From the Guidelines
For treating pyelonephritis without fluoroquinolones, oral cephalosporins are recommended as a first-line alternative, as they achieve significantly lower blood and urinary concentrations than the intravenous route 1.
Treatment Options
- For patients not requiring hospitalization, oral cephalosporins can be used, with the option to initiate treatment with an intravenous antimicrobial regimen, such as an aminoglycoside (with or without ampicillin), or an extended-spectrum cephalosporin or penicillin, and then switch to oral therapy once the patient is stable 1.
- For patients with sulfa allergies or in areas with high resistance rates, ceftriaxone 1-2 g IV daily can be initiated, potentially followed by oral cephalexin 500 mg four times daily to complete 10-14 days of therapy.
- Amoxicillin-clavulanate 875/125 mg twice daily for 10-14 days is another viable option.
Hospitalized Patients
- For hospitalized patients, ampicillin plus gentamicin, or a single agent like ceftriaxone, cefepime, or piperacillin-tazobactam can be used.
Important Considerations
- Treatment selection should be guided by local resistance patterns and adjusted based on urine culture results.
- Adequate hydration and pain management with acetaminophen or NSAIDs are important supportive measures.
- These alternatives are effective because they target the common uropathogens like E. coli that cause most pyelonephritis cases, while avoiding fluoroquinolones which have increasing resistance rates and potential adverse effects including tendon damage and C. difficile infections.
Key Points
- The choice of antibiotic should be based on local resistance patterns and the severity of the infection.
- Urine culture and susceptibility testing should be performed to guide treatment.
- The use of fluoroquinolones should be avoided due to increasing resistance rates and potential adverse effects.
From the FDA Drug Label
Piperacillin and Tazobactam for Injection, USP is an injectable antibacterial combination product consisting of the semisynthetic antibacterial piperacillin sodium and the beta-lactamase inhibitor tazobactam sodium for intravenous administration.
Piperacillin-tazobactam can be used as an alternative to fluoroquinolones for the treatment of pyelonephritis.
- Key points:
- The drug label does not explicitly state its use for pyelonephritis.
- However, piperacillin-tazobactam has a broad spectrum of activity against gram-negative bacteria, which are common causes of pyelonephritis.
- The decision to use piperacillin-tazobactam for pyelonephritis should be based on local susceptibility patterns and clinical judgment 2.
From the Research
Treatment Options for Pyelonephritis without Fluoroquinolones
- Cephalosporins are a potential alternative for the treatment of pyelonephritis, especially in cases where fluoroquinolones are not suitable 3, 4, 5, 6, 7.
- Studies have shown that oral cephalosporins can be effective in treating pyelonephritis, with similar treatment failure rates compared to fluoroquinolones and trimethoprim/sulfamethoxazole (TMP-SMX) 5, 6.
- A systematic review found that cephalosporins displayed effectiveness for the treatment of acute uncomplicated pyelonephritis, regardless of study design or the presence of a comparison group 7.
- The use of cephalosporins may be particularly useful in areas with high resistance rates to fluoroquinolones and TMP-SMX 4, 5, 6.
Key Findings
- A study published in 2020 found that fluoroquinolones and TMP-SMX are effective oral antibiotics for pyelonephritis, but increasing resistance makes empiric use problematic 3.
- A 2018 study found that cephalosporins had a lower failure rate compared to fluoroquinolones and TMP-SMX in the treatment of pyelonephritis 4.
- A 2022 study found no significant difference in urinary tract infection (UTI) recurrence rates between oral cephalosporins and first-line agents in the treatment of acute pyelonephritis 5.
- A 2024 study found that oral cephalosporins were associated with similar treatment failure rates compared to Infectious Diseases Society of America guideline-endorsed treatments for the treatment of pyelonephritis in emergency department patients discharged home 6.
Considerations for Treatment
- Urine culture with antimicrobial susceptibility testing should be performed in all patients to direct therapy 3.
- Imaging, blood cultures, and measurement of serum inflammatory markers should not be performed in uncomplicated cases 3.
- Outpatient management is appropriate in patients who have uncomplicated disease and can tolerate oral therapy 3.
- Patients admitted to the hospital should receive parenteral antibiotic therapy, and those with sepsis or risk of infection with a multidrug-resistant organism should receive antibiotics with activity against extended-spectrum beta-lactamase-producing organisms 3.