What is the treatment for pyelonephritis in a patient with leukocytosis (White Blood Cell count of 13.8), anemia (Hemoglobin of 11.9), elevated C-Reactive Protein (CRP) (23.4), and a urinalysis showing pyuria (WBC urine 50) and bacteriuria, with imaging suggesting nonspecific edema in the proximal right renal collecting system?

From the Guidelines

The patient with pyelonephritis should be treated with intravenous antibiotics such as ceftriaxone 1-2g IV daily or ciprofloxacin 400mg IV twice daily for initial therapy, followed by oral antibiotics (ciprofloxacin 500mg twice daily or trimethoprim-sulfamethoxazole DS twice daily) for a total 7-14 day course, as recommended by the European Association of Urology guidelines 1.

The diagnosis of pyelonephritis is supported by the patient's elevated white blood cell count (13.8), anemia (Hemoglobin of 11.9), elevated C-Reactive Protein (CRP) (23.4), and urinalysis showing pyuria (WBC urine 50) and bacteriuria. The imaging findings of nonspecific edema in the proximal right renal collecting system are consistent with inflammation from infection.

Treatment Options

• Intravenous ceftriaxone 1-2g IV daily or ciprofloxacin 400mg IV twice daily for initial therapy
• Oral ciprofloxacin 500mg twice daily or trimethoprim-sulfamethoxazole DS twice daily for a total 7-14 day course

Additional Recommendations

• The patient should receive adequate hydration and pain control with acetaminophen or NSAIDs if not contraindicated
• Close follow-up with repeat urinalysis after completing antibiotics to ensure resolution
• Blood cultures should be obtained before starting antibiotics if not already done
• If symptoms worsen or fail to improve within 48-72 hours of appropriate antibiotic therapy, reassessment with possible imaging is warranted to rule out complications such as abscess or obstruction, as suggested by the European Association of Urology guidelines 1 and the American College of Physicians 1.

Considerations

• The choice of antibiotic should be based on local resistance patterns and the patient's specific circumstances, as recommended by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases 1
• Fluoroquinolone resistance should be considered, and alternative agents should be used if the prevalence of resistance is high, as suggested by the European Association of Urology guidelines 1 and the Clinical Microbiology and Infection journal 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 in this patient is levofloxacin. The patient's presentation of pyuria, bacteriuria, and imaging suggesting nonspecific edema in the proximal right renal collecting system, along with laboratory results indicating leukocytosis, anemia, and elevated CRP, is consistent with acute pyelonephritis.

• Key points:
  • The patient has a urinalysis showing pyuria (WBC urine 50) and bacteriuria.
  • Imaging suggests nonspecific edema in the proximal right renal collecting system.
  • The patient has leukocytosis (White Blood Cell count of 13.8), anemia (Hemoglobin of 11.9), and elevated C-Reactive Protein (CRP) (23.4).
  • Levofloxacin is indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia 2. The recommended treatment duration for acute pyelonephritis is 5 or 10 days 2.

From the Research

Patient Profile

• Leukocytosis (White Blood Cell count of 13.8)
• Anemia (Hemoglobin of 11.9)
• Elevated C-Reactive Protein (CRP) (23.4)
• Urinalysis showing pyuria (WBC urine 50) and bacteriuria
• Imaging suggesting nonspecific edema in the proximal right renal collecting system

Treatment Approach

• The patient's presentation is consistent with pyelonephritis, a type of urinary tract infection that involves the kidneys 3
• Empiric antimicrobial therapy is necessary for treatment of patients with serious infections, including pyelonephritis, following a thorough evaluation of possible sources, including culture and susceptibility testing 4
• The choice of empiric therapy should consider the likely etiologies and anticipated resistance patterns, as well as local susceptibility patterns 3

Antibiotic Options

• First-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis includes nitrofurantoin, fosfomycin tromethamine, or pivmecillinam 3
• For more complicated infections, such as pyelonephritis, broader-spectrum antibiotics may be necessary, including fluoroquinolones, cephalosporins, or carbapenems 3
• The use of vancomycin may be considered in cases where methicillin-resistant Staphylococcus aureus (MRSA) is suspected 4

Considerations

• The increasing incidence of antibiotic-resistant bacteria, including extended-spectrum β-lactamases (ESBLs)-producing Enterobacteriales, should be considered when selecting empiric therapy 3
• The patient's recent antibiotic use and hospitalization history should also be taken into account when choosing empiric therapy 4
• Clinical deterioration, such as worsening organ function, may necessitate a change in empiric therapy or the addition of anti-fungal therapy 5