What is the treatment for Pyelonephritis (infection of the kidney)?

From the Guidelines

Pyelonephritis treatment typically involves antibiotics, with the specific regimen depending on severity and patient factors, and according to the most recent guidelines from the European Association of Urology 1, oral fluoroquinolones like ciprofloxacin (500mg twice daily for 7 days) or levofloxacin (750mg once daily for 5 days) are effective first-line options. For uncomplicated cases, these oral fluoroquinolones are recommended as first-line treatment options.

• Ciprofloxacin: 500mg twice daily for 7 days
• Levofloxacin: 750mg once daily for 5 days Alternatively, trimethoprim-sulfamethoxazole (160/800mg twice daily for 14 days) can be used if the pathogen is susceptible. For more severe cases requiring hospitalization, initial intravenous therapy with ceftriaxone (1-2g daily), an aminoglycoside plus ampicillin, or a fluoroquinolone is recommended until clinical improvement, followed by oral therapy to complete 7-14 days total, as suggested by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases 1. Patients should increase fluid intake, take medications for pain and fever such as acetaminophen, and complete the entire antibiotic course even if symptoms improve quickly. Treatment success requires addressing the underlying cause, such as removing obstructions or treating vesicoureteral reflux, and antibiotics work by targeting bacterial cell walls or protein synthesis, effectively eliminating the infection while the body's immune system assists in recovery, as noted in several studies 1. It is essential to note that the choice of antibiotic should be based on local resistance patterns and susceptibility testing, and fluoroquinolone resistance should be considered when selecting empirical therapy, with a resistance level of less than 10% being a critical factor in this decision, as emphasized in the guidelines 1.

From the FDA Drug Label

1. 11 Acute Pyelonephritis: 5 or 10 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia [see Clinical Studies (14.7,14.8)].

The treatment for Pyelonephritis (infection of the kidney) is levofloxacin, which is indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia. The recommended treatment regimen is a 5 or 10 day course of levofloxacin tablets 2.

• Key points:
  • Levofloxacin is the indicated treatment
  • Escherichia coli is the targeted pathogen
  • 5 or 10 day treatment regimen is recommended
  • Concurrent bacteremia is included in the indication 2

From the Research

Treatment Options for Pyelonephritis

• Outpatient oral antibiotic therapy with a fluoroquinolone is successful in most patients with mild uncomplicated pyelonephritis 3
• Other effective alternatives include extended-spectrum penicillins, amoxicillin-clavulanate potassium, cephalosporins, and trimethoprim-sulfamethoxazole 3
• Indications for inpatient treatment include complicated infections, sepsis, persistent vomiting, failed outpatient treatment, or extremes of age 3
• In hospitalized patients, intravenous treatment is recommended with a fluoroquinolone, aminoglycoside with or without ampicillin, or a third-generation cephalosporin 3

Antibiotic Regimens

• Fluoroquinolones and trimethoprim/sulfamethoxazole are effective oral antibiotics in most cases, but increasing resistance makes empiric use problematic 4
• Ceftriaxone was more effective than levofloxacin in the treatment of acute pyelonephritis, based on microbiological response 5
• Levofloxacin, ciprofloxacin, and lomefloxacin have been compared in clinical trials, with levofloxacin showing excellent efficacy and good tolerability 6
• The first-choice empirical antibiotic treatment for acute uncomplicated pyelonephritis remains an oral fluoroquinolone (ciprofloxacin or ofloxacin) or, in certain cases, the injectable third-generation cephalosporin ceftriaxone 7

Duration of Therapy and Follow-up

• The standard duration of therapy is seven to 14 days 3
• Urine culture should be repeated one to two weeks after completion of antibiotic therapy 3
• Treatment failure may be caused by resistant organisms, underlying anatomic/functional abnormalities, or immunosuppressed states, and should prompt repeat blood and urine cultures and, possibly, imaging studies 3