What is the duration of treatment for acute pyelonephritis (infection of the kidney)?

From the Guidelines

The recommended duration of treatment for uncomplicated pyelonephritis is typically 5-7 days, depending on the severity of infection and the antibiotic used, as recent studies have shown that shorter courses of fluoroquinolones are noninferior to longer courses 1. For mild to moderate cases, fluoroquinolones like ciprofloxacin (500mg twice daily) or levofloxacin (750mg once daily) are often prescribed for 5-7 days. Some key points to consider when treating pyelonephritis include:

• The choice of antibiotic should be based on local resistance patterns and susceptibility testing, with fluoroquinolones and cephalosporins being the only recommended oral empiric treatments for uncomplicated pyelonephritis 1.
• Patients with uncomplicated pyelonephritis requiring hospitalization should be treated initially with an intravenous antimicrobial regimen, such as a fluoroquinolone, an aminoglycoside, or an extended-spectrum cephalosporin or penicillin 1.
• Complicated pyelonephritis cases, including those with structural abnormalities, immunocompromised patients, or pregnancy, typically require longer treatment durations, often 14-21 days 1.
• Patients should complete the full course of antibiotics even if symptoms improve quickly, drink plenty of fluids, and follow up with their healthcare provider to ensure resolution of the infection. The European Association of Urology guidelines recommend a short outpatient course of antibiotic treatment for acute pyelonephritis, which is equivalent to longer therapy durations in terms of clinical and microbiological success, but may be associated with a higher recurrence rate within 4-6 weeks 1. Overall, the treatment duration for pyelonephritis should be individualized based on the severity of the infection, the patient's underlying health status, and the antibiotic used, with a focus on minimizing the risk of antibiotic resistance and optimizing clinical outcomes 1.

From the FDA Drug Label

1. 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)].
2. 7 Complicated Urinary Tract Infections and Acute Pyelonephritis: 5 Day Treatment Regimen
3. 8 Complicated Urinary Tract Infections and Acute Pyelonephritis: 10 Day Treatment Regimen

The duration of treatment for pyelonephritis with levofloxacin is 5 or 10 days 2 2.

• The 5-day treatment regimen is mentioned in section 14.7 of the drug label 2.
• The 10-day treatment regimen is mentioned in section 14.8 of the drug label 2.

From the Research

Duration of Treatment for Pyelonephritis

• The optimal duration of antibiotic treatment for pyelonephritis is a topic of ongoing research and debate 3, 4, 5, 6.
• A study published in 2017 found that a 7-day course of trimethoprim-sulfamethoxazole (TMP-SMX) may be as effective as a 7-day course of ciprofloxacin for the treatment of pyelonephritis 4.
• A systematic review and meta-analysis published in 2021 found that short-course antibiotic treatment (7-14 days) is at least as effective as long-course treatment (14-42 days) for acute uncomplicated pyelonephritis 5.
• A meta-analysis published in 2008 found no significant differences in clinical success, bacteriologic efficacy, relapse, and adverse events between short-course and long-course treatment with the same antibiotic regimen 6.
• A systematic review published in 2023 found that cephalosporins may be viable treatment options for the management of uncomplicated pyelonephritis, with no trials reporting inferiority of clinical treatment outcomes compared to fluoroquinolones or SMX-TMP 7.

Treatment Options

• Oral fluoroquinolones (ciprofloxacin or ofloxacin) and injectable third-generation cephalosporins (ceftriaxone) are commonly used empirical antibiotic treatments for acute uncomplicated pyelonephritis 3.
• TMP-SMX is also a recommended treatment option, particularly for patients with suspected or confirmed E. coli infection 4.
• Cephalosporins, including cefazolin, cephalexin, and ceftriaxone, may be effective alternatives for the treatment of uncomplicated pyelonephritis 7.

Considerations

• The choice of antibiotic treatment should take into account the patient's medical history, allergy status, and potential for antibiotic resistance 3, 4, 5.
• The duration of treatment should be individualized based on the patient's response to therapy and the presence of any underlying medical conditions 5, 6.
• Further research is needed to determine the optimal duration of antibiotic treatment for pyelonephritis and to identify the most effective treatment options for this condition 3, 4, 5, 6, 7.