Can Toradol (ketorolac) be used to treat pyelonephritis?

Toradol (Ketorolac) is Contraindicated for Pyelonephritis Treatment

Toradol (ketorolac) should not be used to treat pyelonephritis as it is specifically contraindicated in patients with advanced renal impairment or at risk for renal failure due to volume depletion, which can occur in pyelonephritis. 1

Rationale for Contraindication

• Ketorolac is contraindicated in patients with advanced renal impairment or in patients at risk for renal failure due to volume depletion 1
• Pyelonephritis, an infection of the renal parenchyma, can lead to impaired renal function and volume depletion, making ketorolac use potentially dangerous 2
• Cases of acute renal failure and hyperkalemia have been reported with ketorolac use, particularly in patients with predisposing conditions like infection 3

Recommended Treatment Options for Pyelonephritis

First-Line Oral Therapy (for mild-moderate uncomplicated cases)

• Ciprofloxacin 500-750 mg twice daily for 7 days 2
• Levofloxacin 750 mg once daily for 5 days 2
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days (only if susceptibility is known) 2

Parenteral Therapy (for severe cases requiring hospitalization)

• Ciprofloxacin 400 mg twice daily 2
• Levofloxacin 750 mg once daily 2
• Ceftriaxone 1-2 g once daily 2
• Cefotaxime 2 g three times daily 2
• Aminoglycosides (with or without ampicillin) 2
• Extended-spectrum penicillins (with or without aminoglycosides) 2

Important Clinical Considerations

• Urine culture and antimicrobial susceptibility testing should always be performed before initiating antibiotics for pyelonephritis 2
• Local resistance patterns should guide empiric therapy choices, particularly for fluoroquinolones which should be avoided if local resistance exceeds 10% 2
• If fluoroquinolone resistance is suspected (>10%), an initial IV dose of a long-acting parenteral antimicrobial such as ceftriaxone 1g is recommended before oral therapy 2
• Oral β-lactams (cephalosporins) are less effective than fluoroquinolones for pyelonephritis but may be used if other options are unavailable 2, 4

Diagnostic Approach for Pyelonephritis

• Diagnosis is based on fever (>38°C), chills, flank pain, nausea, vomiting, or costovertebral angle tenderness 2
• Urinalysis should be performed to assess for white blood cells, red blood cells, and nitrite 2
• Ultrasound imaging should be considered to rule out urinary tract obstruction or renal stones, particularly in patients with a history of urolithiasis or renal dysfunction 2

Monitoring and Follow-up

• Patients should be reassessed if fever persists after 72 hours of appropriate antibiotic therapy 2
• Additional imaging (contrast-enhanced CT) should be performed if clinical status deteriorates or fever persists 2
• Treatment duration ranges from 5-14 days depending on the antibiotic used and clinical response 2

Pitfalls to Avoid

• Never use ketorolac (Toradol) for pyelonephritis due to the risk of acute renal failure 1, 3
• Avoid nitrofurantoin, oral fosfomycin, and pivmecillinam for pyelonephritis due to insufficient efficacy data 2
• Do not use trimethoprim-sulfamethoxazole empirically without culture and susceptibility testing due to high resistance rates 2
• Reserve carbapenems and novel broad-spectrum antimicrobials for cases with confirmed multidrug-resistant organisms 2