What is a good medication for acute pyelonephritis (infection of the kidney)?

From the Guidelines

Ciprofloxacin is a good medication for pyelonephritis, typically prescribed at 500 mg orally twice daily for 7 days for uncomplicated cases. The choice of antibiotic depends on local resistance patterns and patient factors such as allergies and kidney function. According to the European Association of Urology guidelines, ciprofloxacin is an appropriate choice for empirical oral antimicrobial therapy for uncomplicated pyelonephritis, with a daily dose of 500-750 mg twice daily for 7 days 1. Alternative options include levofloxacin, trimethoprim-sulfamethoxazole, cefpodoxime, and ceftibuten.

Key Considerations

• The prevalence of fluoroquinolone resistance should be less than 10% for empirical use of ciprofloxacin or other fluoroquinolones 1.
• If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial intravenous dose of a long-acting parenteral antimicrobial, such as ceftriaxone, is recommended 1.
• Treatment should begin promptly after urine cultures are collected, and patients should complete the full course even if symptoms improve quickly.
• Patients should drink plenty of fluids during treatment and follow up to ensure the infection has cleared completely.

Recent Guidelines

The most recent guidelines from the European Association of Urology (2024) and the American College of Physicians (2021) support the use of short-course antibiotics for uncomplicated pyelonephritis, including fluoroquinolones and trimethoprim-sulfamethoxazole 1. However, the choice of antibiotic and duration of treatment should be individualized based on patient factors and local resistance patterns. Ciprofloxacin remains a good option for pyelonephritis, but its use should be guided by susceptibility testing and local resistance patterns.

From the FDA Drug Label

Dosing and initial route of therapy (i.e., I.V. or oral) for complicated urinary tract infection or pyelonephritis should be determined by the severity of the infection. In the clinical trial, pediatric patients with moderate to severe infection were initiated on 6 to 10 mg/kg I. V. every 8 hours and allowed to switch to oral therapy (10 to 20 mg/kg every 12 hours), at the discretion of the physician.

Ciprofloxacin can be used to treat pyelonephritis. The dosage may vary depending on the severity of the infection and the patient's age and renal function.

• For pediatric patients with moderate to severe infection, the initial dose is 6 to 10 mg/kg I.V. every 8 hours, which can be switched to oral therapy (10 to 20 mg/kg every 12 hours) at the discretion of the physician 2.
• The clinical success and bacteriologic eradication rates of ciprofloxacin in treating pyelonephritis are similar to those of the comparator group, with a clinical response rate of 95.7% and bacteriologic eradication rate of 84.4% 2.

From the Research

Medication Options for Pyelonephritis

• Aminoglycosides, amino- or carboxypenicillins, ureidopenicillins, fluoroquinolones, cephalosporins, monobactams, carbapenems, and the combination of trimethoprim plus a sulphonamide are potential bactericidal agents for the treatment of pyelonephritis 3.
• Ciprofloxacin, a fluoroquinolone, has been shown to be effective in treating acute uncomplicated pyelonephritis in women, with a 7-day course resulting in higher bacteriologic and clinical cure rates compared to a 14-day course of trimethoprim-sulfamethoxazole 4.
• Oral fluoroquinolones, such as ciprofloxacin and levofloxacin, are effective in treating acute uncomplicated pyelonephritis, with symptoms resolving within 5-7 days in about 96% of women 5.
• Injectable third-generation cephalosporins, such as ceftriaxone, are also effective against enterobacteria, including E. coli, and have good kidney penetration 5.
• Short-course antibiotic treatment has been shown to be at least as effective as long-course treatment for both microbiological and clinical success in the treatment of acute uncomplicated pyelonephritis 6.
• Oral antibiotics, such as cefaclor, ciprofloxacin, and norfloxacin, have been shown to be effective in treating pyelonephritis, with clinical success rates comparable to those of intravenous agents 7.

Considerations for Antibiotic Selection

• The selection of antibiotics for pyelonephritis should take into account the availability, antimicrobial spectrum, tolerance, and cost of the medication 3.
• The increasing resistance to oral antibiotics currently recommended for the treatment of pyelonephritis should be considered when selecting an antibiotic 5.
• The potential for adverse events, such as neuropsychiatric disorders, photosensitivity, tendon disorders, arrhythmia, and cardiac conduction disorders, should be considered when selecting a fluoroquinolone 5.
• The potential for hypersensitivity reactions and C. difficile infection should be considered when selecting a cephalosporin 5.