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%. 1

Initial Assessment and Management

• Always obtain urine culture and susceptibility testing before initiating therapy to guide definitive treatment 1
• Initial empirical therapy should be based on local resistance patterns and adjusted according to culture results 1
• Escherichia coli is the most common causative organism (75-95%), followed by other Enterobacteriaceae such as Proteus mirabilis and Klebsiella pneumoniae 1

Outpatient Treatment Options

• For areas with fluoroquinolone resistance <10%:

  • Ciprofloxacin 500 mg twice daily for 7 days 1
  • Extended-release ciprofloxacin 1000 mg 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 a long-acting parenteral antimicrobial (ceftriaxone 1g or an aminoglycoside) followed by oral therapy 1
  • 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
  • Extended-spectrum penicillins with or without aminoglycosides 1
  • Carbapenems 1

• 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 (levofloxacin 750 mg for 5 days, ciprofloxacin for 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 patients: Should be admitted and treated initially with parenteral therapy due to significantly elevated risk of severe complications 3

Step-Down Therapy

• Once clinical improvement occurs, patients can be switched from IV to oral therapy 1
• Oral β-lactams are less effective than other available agents but can be used if the pathogen is susceptible 1

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

Treatment Response

• Most patients respond to appropriate management within 48 to 72 hours 3
• If no improvement occurs within this timeframe, consider:
  • Repeat urine cultures 3
  • Imaging studies to rule out complications 3
  • Possible urinary tract obstruction requiring urgent decompression 3
  • Alternative diagnoses 3