Pyelonephritis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Overview

All patients with pyelonephritis should be treated empirically with antimicrobial therapy. Mild pyelonephritis may be managed with oral antimicrobial therapy, and an initial intravenous dose may be administered depending on local resistance patterns. Patients with dehydration, nausea, vomiting, or signs of sepsis should be admitted and should receive parenteral therapy. Medical therapies for pyelonephritis include fluoroquinolones, TMP-SMX, β-lactams, and aminoglycosides.

Medical Therapy

The medical therapy for pyelonephritis includes a few important aspects:[1]

  • All patients with pyelonephritis should be treated empirically with antimicrobial therapy.
  • Before initiating antimicrobial treatment for suspected pyelonephritis, a urine culture and susceptibility test should always be performed.
  • Mild pyelonephritis may be managed with oral antimicrobial therapy, and an initial intravenous dose may be administered depending on local resistance patterns. Patients with dehydration, nausea, vomiting, or signs of sepsis should be admitted and should receive parenteral therapy.[2]
  • Optimal management depends on the severity of illness at presentation, regional resistance data, and host factors.
  • When local resistance patterns are unknown, an initial intravenous (IV) dose of a long-acting, broad-spectrum antimicrobial agent may be considered.
  • Oral beta-lactams are less effective than either trimethoprim-sulfamethoxazole, fluoroquinolones, or aminoglycosides in eradicating uropathogens.
  • Uncomplicated pyelonephritis due to MRSA is uncommon, and there is insufficient evidence to support empiric use of an MRSA-active agent.
  • Pregnant women, patients who failed to respond to oral therapy, and patients with nausea, vomiting, high fever, marked leukocytosis, or dehydration should be hospitalized and managed with parenteral antibiotics.[3]

Antimicrobial Therapy

As a broader rule, antibiotics are started only after the sample has been drawn for culture. Uncomplicated pyelonephritis is treated with specific and short duration (5 to 14 days) of antibiotics while complicated pyelonephritis is treated with broad spectrum and longer duration (at least 14-21 days) of antibiotics. In hospitalized cases, treatment with IV until patient is 24-48 hours afebrile is recommended; following this treatment, a 2 week course of PO regimen for uncomplicated pyelonephritis is also recommended.[4]

  • Pyelonephritis empiric therapy
  • Outpatient treatment
  • Inpatient treatment[5]
  • Pathogen-directed therapy[5]
  • Gram positive cocci
  • Preferred regimen:ampicillin-sulbactam with or without an aminoglycoside if a gram positive cocci is the casitive organism.[3]
  • Enterococcus spp.[5]
  • Preferred regimen: Ampicillin 2 g IV q6h for 10-14 days AND Gentamicin 3-5 mg/kg/day IV q8h for 10-14 days
  • Specific considerations
  • Pregnancy and other cases of complicated pyelonephritis

In event of a pregnancy the treatment of pyelonephritis ha stop be done in an in patient setting due to higher and severe complications risks. Intravenous antibiotics should be given for the initial 1-2 days at least until the patient is not febrile and then continued on oral therapy for 10-14 days.

  • Pyelonephritis empiric therapy
  • Catheter Associated UTIs
  • Urinary infections in catheterized patients tend to be polymicrobial with more resistant uropathogens.
  • Urine culture: should be taken before initiation the antimicrobial therapy.[8] For infected patients with indwelling catheters more than 2 weeks, the catheter should be replaced, and urine culture should be sampled from the new catheter to improve the out come of treatment with less complications.[9]
  • Regimen : TMP-SMX DS 1 tab bid x 3 days
  • Duration of treatment
  • Depends on the response to treatment regardless of the catheter is still placed or not. For quick resolution, a 7 days regimen is recommended. While delayed clinical improvement needs extended regimen (10-14 days).[10]
  • For mild catheter associated UTI, levofloxacin for 5 days is recommended. While 3 days regimen of antimicrobials is recommended for women≤65 with lower urinary symptoms only after catheter removal.[11]

Followup Urinalysis

References

  1. Ramakrishnan K, Scheid DC (2005). "Diagnosis and management of acute pyelonephritis in adults". Am Fam Physician. 71 (5): 933–42. PMID 15768623.
  2. Gupta, K.; Hooton, TM.; Naber, KG.; Wullt, B.; Colgan, R.; Miller, LG.; Moran, GJ.; Nicolle, LE.; Raz, R. (2011). "International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 up date by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases". Clin Infect Dis. 52 (5): e103–20. doi:10.1093/cid/ciq257. PMID 21292654. Unknown parameter |month= ignored (help); line feed character in |title= at position 132 (help)
  3. 3.0 3.1 Warren, JW.; Abrutyn, E.; Hebel, JR.; Johnson, JR.; Schaeffer, AJ.; Stamm, WE. (1999). "Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA)". Clin Infect Dis. 29 (4): 745–58. doi:10.1086/520427. PMID 10589881. Unknown parameter |month= ignored (help)
  4. Hooton TM (2012). "Clinical practice. Uncomplicated urinary tract infection". N Engl J Med. 366 (11): 1028–37. doi:10.1056/NEJMcp1104429. PMID 22417256.
  5. 5.0 5.1 5.2 Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG; et al. (2011). "International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases". Clin Infect Dis. 52 (5): e103–20. doi:10.1093/cid/ciq257. PMID 21292654.
  6. D. A. Wing, C. M. Hendershott, L. Debuque & L. K. Millar (1999). "Outpatient treatment of acute pyelonephritis in pregnancy after 24 weeks". Obstetrics and gynecology. 94 (5 Pt 1): 683–688. PMID 10546710. Unknown parameter |month= ignored (help)
  7. D. A. Wing, C. M. Hendershott, L. Debuque & L. K. Millar (1998). "A randomized trial of three antibiotic regimens for the treatment of pyelonephritis in pregnancy". Obstetrics and gynecology. 92 (2): 249–253. PMID 9699761. Unknown parameter |month= ignored (help)
  8. Nicolle, LE. (2001). "A practical guide to antimicrobial management of complicated urinary tract infection". Drugs Aging. 18 (4): 243–54. PMID 11341472.
  9. Raz, R.; Schiller, D.; Nicolle, LE. (2000). "Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection". J Urol. 164 (4): 1254–8. PMID 10992375. Unknown parameter |month= ignored (help)
  10. "The prevention and management of urinary tract infections among people with spinal cord injuries. National Institute on Disability and Rehabilitation Research Consensus Statement. January 27-29, 1992". J Am Paraplegia Soc. 15 (3): 194–204. 1992. PMID 1500945. Unknown parameter |month= ignored (help)
  11. Mohler, JL.; Cowen, DL.; Flanigan, RC. (1987). "Suppression and treatment of urinary tract infection in patients with an intermittently catheterized neurogenic bladder". J Urol. 138 (2): 336–40. PMID 3496470. Unknown parameter |month= ignored (help)
  12. T. F. Patterson & V. T. Andriole (1997). "Detection, significance, and therapy of bacteriuria in pregnancy. Update in the managed health care era". Infectious disease clinics of North America. 11 (3): 593–608. PMID 9378925. Unknown parameter |month= ignored (help)

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