What is the recommended treatment for pyelonephritis?

Treatment of Pyelonephritis

For acute pyelonephritis in outpatients, a fluoroquinolone (ciprofloxacin 500 mg twice daily for 7 days or levofloxacin 750 mg once daily for 5 days) is the recommended first-line treatment where local resistance rates are below 10%. 1

Outpatient Treatment Options

• Fluoroquinolones: First-line therapy for uncomplicated pyelonephritis in areas with resistance rates <10%:

  • Ciprofloxacin 500 mg twice daily for 7 days 2, 1
  • Ciprofloxacin 1000 mg extended-release once daily for 7 days 2, 3
  • Levofloxacin 750 mg once daily for 5 days 2, 4

• Trimethoprim-sulfamethoxazole: 160/800 mg (double-strength tablet) twice daily for 14 days is appropriate ONLY if the uropathogen is known to be susceptible 2, 1

  • If susceptibility is unknown, an initial IV dose of ceftriaxone 1g or a consolidated 24-hour dose of an aminoglycoside should be given before starting oral therapy 2

• Oral β-lactams: Less effective than fluoroquinolones for pyelonephritis 2

  • If used, must be preceded by an initial IV dose of ceftriaxone 1g or aminoglycoside 2
  • Treatment duration should be 10-14 days 2, 1

Inpatient Treatment Options

• Patients requiring hospitalization should receive initial IV antimicrobial therapy with one of the following 2:
  • Fluoroquinolone
  • Aminoglycoside (with or without ampicillin)
  • Extended-spectrum cephalosporin or extended-spectrum penicillin (with or without aminoglycoside)
  • Carbapenem

Important Clinical Considerations

• Urine culture and susceptibility testing should be obtained before initiating therapy to guide treatment 1, 5

• If local fluoroquinolone resistance exceeds 10%, an initial IV dose of a long-acting parenteral antimicrobial (ceftriaxone 1g or aminoglycoside) should be administered before starting oral therapy 2, 1

• Treatment duration:

  • Fluoroquinolones: 5-7 days 1, 3, 6
  • Trimethoprim-sulfamethoxazole: 14 days 2
  • β-lactams: 10-14 days 2

• Response to therapy should be seen within 48-72 hours; patients who do not improve should undergo imaging and repeat cultures 7

Special Populations

• Pregnant patients are at elevated risk of severe complications and should be admitted for initial parenteral therapy 7

• Patients with urinary tract obstruction require urgent decompression in addition to antimicrobial therapy 7

Common Pitfalls to Avoid

• Using oral β-lactams as monotherapy without an initial parenteral dose can lead to treatment failure due to their inferior efficacy 1

• Failing to consider local resistance patterns when selecting empiric therapy can contribute to treatment failure and antimicrobial resistance 1, 8

• Using agents like nitrofurantoin or oral fosfomycin for pyelonephritis is not recommended due to insufficient data regarding efficacy 1

• Continuing broad-spectrum therapy after culture results are available instead of narrowing therapy based on susceptibility testing 2, 5