From the Guidelines
Outpatient treatment for uncomplicated pyelonephritis typically involves oral antibiotics for 7-14 days, with first-line therapy being fluoroquinolones such as ciprofloxacin 500mg twice daily or levofloxacin 750mg once daily for 5-7 days, as recommended by the most recent guidelines 1. The choice of antibiotic should be based on the susceptibility of the infecting organism and the prevalence of resistance in the community.
- For areas with low fluoroquinolone resistance (<10%), fluoroquinolones are a suitable choice.
- For areas with high fluoroquinolone resistance (>10%), consider trimethoprim-sulfamethoxazole (TMP-SMX) 160/800mg twice daily for 14 days if the pathogen is known to be susceptible. Alternative options include ceftriaxone 1-2g IV as a single dose followed by oral cephalexin 500mg four times daily for 14 days, or amoxicillin-clavulanate 875/125mg twice daily for 14 days, as suggested by previous studies 1. Patients should increase fluid intake, take analgesics for pain/fever such as acetaminophen, and follow up within 48-72 hours to ensure clinical improvement. If symptoms worsen, fever persists beyond 72 hours, or the patient develops nausea/vomiting preventing oral medication intake, immediate reevaluation is necessary as hospitalization may be required. Antibiotic selection targets the most common causative organism, Escherichia coli, while providing adequate renal tissue penetration to effectively treat the infection in the kidney parenchyma, as highlighted in recent guidelines 1.
From the FDA Drug Label
14.7 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).
Outpatient treatment for pyelonephritis can be done with levofloxacin 750 mg orally once daily for 5 days 2.
- The bacteriologic cure rates for levofloxacin in the treatment of acute pyelonephritis are presented in Table 20 and Table 21.
- It is essential to note that patients with AP complicated by underlying renal diseases or conditions were excluded from the study.
- The study compared levofloxacin with ciprofloxacin and found that levofloxacin is effective in the treatment of acute pyelonephritis.
From the Research
Outpatient Treatment for Pyelonephritis
- The optimal antimicrobial regimen and treatment duration for acute uncomplicated pyelonephritis are unknown 3.
- A 7-day ciprofloxacin regimen was associated with greater bacteriologic and clinical cure rates than a 14-day trimethoprim-sulfamethoxazole regimen, especially in patients infected with trimethoprim-sulfamethoxazole-resistant strains 3.
- Oral cephalosporins may be a viable alternative to first-line agents such as fluoroquinolones and trimethoprim-sulfamethoxazole for the treatment of acute pyelonephritis in the outpatient setting 4, 5.
- Cephalosporins displayed effectiveness for the treatment of acute uncomplicated pyelonephritis regardless of study design or the presence of a comparison group 6.
- The clinical success of outpatient treatment of pyelonephritis by cefaclor, ciprofloxacin, and norfloxacin at 4 to 6 weeks was comparable at between 83 to 95% 7.
Comparison of Antibiotics
- Ciprofloxacin and trimethoprim-sulfamethoxazole are commonly used first-line agents for acute pyelonephritis, but resistance rates are increasing 3, 4.
- Cephalosporins, such as cefazolin, cephalexin, and cefdinir, may be effective alternatives to first-line agents 5, 6.
- Norfloxacin and cefaclor may also be considered for outpatient treatment of pyelonephritis in adults 7.
Treatment Outcomes
- Bacteriologic cure rates were 99% for the ciprofloxacin regimen and 89% for the trimethoprim-sulfamethoxazole regimen at 4 to 11 days posttherapy 3.
- Clinical cure rates were 96% for the ciprofloxacin regimen and 83% for the trimethoprim-sulfamethoxazole regimen at 4 to 11 days posttherapy 3.
- UTI recurrence rates were similar between oral cephalosporins and first-line agents at 30 days 4.