What is the recommended treatment for pyelonephritis?

Treatment for Pyelonephritis

For pyelonephritis treatment, oral ciprofloxacin 500 mg twice daily for 7 days is recommended as first-line therapy in areas where fluoroquinolone resistance is below 10%. 1

Initial Assessment and Management

• Always obtain urine culture and susceptibility testing before initiating antibiotics to guide definitive therapy 1
• Initial empiric therapy should be based on local resistance patterns and adjusted according to culture results 1

Outpatient Treatment Options

• For areas with fluoroquinolone resistance <10%:

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

• For areas with fluoroquinolone resistance >10%:

  • Initial one-time IV dose of ceftriaxone 1g or an aminoglycoside, followed by oral fluoroquinolone therapy 1, 3
  • Trimethoprim-Sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 14 days if the pathogen is known to be susceptible 1

Inpatient Treatment Options

• For patients requiring hospitalization, recommended IV regimens include:

  • Fluoroquinolones 1
  • Aminoglycosides with or without ampicillin 1
  • Extended-spectrum cephalosporins (e.g., ceftriaxone) 1, 4
  • Extended-spectrum penicillins with or without aminoglycosides 1
  • Carbapenems 1

• The FDA has approved levofloxacin 750 mg IV or orally once daily for 5 days for complicated UTI and acute pyelonephritis 2

Treatment Duration

• Fluoroquinolones: 5-7 days (ciprofloxacin 7 days, levofloxacin 5 days) 1, 5
• TMP-SMX: 14 days 1
• β-lactams: 10-14 days 1

Special Considerations

• Escherichia coli is the most common pathogen (75-95%), followed by other Enterobacteriaceae such as Proteus mirabilis and Klebsiella pneumoniae 1, 6
• Oral β-lactams are less effective than other available agents but can be used if the pathogen is susceptible 1
• Monitor elderly patients closely for adverse effects, particularly with aminoglycosides and fluoroquinolones 1
• Aminoglycosides can be administered as a consolidated 24-hour dose (e.g., gentamicin 5-7mg/kg once daily) 1

Factors Affecting Treatment Choice

• Local resistance patterns are crucial in selecting empiric therapy 1, 7
• Recent studies show increasing resistance rates to commonly used antibiotics:
  • In some regions, E. coli resistance to ciprofloxacin can reach 48% 4
  • Resistance to third-generation cephalosporins has been increasing (up to 34.4% for E. coli in some areas) 4, 7

Common Pitfalls to Avoid

• Failing to obtain urine cultures before starting antibiotics 1
• Not considering local resistance patterns when selecting empiric therapy 1, 7
• Using fluoroquinolones empirically in areas with >10% resistance without an initial parenteral dose 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