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__NOTOC__ | __NOTOC__ | ||
{{Pyelonephritis}} | {{Pyelonephritis}} | ||
{{CMG}} | {{CMG}} | ||
==Overview== | ==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 [[fluoroquinolone]]s, [[TMP-SMX]], [[β-lactam]]s, and [[aminoglycoside]]s. | |||
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 Therapy== | ||
* 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.<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> | |||
* 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. | |||
* Optimal management depends on severity of illness at presentation, | * Oral [[beta-lactam]]s are less effective than either [[TMP/SMX|trimethoprim-sulfamethoxazole]], [[fluoroquinolone]]s, 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. | |||
* Oral [[beta-lactam]]s are less effective than [[TMP/ | |||
* 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.<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> | * 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.<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> | ||
== | ===Antimicrobial Therapy=== | ||
*'''Pyelonephritis empiric therapy''' | |||
:*'''Outpatient treatment''' | |||
::*Preferred regimen, regional fluoroquinolone resistance < 10%: [[Ciprofloxacin]] 500 mg PO q12h x 7 days '''±''' 400 mg IV in a single dose {{or}} [[Ciprofloxacin]] XR 1000 mg PO q24h for 7 days {{or}} [[Levofloxacin]] 750 mg PO q24h for 5 days | |||
::*Preferred regimen, regional fluoroquinolone resistance > 10%: ([[Ciprofloxacin]] 500 mg PO q12h x 7 days '''±''' 400 mg IV in a single dose {{or}} [[Ciprofloxacin]] XR 1000 mg PO q24h for 7 days {{or}} [[Levofloxacin]] 750 mg PO q24h for 5 days) {{and}} ([[Ceftriaxone]] 1 g IV x 1 dose {{or}} [[Gentamicin]] 7 mg/kg IV x 1 dose {{or}} [[Tobramycin]] 7 mg/kg IV x 1 dose {{or}} [[Amikacin]] 20 mg/kg IV x 1 dose) | |||
::*Alternative regimen (1), regional fluoroquinolone resistance < 10%: [[TMP-SMX]] 160/800 mg PO q12h x 14 days | |||
::Alternative regimen (2), regional fluoroquinolone resistance > 10%: [[TMP-SMX]] 160/800 mg PO q12h x 14 days {{and}} ([[Ceftriaxone]] 1 g IV x 1 dose {{or}} [[Gentamicin]] 7 mg/kg IV x 1 dose {{or}} [[Tobramycin]] 7 mg/kg IV x 1 {{or}} [[Amikacin]] 20 mg/kg IV x 1 dose | |||
::*Alternative regimen (3): ([[Amoxicillin-clavulanate potassium|Amoxicillin–Clavulanate]] 500/125 mg PO q12h x 14 days {{or}} [[Amoxicillin-clavulanate potassium|Amoxicillin–Clavulanate]] 250/125 mg PO q8h x 5–7 days {{or} [[Cefaclor]] 500 mg PO q8h x 7 days) {{and}} ([[Ceftriaxone]] 1 g IV in a single dose {{or}} [[Gentamicin]] 7 mg/kg IV in a single dose {{or}} [[Tobramycin]] 7 mg/kg IV in a single dose {{or}} [[Amikacin]] 20 mg/kg IV in a single dose ) | |||
:*'''Inpatient treatment'''<ref name="pmid21292654">{{cite journal| author=Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al.| 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 | year= 2011 | volume= 52 | issue= 5 | pages= e103-20 | pmid=21292654 | doi=10.1093/cid/ciq257 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21292654 }} </ref>::*Preferred regimen: [[Ciprofloxacin]] 400 mg IV q12h for 10-14 days {{or}} [[Levofloxacin]] 750 mg IV q24h for 10-14 days | |||
::*Alternative regimen (1): [[Gentamicin]] 7 mg/kg IV q24h for 10-14 days '''±''' [[Ampicillin]] 500 mg IV q6h for 10-14 days | |||
::*Alternative regimen (2): [[Tobramycin]] 7 mg/kg IV q24h for 10-14 days '''±''' [[Ampicillin]] 500 mg IV q6h for 10-14 days | |||
::*Alternative regimen (3): [[Amikacin]] 20 mg/kg IV q24h for 10-14 days '''±''' [[Ampicillin]] 500 mg IV q6h for 10-14 days | |||
::*Alternative regimen (4): [[Cefotaxime]] 1-2 g IV q8h for 10-14 days '''±''' ([[Gentamicin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Tobramycin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Amikacin]] 20 mg/kg IV q24h for 10-14 days) | |||
