From the Guidelines
The recommended dose of levofloxacin for pyelonephritis is 750 mg once daily for 5 days, as supported by the most recent and highest quality study 1. This dose is preferred due to its ability to achieve better urinary tract penetration and potentially lead to faster clinical improvement.
Key Considerations
- For patients with normal renal function, no dose adjustment is needed.
- However, dose reduction is necessary for patients with impaired renal function:
- For creatinine clearance 20-49 mL/min, use 750 mg every 48 hours;
- For clearance 10-19 mL/min, use 750 mg initially followed by 500 mg every 48 hours.
- Levofloxacin is effective against most uropathogens, including E. coli, which causes approximately 80% of uncomplicated pyelonephritis cases.
- Before starting therapy, obtain urine cultures to confirm the diagnosis and ensure pathogen susceptibility, as fluoroquinolone resistance is increasing in many regions 1.
- Ensure adequate hydration during treatment and monitor for potential side effects, including tendinopathy, QT prolongation, and CNS effects.
Treatment Duration
The treatment duration for pyelonephritis with levofloxacin is typically 5-7 days, but this may vary depending on the severity of the infection and the patient's response to treatment 1.
Resistance Considerations
If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone or a consolidated 24-h dose of an aminoglycoside, is recommended 1.
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 dose of levofloxacin for acute pyelonephritis is 750 mg orally once daily for 5 days or 250 mg orally once daily for 10 days 2, 2, 2.
- Key points:
- The 5-day treatment regimen uses a higher dose of 750 mg.
- The 10-day treatment regimen uses a lower dose of 250 mg.
- Both regimens are effective for the treatment of acute pyelonephritis caused by Escherichia coli.
From the Research
Dosage of Levofloxacin for Pyelonephritis
- The dosage of levofloxacin for pyelonephritis is not explicitly stated in the study from 1992 3.
- A study from 2013 4 used a sequential therapy of pazufloxacin followed by oral fluoroquinolones, including levofloxacin 100 mg, three times a day for at least 5 days.
- In a study from 1998 5, levofloxacin was administered at a dose of 250 mg once daily.
- A review from 2013 6 mentions that high-dose (750 mg) orally administered levofloxacin over a short 5-day course is a reasonable option for patients eligible for outpatient management.
- A clinical trial from 2017 7 compared the efficacy and safety of short-course intravenous levofloxacin (750 mg/day) with a conventional intravenous/oral regimen of levofloxacin (500 mg/day) and found that the short-course therapy was non-inferior to the conventional therapy.