What is the treatment for pyelonephritis (infection of the kidney)?

From the Guidelines

Treatment of pyelonephritis should prioritize the use of fluoroquinolones or cephalosporins as the first-line empiric therapy, with adjustments based on culture results and local resistance patterns, as recommended by the European Association of Urology guidelines in 2024 1. The choice of antibiotic regimen depends on the severity of the disease, patient factors, and local resistance patterns.

• For uncomplicated pyelonephritis, oral fluoroquinolones like ciprofloxacin (500mg twice daily for 7 days) or levofloxacin (750mg once daily for 5-7 days) are commonly used, as they achieve high concentrations in the urinary tract and have a broad spectrum of activity against common uropathogens, including E. coli 1.
• Alternative options include trimethoprim-sulfamethoxazole (160/800mg twice daily for 14 days) or an oral beta-lactam plus an aminoglyroside, although their use may be limited by resistance patterns and side effects 1.
• For hospitalized patients with complicated pyelonephritis, intravenous antibiotics are recommended, such as ceftriaxone (1-2g daily), ampicillin plus gentamicin, or a fluoroquinolone, with the choice of agent based on local resistance data and susceptibility results 1.
• Supportive care includes adequate hydration, fever control with acetaminophen or NSAIDs, and pain management, with patients following up after treatment to ensure resolution of infection and prevent complications like sepsis or renal abscess 1. Key considerations in the treatment of pyelonephritis include:
• Prompt differentiation between uncomplicated and potentially obstructive pyelonephritis to prevent progression to urosepsis 1
• Use of urine culture and susceptibility testing to guide antibiotic therapy and adjust treatment as needed 1
• Consideration of local resistance patterns and adjustment of antibiotic therapy accordingly 1
• Use of imaging techniques, such as ultrasound or CT scans, to evaluate the upper urinary tract and rule out complications like urinary tract obstruction or renal stone disease 1.

From the FDA Drug Label

1. 11 Acute Pyelonephritis: 5 or 10 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia [see Clinical Studies (14.7,14.8)].

2. 7 Complicated Urinary Tract Infections and Acute Pyelonephritis: 5 Day Treatment Regimen To evaluate the safety and efficacy of the higher dose and shorter course of levofloxacin, 1109 patients with cUTI and AP were enrolled in a randomized, double-blind, multicenter clinical trial conducted in the U.S. from November 2004 to April 2006 comparing levofloxacin 750 mg I. V. or orally once daily for 5 days (546 patients) with ciprofloxacin 400 mg I. V. or 500 mg orally twice daily for 10 days (563 patients).

3. 8 Complicated Urinary Tract Infections and Acute Pyelonephritis: 10 Day Treatment Regimen To evaluate the safety and efficacy of the 250 mg dose, 10 day regimen of levofloxacin, 567 patients with uncomplicated UTI, mild-to-moderate cUTI, and mild-to-moderate AP were enrolled in a randomized, double-blind, multicenter clinical trial conducted in the U. S. from June 1993 to January 1995 comparing levofloxacin 250 mg orally once daily for 10 days (285 patients) with ciprofloxacin 500 mg orally twice daily for 10 days (282 patients).

Treatment of Pyelonephritis:

• Levofloxacin is indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia.
• The recommended treatment regimens are 5 or 10 days.
• The dosage for the 5-day treatment regimen is 750 mg orally once daily 2.
• The dosage for the 10-day treatment regimen is 250 mg orally once daily 2.
• Clinical studies have demonstrated the efficacy of levofloxacin in the treatment of acute pyelonephritis, with bacteriologic cure rates and clinical success rates comparable to those of ciprofloxacin 2 2.

From the Research

Treatment Options for Pyelonephritis

• The treatment of pyelonephritis typically involves antibiotic therapy, with the choice of antibiotic depending on the severity of the infection and the patient's overall health 3, 4.
• For mild uncomplicated pyelonephritis, outpatient oral antibiotic therapy with a fluoroquinolone, such as ciprofloxacin or levofloxacin, is often effective 3, 4.
• Other effective alternatives for mild uncomplicated pyelonephritis include extended-spectrum penicillins, amoxicillin-clavulanate potassium, cephalosporins, and trimethoprim-sulfamethoxazole 3.
• For more severe infections, including those that are complicated or occur in hospitalized patients, intravenous antibiotic therapy may be necessary, with options including fluoroquinolones, aminoglycosides, and third-generation cephalosporins 3, 4.

Duration of Antibiotic Therapy

• The standard duration of antibiotic therapy for pyelonephritis is typically 7-14 days 3.
• However, some studies have suggested that shorter courses of antibiotic therapy, such as 7 days, may be effective for uncomplicated pyelonephritis 5, 6.
• A systematic review of randomized controlled trials found that short-course antibiotic treatment was at least as effective as longer courses for both microbiological and clinical success in the treatment of acute uncomplicated pyelonephritis 6.

Considerations for Antibiotic Resistance

• The increasing prevalence of antibiotic-resistant bacteria, including Escherichia coli, is a concern in the treatment of pyelonephritis 4.
• The use of broad-spectrum antibiotics should be reserved for severe or complicated infections, and narrower-spectrum antibiotics should be used whenever possible to minimize the risk of resistance 4.
• Antibiotic therapy should be adjusted based on the results of antimicrobial susceptibility testing to ensure that the most effective antibiotic is being used 3, 4.