::*Alternative regimen (5): [[Ceftriaxone]] 1 g IV q24h '''±''' ([[Gentamicin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Tobramycin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Amikacin]] 20 mg/kg IV q24h for 10-14 days) | |||
::*Alternative regimen (6): [[Ceftazidime]] 12 g IV q8h '''±''' ([[Gentamicin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Tobramycin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Amikacin]] 20 mg/kg IV q24h for 10-14 days) | |||
::*Alternative regimen (7): [[Ampicillin-Sulbactam]] 1.5 g IV q6h '''±''' ([[Gentamicin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Tobramycin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Amikacin]] 20 mg/kg IV q24h for 10-14 days) | |||
::*Alternative regimen (8): [[Piperacillin-Tazobactam]] 3.375 g IV q4-6h '''±''' ([[Gentamicin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Tobramycin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Amikacin]] 20 mg/kg IV q24h for 10-14 days) | |||
::*Alternative regimen (9): [[Ticarcillin-Clavulanate]] 3.1 g IV q4-6h '''±''' ([[Gentamicin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Tobramycin]] 7 mg/kg IV q24h for 10-14 days {{or}} [[Amikacin]] 20 mg/kg IV q24h for 10-14 days) | |||
::*Alternative regimen (10): [[Meropenem]] 500 mg IV q8h for 10-14 days | |||
::*Alternative regimen (11): [[Ertapenem]] 1 g IV q24h for 10-14 days | |||
::*Alternative regimen (12): [[Doripenem]] 500 mg IV q8h for 10-14 days | |||
::*Alternative regimen (13): [[Aztreonam]] 1 g IV q8-12h for 10-14 days | |||
|} | |} | ||
*'''Pathogen-directed therapy'''<ref name="pmid21292654">{{cite journal| author=Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al.| 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 | year= 2011 | volume= 52 | issue= 5 | pages= e103-20 | pmid=21292654 | doi=10.1093/cid/ciq257 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21292654 }} </ref> | |||
:*'''''Enterococcus spp.'''''<ref name="pmid21292654">{{cite journal| author=Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al.| 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 | year= 2011 | volume= 52 | issue= 5 | pages= e103-20 | pmid=21292654 | doi=10.1093/cid/ciq257 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21292654 }} </ref>::*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'''<ref>{{Cite web | last = | first = | title = http://www.uroweb.org/gls/pdf/18_Urological%20infections_LR.pdf | url =http://www.uroweb.org/gls/pdf/18_Urological%20infections_LR.pdf | publisher = | date = | accessdate = }}</ref> | |||
{| | ::*'''Pyelonephritis empiric therapy''' | ||
:::*Preferred regimen (1): [[Ceftriaxone]] 1-2 g IV/IM q24h for 10-14 days | |||
:::*Preferred regimen (2): [[Aztreonam]] 1 g IV q8-12h for 10-14 days | |||
:::*Preferred regimen (3): [[Piperacillin-Tazobactam]] 3.375-4.5 g IV q6h for 10-14 days | |||
:::*Preferred regimen (4): [[Imipenem-Cilastatin]] 500 mg IV q6h for 10-14 days | |||
:::*Note: Fluoroquinolones and aminoglycosides should be avoided in pregnant patients | |||
| | |||
| | |||
::* Preferred regimen: [[ | |||
: | |||
::* Preferred regimen: [[ | |||
:::* | |||
:::* | |||
: | |||
::* Preferred regimen: | |||
:::* Note: | |||
==References== | ==References== | ||
Revision as of 14:31, 6 October 2015
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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
- 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.[1]
- 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.[2]
Antimicrobial Therapy
- Pyelonephritis empiric therapy
- Outpatient treatment
- Preferred regimen, regional fluoroquinolone resistance < 10%: Ciprofloxacin 500 mg PO q12h x 7 days ± 400 mg IV in a single dose OR Ciprofloxacin XR 1000 mg PO q24h for 7 days OR Levofloxacin 750 mg PO q24h for 5 days
