What is the recommended treatment for pyelonephritis?

Treatment of 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%, with alternative options including extended-release ciprofloxacin 1000 mg daily for 7 days or levofloxacin 750 mg daily for 5 days. 1

Initial Assessment and Management

• Urine culture and susceptibility testing should always be performed before initiating therapy to guide definitive treatment 1
• Initial empirical therapy should be tailored based on local resistance patterns and subsequently adjusted according to culture results 1
• Escherichia coli is the most common pathogen (75-95%), with occasional other Enterobacteriaceae such as Proteus mirabilis and Klebsiella pneumoniae 1

Outpatient Treatment Options

First-line options:

• Fluoroquinolones (in areas with <10% resistance):
  • 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

When local fluoroquinolone resistance exceeds 10%:

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

Alternative oral options:

• Trimethoprim-Sulfamethoxazole (TMP-SMX) 160/800 mg (double-strength) twice daily for 14 days if the pathogen is known to be susceptible 1
• Oral β-lactams can be used if the pathogen is susceptible, but they are generally less effective than other available agents 1, 3

Inpatient Treatment Options

• For patients requiring hospitalization, initial IV antimicrobial regimens include:
  • Fluoroquinolones 1
  • Aminoglycosides with or without ampicillin 1
  • Extended-spectrum cephalosporins (e.g., ceftriaxone) 1, 4
  • Extended-spectrum penicillins, with or without aminoglycoside 1
  • Carbapenems 1

Treatment Duration

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

Special Populations

Patients with sepsis or risk of multidrug-resistant organisms:

• Use antibiotics with activity against extended-spectrum beta-lactamase-producing organisms 5

Elderly patients:

• Monitor closely for adverse effects, particularly with aminoglycosides and fluoroquinolones 1

Pregnant patients:

• Require admission and initial parenteral therapy due to significantly elevated risk of severe complications 5

Monitoring and Follow-up

• Most patients respond to appropriate therapy within 48-72 hours 5
• If no improvement occurs within this timeframe, consider:
  • Imaging studies 5
  • Repeat cultures 5
  • Alternative diagnoses 5
  • Presence of urinary tract obstruction requiring urgent decompression 5

Common Pitfalls to Avoid

• Failing to obtain urine cultures before initiating antibiotics 1
• Not considering local resistance patterns when selecting empiric therapy 1, 6
• Using fluoroquinolones empirically in areas with >10% resistance without adding an initial dose of a parenteral agent 1, 6
• 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
• Using broader-spectrum antibiotics than necessary, which contributes to increasing resistance rates 6