Pitfalls

• Failing to obtain urine culture before starting antibiotics
• Not considering local resistance patterns when selecting empiric therapy
• Using oral beta-lactams or trimethoprim/sulfamethoxazole empirically in areas with high resistance
• Inadequate follow-up to ensure infection clearance
• Missing concurrent urinary tract obstruction that requires urgent decompression 4