From the Guidelines
For uncomplicated pyelonephritis, I recommend starting with oral ciprofloxacin 500 mg twice daily for 7 days as first-line therapy. This recommendation is based on the most recent and highest quality study available, which suggests that fluoroquinolones and cephalosporins are the only antimicrobial agents that can be recommended for oral empiric treatment of uncomplicated pyelonephritis 1. The European Association of Urology guidelines on urological infections also support the use of fluoroquinolones, such as ciprofloxacin, as a first-line treatment for uncomplicated pyelonephritis 1.
Some key points to consider when treating pyelonephritis include:
- Urine culture and susceptibility testing should be performed in all cases of pyelonephritis to guide antibiotic therapy 1
- Local antibiotic resistance patterns should be considered when selecting therapy, as resistance to fluoroquinolones and other antibiotics is increasing in many regions 1
- Patients should complete the full course of antibiotics even if symptoms improve quickly, and drink plenty of fluids to help clear the infection
- Analgesics like acetaminophen can be used to manage pain and fever associated with pyelonephritis
For more severe cases requiring hospitalization, intravenous options include ceftriaxone 1-2 g daily, ampicillin plus gentamicin, or a carbapenem like ertapenem 1 g daily 1. Treatment should be adjusted based on urine culture results when available, and patients should be closely monitored for signs of improvement or deterioration.
It's worth noting that other antibiotics, such as trimethoprim-sulfamethoxazole (TMP-SMX), may be effective in some cases, but their use is limited by increasing resistance rates 1. Additionally, the use of fluoroquinolones, such as ciprofloxacin, is generally preferred due to their high urinary and renal tissue concentrations, which make them effective for kidney infections 1.
From the FDA Drug Label
Ciprofloxacin has been shown to be active against most strains of the following microorganisms, both in vitro and in clinical infections... Aerobic gram-negative microorganisms ...Escherichia coli
The recommended antibiotic for treatment of pyelonephritis is ciprofloxacin 2.
- Ciprofloxacin is active against Escherichia coli, a common cause of pyelonephritis.
- The drug label does not provide explicit dosing recommendations for pyelonephritis, but it does describe the drug's activity against E. coli.
From the Research
Treatment Options for Pyelonephritis
- Levofloxacin is a commonly used antibiotic for the treatment of pyelonephritis, with studies showing its efficacy in achieving microbiologic eradication and clinical success 3, 4, 5, 6, 7.
- The recommended dosage of levofloxacin for pyelonephritis is 750 mg once daily for 5 days, which has been shown to be as effective as a 10-day course of ciprofloxacin 3.
- Levofloxacin has been compared to other fluoroquinolones, such as ciprofloxacin and lomefloxacin, and has been found to have similar efficacy and safety profiles 4, 5.
Efficacy and Safety of Levofloxacin
- Studies have reported high microbiologic eradication rates with levofloxacin, ranging from 79.8% to 95.3% 5, 6.
- Clinical success rates with levofloxacin have been reported to range from 82.6% to 93% 5, 6.
- Levofloxacin has been found to be well tolerated, with common adverse events including headache, gastrointestinal effects, and dizziness 5, 7.
Considerations for Use
- The emergence of fluoroquinolone resistance has prompted re-examination of the use of levofloxacin for pyelonephritis, particularly in areas with high resistance rates (> 10%) 6, 7.
- Judicious use of levofloxacin and other fluoroquinolones, as well as careful implementation of infection control procedures, are recommended for the management of UTIs and pyelonephritis 7.