Pyelonephritis medical therapy: Difference between revisions

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*Before starting treatment for suspected pyelonephritis, a urine culture and susceptibility test should be done in order to select the empirical antimicrobial that covers the causing organism.
*Before starting treatment for suspected pyelonephritis, a urine culture and susceptibility test should be done in order to select the empirical antimicrobial that covers the causing organism.
== Empiric Therapy==
== Empiric Therapy==
===Uncomplicated Pyelonephritis===
 
====Out-Patient Treatment====
 
{|
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
| valign=top |
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Acute Pyelonephritis, Outpatient}}
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:25em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B| Acute Bacterial Uncomplicated Pyelonephritis}}''
|-
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Fluoroquinolones]] †'''''<br>'''''[[Ciprofloxacin]] 500 mg PO bid ×7 days<br>[[Levofloxacin]] 750 mg PO q24 × 5 days<br>[[Ofloxacin]] 400 mg PO bid<br>[[Moxifloxacin]] 400 mg PO q24h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 500 mg PO q12h for 7 days'''''
|-
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen (14 day regimen)''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | WITH OR WITHOUT
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[TMP-SMX]] ‡ 160/800 mg PO bid'''''<br>OR<br>'''''▸[[β-lactams]] ¿<br>[[Amoxicillin-clavulanate]]  875/125 mg PO q12h or 500/125 mg PO tid or 1000 /125 mg PO bid <br>[[Cefdinir]]  300 mg PO q12h or 600 mg po q24 <br>[[Cefaclor]] 250-500 mg PO q8h<br>[[Cefpodoxime proxetil|Cefpodoxime-proxetil]]  100-200 mg PO q12h<br>[[Cephalexin]] 250-500 mg PO q6h not studied well but effective.'''''  
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 400 mg IV x 1 dose'''''
|-
|-
|}
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|}
 
†It's optional to initiate oral [[fluoroquinolones]] therapy with 400 mg IV [[ciprofloxacin]]
†If the pathogen resistance to [[fluoroquinolones]] in the community is >10% or unknown, it's recommended to start an initial one-time intravenous dose of a long-acting parenteral antimicrobials like 1 g of [[ceftriaxone]] or a consolidated 24-h dose of an [[aminoglycoside]].<br>
‡If the pathogen susceptibility to [[TMP-SMX]] is unknown, It's recommended  to begin with an initial one-time intravenous dose of a long-acting parenteral antimicrobials like 1 g of [[ceftriaxone]] or a consolidated 24-h dose of an [[aminoglycoside]].<br>
¿It's recommended  to begin beta-lactams regimen with an initial one-time intravenous dose of a long-acting parenteral antimicrobials like 1 g of [[ceftriaxone]] or a consolidated 24-h dose of an [[aminoglycoside]].<br>
 
====In-Patient Treatment====
When the patient fails to response to oral out patient treatment, or shows signs of severe illness/sepsis like high fever, high WBC, nausa or vomiting, dehydration; it's required to change to inpatient treatment, [[intravenous fluid]]s may be administered to compensate for the reduced oral intake, insensible losses (due to the raised temperature) and [[vasodilation]] and to maximize urine output.<ref name="Warren-1999">{{Cite journal  | last1 = Warren | first1 = JW. | last2 = Abrutyn | first2 = E. | last3 = Hebel | first3 = JR. | last4 = Johnson | first4 = JR. | last5 = Schaeffer | first5 = AJ. | last6 = Stamm | first6 = WE. | title = Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA). | journal = Clin Infect Dis | volume = 29 | issue = 4 | pages = 745-58 | month = Oct | year = 1999 | doi = 10.1086/520427 | PMID = 10589881 }}</ref>
 
Intravenous antimicrobials should be used based on susceptibility resullts and local resistance data.
{|
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:25em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B| Acute Pyelonephritis-In Patient}}''
|-
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen (14 days)''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 1000 mg PO q24h for 7 days'''''<BR> OR<BR> ▸ '''''[[Levofloxacin]] 750 mg PO q24h for 5 days'''''<BR> OR <BR> ▸ '''''[[TMP/SMZ]] 160/800 mg PO q12h for 14 days '''''
 
