From the Guidelines
Pyelonephritis treatment should start with empiric antibiotic coverage, prioritizing fluoroquinolones or cephalosporins, and adjusting based on urine culture results and local resistance patterns, as recommended by the most recent guidelines 1.
Treatment Approach
The treatment approach for pyelonephritis depends on the severity of the illness and local resistance patterns. For uncomplicated cases, oral fluoroquinolones like ciprofloxacin (500mg twice daily for 7 days) or levofloxacin (750mg daily for 5-7 days) are effective first-line options, as they achieve high urinary concentrations and have a broad spectrum of activity against common uropathogens 1.
Hospitalization and Intravenous Therapy
For more severe cases requiring hospitalization, intravenous options include a fluoroquinolone, an aminoglycoside (with or without ampicillin), or an extended-spectrum cephalosporin or penicillin, with the choice based on local resistance patterns and optimized according to culture results 1.
Duration of Therapy
The duration of therapy should be tailored to the individual case, with a short outpatient course of antibiotic treatment being equivalent to longer therapy durations in terms of clinical and microbiological success, but associated with a higher recurrence rate within 4-6 weeks 1.
Key Considerations
- Urine culture and antimicrobial susceptibility testing should be performed in all cases of pyelonephritis to guide antibiotic therapy 1.
- Evaluation of the upper urinary tract via ultrasound should be performed to rule out urinary tract obstruction or renal stone disease in patients with a history of urolithiasis, renal function disturbances, or a high urine pH 1.
- Patients should complete the full antibiotic course even if symptoms improve quickly to prevent recurrence and antibiotic resistance.
- Fever and flank pain typically improve within 48-72 hours of starting appropriate antibiotics, and further evaluation for complications like abscess formation or obstruction may be necessary if symptoms persist beyond this timeframe.
From the FDA Drug Label
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)].
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).
The treatment for pyelonephritis is levofloxacin 750 mg orally once daily for 5 days or levofloxacin 250 mg orally once daily for 10 days.
- The 5-day treatment regimen is used for complicated urinary tract infections and acute pyelonephritis.
- The 10-day treatment regimen is used for mild-to-moderate complicated urinary tract infections and acute pyelonephritis. The bacteriologic cure rates overall for levofloxacin at the test-of-cure visit were summarized in Tables 20 and 22 2, 2, 2.
From the Research
Treatment Options for Pyelonephritis
- Levofloxacin is a fluoroquinolone antibacterial agent that has been used to treat pyelonephritis, with satisfactory bacterial eradication rates and clinical success across all available trials 3.
- High-dose (750 mg) orally administered levofloxacin over a short 5-day course is a reasonable option for patients eligible for outpatient management 3.
- However, levofloxacin is no longer a suitable option for first-line empirical treatment of pyelonephritis in areas where resistance rates are high (> 10%) when pyelonephritis is hospital-acquired 3.
Alternative Treatment Options
- Cephalosporins, such as cefazolin, cephalexin, cefuroxime, cefotaxime, cefdinir, cefditoren, and ceftriaxone, may be viable treatment options for the management of uncomplicated pyelonephritis 4.
- Antibiotics targeted toward Escherichia coli, Proteus, Klebsiella, and Staphylococcus saprophyticus are recommended for the treatment of pyelonephritis 5.
- The duration of treatment varies by specific drug and type of infection, ranging from 3 to 5 days for uncomplicated cystitis to 7 to 14 days for pyelonephritis 5.
Considerations for Treatment
- Efforts to promote fluoroquinolone-sparing agents should be encouraged, and prescription should be performed in compliance with antimicrobial guidelines 3.
- Urine culture is recommended for the diagnosis and management of pyelonephritis, recurrent urinary tract infection, and complicated urinary tract infections 5.
- The choice of treatment should be based on the severity of the infection, the presence of underlying medical conditions, and the susceptibility of the causative organism to antibiotics 5, 4.