Pyelonephritis medical therapy

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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.

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.

• 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 fluids may be administered to compensate for the reduced oral intake, insensible losses (due to the raised temperature) and vasodilation and to maximize urine output.

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.

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.