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ ''''' [[Fluoroquinolones]]'''''<br>'''''[[Ciprofloxacin]] 400 mg IV q12h<br>[[Levofloxacin]] 750 mg IV q24h<br>[[Gatifloxacin]] 400 mg IV q24h'''''<br>OR<br>'''''▸[[Ampicillin]]-[[gentamicin]] 150–200 mg/kg IV/day-MDD: 2 mg per kg load, then 1.7 mg per kg q8h or OD: 5.1 (7 if critically ill) mg/kg q24h'''''<br>OR<br>'''''▸[[Ceftriaxone]] 1-2 gm IV q24h'''''<br>OR<br>'''''▸[[Piperacillin-tazobactam]] 3.375 gm IV q4-6h'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left | <SMALL>If FQ resistance >10% or unknown resistance to '''''[[TMP-SMX]]''''', add 1 IV dose of'''''[[Ceftriaxone]] 1 g''''' OR '''''[[Gentamicin]] 5–7 mg/kg'''''.<ref name="Gupta-2011">{{Cite journal  | last1 = Gupta | first1 = K. | last2 = Hooton | first2 = TM. | last3 = Naber | first3 = KG. | last4 = Wullt | first4 = B. | last5 = Colgan | first5 = R. | last6 = Miller | first6 = LG. | last7 = Moran | first7 = GJ. | last8 = Nicolle | first8 = LE. | last9 = Raz | first9 = R. | title = 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. | journal = Clin Infect Dis | volume = 52 | issue = 5 | pages = e103-20 | month = Mar | year = 2011 | doi = 10.1093/cid/ciq257 | PMID = 21292654 }}</ref>
</SMALL>
|-
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen (14 day)''
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ticarcillin clavulanate|Ticarcillin-clavulanate]] 3.1 gm IV q6h'''''<br>OR<br>'''''▸[[Ampicillin sulbactam|Ampicillin-sulbactam]] 3 gm IV q6h'''''<br>OR<br>'''''▸[[Piperacillin-tazobactam]] 3.375 gm IV q4-6h'''''<br>OR<br>'''''▸[[Ertapenem]] 31 gm IV q24h'''''<br>OR<br>'''''▸[[Doripenem]] 500 mg IV q8h (1 hr infusion for 10 days)'''''
|-
|}
|}
|}
*Treat with intravenously until 24-48 hours after patient becomes afebrile, then start 2 weeks course of PO regimen in the first table(uncomplicated pyelonephritis).
* Treat with [[Ampicillin sulbactam|ampicillin-sulbactam]] with or without an aminoglycoside if a gram positive cocci is the casitive organism.<ref name="Warren-1999">{{Cite journal  | last1 = Warren | first1 = JW. | last2 = Abrutyn | first2 = E. | last3 = Hebel | first3 = JR. | last4 = Johnson | first4 = JR. | last5 = Schaeffer | first5 = AJ. | last6 = Stamm | first6 = WE. | title = Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA). | journal = Clin Infect Dis | volume = 29 | issue = 4 | pages = 745-58 | month = Oct | year = 1999 | doi = 10.1086/520427 | PMID = 10589881 }}</ref>


===Complicated pyelonephritis===
{| style="float: center; cellpadding=0; cellspacing= 0; width: 400px;"
 
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Acute Pyelonephritis, Inpatient}}
All men considered as complicated infection, others include pregnant women and children with metabolic or anatomical abnoramlities, as a general rule all patients with risk of serious complications and/or failure of treatment (stones, obstruction, immunocompromised patients, [[neurogenic bladder]], [[renal failure]],[[transplant]] patients) considered as complicated infections.<ref>{{Cite journal  | last1 = Hooton | first1 = TM. | title = Clinical practice. Uncomplicated urinary tract infection. | journal = N Engl J Med | volume = 366 | issue = 11 | pages = 1028-37 | month = Mar | year = 2012 | doi = 10.1056/NEJMcp1104429 | PMID = 22417256 }}</ref>
 
