What is the recommended treatment for pyelonephritis?

Treatment for Pyelonephritis

For patients with pyelonephritis, oral ciprofloxacin (500 mg twice daily) for 7 days, with or without an initial 400-mg dose of intravenous ciprofloxacin, is the recommended first-line treatment in areas where fluoroquinolone resistance is below 10%. 1

Initial Assessment and Management

• Urine culture and susceptibility testing should always be performed before initiating therapy in all patients with suspected pyelonephritis to guide definitive therapy 1
• Initial empirical therapy should be tailored based on local resistance patterns and subsequently adjusted according to culture results 1
• The severity of illness at presentation determines whether outpatient or inpatient management is appropriate 2

Outpatient Treatment Options

Fluoroquinolones (First-line when local resistance <10%)

• Oral ciprofloxacin 500 mg twice daily for 7 days 1
• Once-daily options: ciprofloxacin 1000 mg extended-release for 7 days or levofloxacin 750 mg for 5 days 1
• If local fluoroquinolone resistance exceeds 10%, an initial one-time intravenous dose of a long-acting parenteral antimicrobial (ceftriaxone 1g or aminoglycoside) should be administered before starting oral therapy 1

Trimethoprim-Sulfamethoxazole (TMP-SMX)

• TMP-SMX 160/800 mg (double-strength tablet) twice daily for 14 days is appropriate if the uropathogen is known to be susceptible 1
• If susceptibility is unknown, an initial intravenous dose of ceftriaxone 1g or aminoglycoside is recommended 1
• Recent evidence suggests that a 7-day course of TMP-SMX may be as effective as a 7-day course of ciprofloxacin for susceptible organisms 3

Oral β-lactams

• Less effective than fluoroquinolones or TMP-SMX for pyelonephritis 1
• If used, should be accompanied by an initial intravenous dose of ceftriaxone 1g or aminoglycoside 1
• Recommended duration is 10-14 days 1

Inpatient Treatment Options

• For patients requiring hospitalization, initial intravenous antimicrobial regimens include 1, 4:

  • Fluoroquinolone (ciprofloxacin 400 mg every 12 hours or levofloxacin 750 mg once daily)
  • Aminoglycoside with or without ampicillin
  • Extended-spectrum cephalosporin or extended-spectrum penicillin, with or without aminoglycoside
  • Carbapenem

• The choice between these agents should be based on local resistance patterns and adjusted according to culture results 1

Special Considerations

• In elderly patients, monitor closely for adverse effects, particularly with aminoglycosides (nephrotoxicity, ototoxicity) and fluoroquinolones (CNS effects, tendinopathy) 4
• For patients with renal impairment, dose adjustments are necessary, particularly for ciprofloxacin 5:
  • Creatinine clearance 30-50 mL/min: 250-500 mg every 12 hours
  • Creatinine clearance 5-29 mL/min: 250-500 mg every 18 hours
  • Hemodialysis/peritoneal dialysis: 250-500 mg every 24 hours (after dialysis)

Treatment Duration and Follow-up

• Fluoroquinolones: 5-7 days (depending on the specific agent) 1
• TMP-SMX: 14 days (traditional recommendation) 1
• β-lactams: 10-14 days 1
• Most patients should respond to appropriate therapy within 48-72 hours 2
• If no improvement occurs within this timeframe, consider imaging, repeat cultures, and alternative diagnoses 2

Common Pitfalls to Avoid

• Failing to obtain urine cultures before initiating antibiotics 1
• Not considering local resistance patterns when selecting empiric therapy 1
• Using fluoroquinolones empirically in areas with >10% resistance without adding an initial dose of a parenteral agent 1
• Using oral β-lactams as monotherapy without an initial parenteral dose 1
• Not adjusting therapy based on culture results 1
• Inadequate treatment duration, especially with β-lactam agents 1