What is the antibiotic of choice for pyelonephritis in a patient with a nephrostomy (nephrostomy tube)?

From the Guidelines

For pyelonephritis in a patient with a nephrostomy tube, empiric antibiotic therapy should include intravenous ceftriaxone 1-2g daily, piperacillin-tazobactam 3.375g every 6 hours, or a fluoroquinolone such as ciprofloxacin 400mg every 12 hours if local resistance rates are low, as recommended by the European Association of Urology guidelines 1. The presence of a nephrostomy tube increases the risk of resistant organisms, particularly Pseudomonas aeruginosa and other gram-negative bacteria, so broader coverage is often warranted initially. Some key points to consider in the management of pyelonephritis in patients with a nephrostomy tube include:

• Treatment should be adjusted based on urine culture results from both the nephrostomy tube and voided urine if possible, to ensure the chosen antibiotic is effective against the causative organism 1.
• Duration of therapy typically ranges from 10-14 days, with potential conversion to oral antibiotics after clinical improvement, although patients with nephrostomy tubes may require longer treatment courses due to biofilm formation on the tube surface 1.
• The nephrostomy tube may need replacement if infection persists despite appropriate antibiotic therapy, as bacteria can colonize the tube material 1.
• Adequate hydration and ensuring proper nephrostomy tube function are essential adjunctive measures to antibiotic therapy, to help prevent further complications and promote recovery 1.
• Patients should be monitored closely for clinical improvement, with follow-up urine cultures to confirm resolution of infection, and adjustments to the treatment plan made as necessary to ensure the best possible outcome 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)].

The antibiotic choice for pyelonephritis in a patient with a nephrostomy tube is levofloxacin.

• Key points:
  • The patient has a nephrostomy tube, but the label does not specifically address the use of levofloxacin in patients with nephrostomy tubes.
  • The label indicates that levofloxacin is effective for the treatment of acute pyelonephritis caused by Escherichia coli.
  • The use of levofloxacin in this patient should be based on clinical judgment, taking into account the potential benefits and risks of treatment 2.

From the Research

Antibiotic Choice for Pyelonephritis in Patients with Nephrostomy Tube

• The choice of antibiotic for pyelonephritis in patients with a nephrostomy tube is crucial to prevent further complications 3.
• A study published in 2022 compared the effectiveness of cefepime/enmetazobactam and piperacillin/tazobactam in treating complicated urinary tract infections or acute pyelonephritis, and found that cefepime/enmetazobactam was superior in achieving clinical cure and microbiological eradication 4.
• Another study from 1989 investigated the use of antibiotics in preventing bacteremia during nephrostomy tube changes, but found that prophylactic antibiotics were not effective in preventing transient bacteremia 5.
• A systematic review published in 2020 highlighted the importance of nephrostomy urine cultures in guiding antimicrobial treatment and preventing infection or pyelonephritis 6.

Considerations for Antibiotic Selection

• The selection of antibiotics should be based on the results of nephrostomy urine cultures, as well as the patient's medical history and risk factors for infection 6.
• Patients with a history of urinary tract infection or neutropenia may be at higher risk for developing pyelonephritis, and may require more aggressive antibiotic treatment 3.
• The use of nephrostomy tubes can lead to subsequent urosepsis, emphasizing the need for careful antibiotic selection and monitoring 6.

Clinical Implications

• The results of these studies suggest that cefepime/enmetazobactam may be a suitable option for treating pyelonephritis in patients with a nephrostomy tube, particularly in cases where gram-negative pathogens are suspected 4.
• However, further research is needed to determine the optimal antibiotic regimen for these patients, and to develop effective strategies for preventing infection and promoting antimicrobial stewardship 4, 6.