{|
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:25em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B| Complicated pyelonephritis}}''
|-
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen (2-3 weeks)''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]]-[[gentamicin]] 150–200 mg/kg IV/day-MDD: 2 mg per kg load, then 1.7 mg per kg q8h or OD: 5.1 (7 if critically ill) mg/kg q24h'''''<br>OR<br>'''''▸[[Piperacillin-tazobactam]] 3.375 gm IV 6h'''''<br>OR<br>▸ '''''[[Ticarcillin clavulanate|Ticarcillin-clavulanate]] 3.1 gm IV q6h'''''<br>OR<br>'''''▸[[Carbapenems]]:<br>[[Doripenem]] 500 mg IV q8h (1 hr infusion for 10 days)<br>[[Imipenem]] 0.5 gm IV q12h (max 4 gm/day<br>[[Meropenem]] 1 gm IV q8h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 400 mg IV q12h'''''<BR> OR <BR> ▸'''''[[Levofloxacin]] 750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Gentamicin]] 5–7 mg/kg IV q24h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 1–2 gm IV q24h'''''<BR> OR <BR> ▸ '''''[[Cefotaxime]] 2 gm IV q8h'''''<BR> OR <BR> ▸ '''''[[Piperacillin/Tazobactam]] 3.375 gm IV q4–6h'''''<BR> OR<BR> ▸ '''''[[Ertapenem]] 1 gm IV q24h'''''<BR> OR <BR> ▸ '''''[[Doripenem]] 500 mg IV q8h'''''
|-
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen (2-3 weeks)''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left | <SMALL>Switch to PO 24-48 hr after fever resolution.<br>The choice of antiobiotics should be based on resistance pattern.<ref name="Gupta-2011">{{Cite journal  | last1 = Gupta | first1 = K. | last2 = Hooton | first2 = TM. | last3 = Naber | first3 = KG. | last4 = Wullt | first4 = B. | last5 = Colgan | first5 = R. | last6 = Miller | first6 = LG. | last7 = Moran | first7 = GJ. | last8 = Nicolle | first8 = LE. | last9 = Raz | first9 = R. | title = 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. | journal = Clin Infect Dis | volume = 52 | issue = 5 | pages = e103-20 | month = Mar | year = 2011 | doi = 10.1093/cid/ciq257 | PMID = 21292654 }}</ref>
</SMALL>
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | '''''▸ [[Fluoroquinolones]]:<br>[[Ciprofloxacin]] 400 mg IV q12h<br>[[Levofloxacin]] 750 mg IV/PO x 5 days<br>[[Gatifloxacin]] 400 mg IV q24h'''''<br>OR<br>'''''▸[[Ceftazidime]] 2 gm IV q8h'''''<br>OR<br>'''''▸[[Cefepime]] 2 gm IV q12h'''''
|-
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|}
|}
*Switch to oral [[fluoroquinolone]] or [[TMP-SMX]] when is possible.


==References==
==References==

Revision as of 17:44, 22 February 2014

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: :Abdurahman Khalil, M.D. [2]

Overview

As practically all cases of pyelonephritis are due to bacterial infections, antibiotics are the mainstay of treatment. Mild cases may be treated with oral therapy, but generally intravenous antibiotics are required for the initial stages of treatment. The type of antibiotic depends on local practice, and may include fluoroquinolones (e.g. ciprofloxacin), beta-lactam antibiotics (e.g. amoxicillin or acephalosporin), trimethoprim (or co-trimoxazole) or nitrofurantoin. Aminoglycosides are avoided due to their toxicity, but may be added for a short duration.[1]

Principles of therapy for pyelonephritis

  • Before starting treatment for suspected pyelonephritis, a urine culture and susceptibility test should be done in order to select the empirical antimicrobial that covers the causing organism.

Empiric Therapy

Acute Pyelonephritis, Outpatient
Preferred Regimen
▸ Ciprofloxacin 500 mg PO q12h for 7 days
WITH OR WITHOUT
▸ Ciprofloxacin 400 mg IV x 1 dose
Alternative Regimen
▸ Ciprofloxacin 1000 mg PO q24h for 7 days
OR
▸ Levofloxacin 750 mg PO q24h for 5 days
OR
▸ TMP/SMZ 160/800 mg PO q12h for 14 days
If FQ resistance >10% or unknown resistance to TMP-SMX, add 1 IV dose ofCeftriaxone 1 g OR Gentamicin 5–7 mg/kg.[1]

Acute Pyelonephritis, Inpatient
Preferred Regimen
▸ Ciprofloxacin 400 mg IV q12h
OR
▸Levofloxacin 750 mg IV q24h
OR
▸ Gentamicin 5–7 mg/kg IV q24h
OR
▸ Ceftriaxone 1–2 gm IV q24h
OR
▸ Cefotaxime 2 gm IV q8h
OR
▸ Piperacillin/Tazobactam 3.375 gm IV q4–6h
OR
▸ Ertapenem 1 gm IV q24h
OR
▸ Doripenem 500 mg IV q8h
Switch to PO 24-48 hr after fever resolution.
The choice of antiobiotics should be based on resistance pattern.[1]

References

  1. ↑ 1.0 1.1 1.2 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 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. Unknown parameter |month= ignored (help)

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