What is the treatment for pyelitis?

Treatment of Pyelonephritis (Pyelitis)

For uncomplicated pyelonephritis, treat with fluoroquinolones for 5-7 days (ciprofloxacin 500-750 mg twice daily or levofloxacin 750 mg daily) or trimethoprim-sulfamethoxazole for 14 days (160/800 mg twice daily) based on antibiotic susceptibility testing. 1

Outpatient Oral Treatment (Mild Cases)

Fluoroquinolones are the preferred first-line agents for outpatient management:

• Ciprofloxacin 500-750 mg twice daily for 7 days (can be shortened to 5 days with clinical cure rates >93%) 1, 2
• Levofloxacin 750 mg once daily for 5 days 1, 2
• Fluoroquinolones should only be used when local resistance is <10% 1

Alternative oral agents when susceptibility is confirmed:

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days - requires culture confirmation due to high resistance rates (clinical cure 92% in susceptible strains) 1, 2
• Cefpodoxime 200 mg twice daily for 10 days or Ceftibuten 400 mg daily for 10 days 1
• If oral cephalosporins are used empirically, administer an initial IV dose of ceftriaxone 1-2g 1, 2

Inpatient Intravenous Treatment (Severe Cases)

Patients requiring hospitalization should receive initial IV therapy:

• Ciprofloxacin 400 mg twice daily IV or Levofloxacin 750 mg daily IV 1
• Ceftriaxone 1-2 g daily or Cefotaxime 2 g three times daily 1
• Cefepime 1-2 g twice daily 1
• Piperacillin/tazobactam 2.5-4.5 g three times daily 1
• Aminoglycosides (Gentamicin 5 mg/kg daily or Amikacin 15 mg/kg daily) with or without ampicillin 1

Reserve carbapenems and novel broad-spectrum agents only for confirmed multidrug-resistant organisms:

• Imipenem/cilastatin, Meropenem, Ceftolozane/tazobactam, Ceftazidime/avibactam 1

Indications for Hospitalization

Admit patients with:

• Complicated infections (obstruction, anatomic abnormalities) 3
• Sepsis or hemodynamic instability 3, 4
• Persistent vomiting preventing oral intake 3
• Failed outpatient treatment 3
• Extremes of age or immunosuppression 3

Essential Diagnostic Steps

Always obtain urine culture and susceptibility testing before initiating antibiotics (positive in 90% of cases) 2, 3

Imaging is critical when:

• Patient remains febrile after 72 hours of appropriate antibiotics 1
• Clinical deterioration occurs 1
• Suspicion of obstruction or abscess 1, 4
• CT scan is the gold standard for detecting complications including emphysematous pyelitis 4

Critical Pitfalls to Avoid

Do not use TMP-SMX empirically without culture confirmation - resistance rates are high (18.4% in studies), leading to treatment failure 1, 2

Avoid nitrofurantoin, oral fosfomycin, and pivmecillinam for pyelonephritis - insufficient data on efficacy for upper tract infections 1, 2

Do not underdose fluoroquinolones - use pyelonephritis doses (ciprofloxacin 500-750 mg twice daily), not cystitis doses 2

Insufficient data exist for oral β-lactams as monotherapy - they achieve lower blood/urinary concentrations than IV formulations 1

Follow-Up and Treatment Failure

Repeat urine culture 1-2 weeks after completing antibiotics 2, 3

If no clinical improvement after 72 hours:

• Obtain repeat blood and urine cultures 3
• Perform imaging (CT scan) to identify obstruction, abscess, or anatomic abnormalities 1, 3
• Consider resistant organisms, immunosuppression, or need for surgical intervention 3

Note: Shorter antibiotic courses are associated with higher recurrence rates within 4-6 weeks but equivalent clinical cure rates, so tailor duration to local resistance patterns and patient risk factors 1