- Preferred regimen, regional fluoroquinolone resistance > 10%: (Ciprofloxacin 500 mg PO q12h x 7 days ± 400 mg IV in a single dose OR Ciprofloxacin XR 1000 mg PO q24h for 7 days OR Levofloxacin 750 mg PO q24h for 5 days) AND (Ceftriaxone 1 g IV x 1 dose OR Gentamicin 7 mg/kg IV x 1 dose OR Tobramycin 7 mg/kg IV x 1 dose OR Amikacin 20 mg/kg IV x 1 dose)
- Alternative regimen (1), regional fluoroquinolone resistance < 10%: TMP-SMX 160/800 mg PO q12h x 14 days
- Alternative regimen (2), regional fluoroquinolone resistance > 10%: TMP-SMX 160/800 mg PO q12h x 14 days AND (Ceftriaxone 1 g IV x 1 dose OR Gentamicin 7 mg/kg IV x 1 dose OR Tobramycin 7 mg/kg IV x 1 OR Amikacin 20 mg/kg IV x 1 dose
- Alternative regimen (3): (Amoxicillin–Clavulanate 500/125 mg PO q12h x 14 days OR Amoxicillin–Clavulanate 250/125 mg PO q8h x 5–7 days {{or} Cefaclor 500 mg PO q8h x 7 days) AND (Ceftriaxone 1 g IV in a single dose OR Gentamicin 7 mg/kg IV in a single dose OR Tobramycin 7 mg/kg IV in a single dose OR Amikacin 20 mg/kg IV in a single dose )
- Inpatient treatment[3]::*Preferred regimen: Ciprofloxacin 400 mg IV q12h for 10-14 days OR Levofloxacin 750 mg IV q24h for 10-14 days
- Alternative regimen (1): Gentamicin 7 mg/kg IV q24h for 10-14 days ± Ampicillin 500 mg IV q6h for 10-14 days
- Alternative regimen (2): Tobramycin 7 mg/kg IV q24h for 10-14 days ± Ampicillin 500 mg IV q6h for 10-14 days
- Alternative regimen (3): Amikacin 20 mg/kg IV q24h for 10-14 days ± Ampicillin 500 mg IV q6h for 10-14 days
::*Alternative regimen (4): Cefotaxime 1-2 g IV q8h for 10-14 days ± (Gentamicin 7 mg/kg IV q24h for 10-14 days OR Tobramycin 7 mg/kg IV q24h for 10-14 days OR Amikacin 20 mg/kg IV q24h for 10-14 days)
- Alternative regimen (5): Ceftriaxone 1 g IV q24h ± (Gentamicin 7 mg/kg IV q24h for 10-14 days OR Tobramycin 7 mg/kg IV q24h for 10-14 days OR Amikacin 20 mg/kg IV q24h for 10-14 days)
- Alternative regimen (6): Ceftazidime 12 g IV q8h ± (Gentamicin 7 mg/kg IV q24h for 10-14 days OR Tobramycin 7 mg/kg IV q24h for 10-14 days OR Amikacin 20 mg/kg IV q24h for 10-14 days)
- Alternative regimen (7): Ampicillin-Sulbactam 1.5 g IV q6h ± (Gentamicin 7 mg/kg IV q24h for 10-14 days OR Tobramycin 7 mg/kg IV q24h for 10-14 days OR Amikacin 20 mg/kg IV q24h for 10-14 days)
- Alternative regimen (8): Piperacillin-Tazobactam 3.375 g IV q4-6h ± (Gentamicin 7 mg/kg IV q24h for 10-14 days OR Tobramycin 7 mg/kg IV q24h for 10-14 days OR Amikacin 20 mg/kg IV q24h for 10-14 days)
- Alternative regimen (9): Ticarcillin-Clavulanate 3.1 g IV q4-6h ± (Gentamicin 7 mg/kg IV q24h for 10-14 days OR Tobramycin 7 mg/kg IV q24h for 10-14 days OR Amikacin 20 mg/kg IV q24h for 10-14 days)
- Alternative regimen (10): Meropenem 500 mg IV q8h for 10-14 days
- Alternative regimen (11): Ertapenem 1 g IV q24h for 10-14 days
- Alternative regimen (12): Doripenem 500 mg IV q8h for 10-14 days
- Alternative regimen (13): Aztreonam 1 g IV q8-12h for 10-14 days
|}
- Pathogen-directed therapy[3]
- Enterococcus spp.[3]::*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[4]
- Pyelonephritis empiric therapy
- Preferred regimen (1): Ceftriaxone 1-2 g IV/IM q24h for 10-14 days
- Preferred regimen (2): Aztreonam 1 g IV q8-12h for 10-14 days
- Preferred regimen (3): Piperacillin-Tazobactam 3.375-4.5 g IV q6h for 10-14 days
- Preferred regimen (4): Imipenem-Cilastatin 500 mg IV q6h for 10-14 days
- Note: Fluoroquinolones and aminoglycosides should be avoided in pregnant patients
References
- ↑ 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) - ↑ 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) - ↑ 3.0 3.1 3.2 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.
- ↑ "http://www.uroweb.org/gls/pdf/18_Urological%20infections_LR.pdf" (PDF). External link in
|title=(help)