What is the recommended treatment for left pyelonephritis?

Treatment of Left Pyelonephritis

For patients with left pyelonephritis, oral ciprofloxacin (500 mg twice daily) for 7 days is the recommended first-line treatment in outpatient settings where fluoroquinolone resistance is <10%, with an initial intravenous dose of ceftriaxone 1g recommended if local resistance exceeds 10%. 1

Diagnosis and Initial Assessment

• Pyelonephritis typically presents with fever (>38°C), chills, flank pain, nausea, vomiting, or tenderness at the costovertebral angle, with or without symptoms of cystitis 1
• Urinalysis including assessment of white and red blood cells and nitrite is recommended for routine diagnosis 1
• A urine culture and susceptibility test should always be performed in all cases of pyelonephritis to guide targeted therapy 1
• Evaluation of the upper urinary tract via ultrasound should be performed to rule out urinary tract obstruction or renal stone disease in patients with history of urolithiasis, renal function disturbances, or high urine pH 1

Treatment Algorithm for Outpatient Management

First-line therapy:

• Oral ciprofloxacin (500 mg twice daily) for 7 days is appropriate when local fluoroquinolone resistance is <10% 1
• Alternative: Levofloxacin (750 mg once daily) for 5 days 1

Important considerations:

• If local fluoroquinolone resistance exceeds 10%, an initial one-time intravenous dose of a long-acting parenteral antimicrobial is recommended before starting oral therapy: 1
  • Ceftriaxone 1-2g (preferred) 1
  • OR a consolidated 24-hour dose of an aminoglycoside 1

Alternative oral regimens (when susceptibility is known):

• Trimethoprim-sulfamethoxazole (160/800 mg twice daily) for 14 days if the pathogen is known to be susceptible 1
• Oral cephalosporins (if other options cannot be used): 1
  • Cefpodoxime 200 mg twice daily for 10 days
  • Ceftibuten 400 mg once daily for 10 days

Treatment for Hospitalized Patients

For patients requiring hospitalization (severe infection, inability to tolerate oral medications, or complicating factors): 1

• Initial intravenous antimicrobial regimen options: 1

  • Ciprofloxacin 400 mg twice daily
  • Levofloxacin 750 mg once daily
  • Ceftriaxone 1-2 g once daily
  • Cefotaxime 2 g three times daily
  • Cefepime 1-2 g twice daily
  • Piperacillin/tazobactam 2.5-4.5 g three times daily
  • Aminoglycoside (with or without ampicillin)

• Switch to oral therapy when clinically improved 2

Special Considerations

• Prompt differentiation between uncomplicated and potentially obstructive pyelonephritis is crucial, as the latter can swiftly progress to urosepsis 1
• Additional imaging (CT scan or excretory urography) should be considered if the patient remains febrile after 72 hours of treatment or if there is clinical deterioration 1
• Carbapenems and novel broad-spectrum antimicrobial agents should only be considered in patients with early culture results indicating multidrug-resistant organisms 1
• β-lactam agents are generally less effective than fluoroquinolones for pyelonephritis treatment 1
• If using β-lactams, treatment duration should be 10-14 days 1

Common Pitfalls to Avoid

• Failure to obtain urine culture before starting antibiotics 1, 3
• Not considering local resistance patterns when selecting empiric therapy 3, 4
• Using nitrofurantoin, oral fosfomycin, or pivmecillinam for pyelonephritis (insufficient data regarding efficacy) 1
• Not administering an initial dose of long-acting parenteral antibiotic when using oral agents in areas with high resistance rates 3
• Delaying appropriate imaging in patients with suspected complicated pyelonephritis 1
• Using amoxicillin or ampicillin as empirical treatment due to poor efficacy and high resistance rates 1

The treatment should be adjusted based on culture results and clinical response, with follow-up evaluation if symptoms persist beyond 48-72 hours of appropriate therapy 5.