What is the recommended treatment for pyelonephritis?

Treatment for Pyelonephritis

The recommended first-line treatment for pyelonephritis is oral ciprofloxacin 500 mg twice daily for 7 days in areas where fluoroquinolone resistance is below 10%, or levofloxacin 750 mg once daily for 5 days as an equally effective alternative. 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

Fluoroquinolones (First-line)

• 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
  • FDA-approved 5-day regimen with comparable efficacy to 10-day ciprofloxacin treatment 2

When Fluoroquinolone Resistance >10%

• Administer initial one-time IV dose of a long-acting parenteral antimicrobial (ceftriaxone 1g or aminoglycoside) before starting oral therapy 1, 3
• Then continue with oral fluoroquinolone regimen 1

Alternative Oral Options

• Trimethoprim-Sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 14 days if the pathogen is known to be susceptible 1
  • Note: High resistance rates may limit empiric use 3, 4

Inpatient Treatment Options

• Recommended IV regimens include: 1

  • Fluoroquinolones (ciprofloxacin or levofloxacin)
  • Aminoglycosides with or without ampicillin
  • Extended-spectrum cephalosporins (e.g., ceftriaxone 1g every 12 hours) 1, 5
  • Extended-spectrum penicillins with or without aminoglycosides
  • Carbapenems (for severe infections or suspected resistant organisms)

• Aminoglycosides can be administered as a consolidated 24-hour dose (e.g., gentamicin 5-7mg/kg once daily) 1

Treatment Duration

• Fluoroquinolones: 5-7 days 1, 2
• TMP-SMX: 14 days 1
• β-lactams: 10-14 days 1

Special Populations

• Elderly patients: Monitor closely for adverse effects, particularly with aminoglycosides and fluoroquinolones 1
• Pregnant women: Avoid fluoroquinolones; cephalosporins are generally preferred 6

Oral Step-Down Therapy

• Once clinical improvement occurs in hospitalized patients, transition to oral therapy based on culture results 1
• Oral β-lactams are less effective than other agents but can be used if the pathogen is susceptible 1

Microbiology Considerations

• Escherichia coli is the most common pathogen (75-95%), followed by Klebsiella pneumoniae and Proteus mirabilis 1, 7, 5
• Rising resistance rates to fluoroquinolones (up to 18% in hospital settings) and third-generation cephalosporins (up to 10%) are concerning 4
• Recent data shows ceftriaxone may have better microbiological eradication rates compared to levofloxacin in some regions with high resistance 5

Common Pitfalls to Avoid

• Failing to obtain urine cultures before starting antibiotics 1, 7
• Not considering local resistance patterns when selecting empiric therapy 1, 4
• Using fluoroquinolones empirically in areas with >10% resistance without an initial parenteral dose 1, 3
• 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