Pyelonephritis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Most cases of pyelonephritis are caused by bacteria. Mild pyelonephritis may be managed with oral antibiotics, 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 receive parenteral therapy. Fluoroquinolones, aminoglycosides, trimethoprim-sulfamethoxazole, carbapenems, and extended-spectrum cephalosporins and penicillins are commonly used in the treatment of acute pyelonephritis.

Principles of Therapy for Acute Pyelonephritis

• Before initiating antimicrobial treatment for suspected pyelonephritis, a urine culture and susceptibility test should always be performed to help tailor empiric therapy.

• Optimal management depends on severity of illness at presentation, local resistance data, and host factors; when local resistance patterns are unknown, an initial intravenous dose of a long-acting, broad-spectrum antimicrobial agent may be considered.

• Oral beta-lactams are less effective than 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.

• Ampicillin should be limited to treating suspected Enterococcus infection and co-administered with an aminoglycoside.

• Fluoroquinolones and aminoglycosides should be avoided in pregnant patients.

• 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.

Empiric Therapy for Acute Pyelonephritis (Outpatient & Inpatient) Adapted from Clin Infect Dis. 2011;52(5):e103-20.

Acute Pyelonephritis, Outpatient Preferred Regimen ▸ Ciprofloxacin 500 mg PO q12h x 7 days ± 400 mg IV x 1 dose OR ▸ Ciprofloxacin XR 1000 mg PO q24h for 7 days OR ▸ Levofloxacin 750 mg PO q24h for 5 days PLUS (if fluoroquinolone resistance >10%) ▸ 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 ▸ TMP/SMZ 160/800 mg PO q12h x 14 days PLUS (if TMP/SMZ resistance unknown) ▸ 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 2 ▸ 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 PLUS ▸ 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

Acute Pyelonephritis, Inpatient Preferred Regimen ▸ Ciprofloxacin 400 mg IV q12h OR ▸ Levofloxacin 750 mg IV q24h Alternative Regimen 1 ▸ Gentamicin 7 mg/kg IV q24h ± Ampicillin 500 mg IV q6h OR ▸ Tobramycin 7 mg/kg IV q24h ± Ampicillin 500 mg IV q6h OR ▸ Amikacin 20 mg/kg IV q24h ± Ampicillin 500 mg IV q6h Alternative Regimen 2 ▸ Cefotaxime 1–2 gm IV q8h OR ▸ Ceftriaxone 1 gm IV q24h OR ▸ Ceftazidime 2 gm IV q8h OR ▸ Ampicillin–Sulbactam 1.5 g IV q6h OR ▸ Piperacillin–Tazobactam 3.375 gm IV q4–6h OR ▸ Ticarcillin–Clavulanate 3.1 gm IV q4–6h WITH OR WITHOUT ▸ Gentamicin 7 mg/kg IV q24h OR ▸ Tobramycin 7 mg/kg IV q24h OR ▸ Amikacin 20 mg/kg IV q24h Alternative Regimen 3 ▸ Meropenem 500 mg IV q8h OR ▸ Ertapenem 1 g IV q24h OR ▸ Doripenem 500 mg IV q8h OR ▸ Aztreonam 1 g IV q8–12h Antibiotics should be administered for ≥10–14 days based on local resistance patterns. De-escalation to oral antibiotics may be considered 24–48 hours after defervescence.

Empiric Therapy for Acute Pyelonephritis (Pregnancy) Adapted from European Association of Urology's Guidelines on Urological Infections.

Pyelonephritis, Pregnancy Preferred Regimen ▸ Ceftriaxone 1–2 g IV/IM q24h OR ▸ Aztreonam 1 g IV q8–12h OR ▸ Piperacillin–Tazobactam 3.375–4.5 g IV q6h OR ▸ Cefepime 1 g IV q12h OR ▸ Imipenem–Cilastatin 500 mg IV q6h OR ▸ Ampicillin 2 g IV q6h PLUS ▸ Gentamicin 3–5 mg/kg/day IV q8h

Antimicrobial regimen

• Pyelonephritis

• Condition 1: patients not requiring hospitalization where the prevalence of resistance of community uropathogens to fluoroquinolones is not known to exceed 10%

• Preferred regimen: Ciprofloxacin PO 500 mg bid for 7 days ± an initial Ciprofloxacin 400mg IV single dose

• Note (1): If an initial one-time intravenous agent is used, a long-acting antimicrobial, such as 1 g of Ceftriaxone or a consolidated 24-h dose of an Aminoglycoside, could be used in lieu of an intravenous fluoroquinolone
• Note (2): If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial one-time intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone or a consolidated 24-h dose of an aminoglycoside, is recommended.

• Alternative regimen: A once-daily oral fluoroquinolone, Ciprofloxacin 1000 mg extended release PO qd for 7 days OR Levofloxacin 750 mg PO qd for 5 days.

• Note: If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial intravenous dose of a long-acting parenteral antimicrobial, such as Ceftriaxone 1 g IM/IV or a consolidated 24-h dose of an Aminoglycoside, is recommended.

• Condition 2: When the uropathogen is known to be susceptible

• Preferred regimen: Trimethoprim-sulfamethoxazole 160/800 mg (1 double-strength tablet) bid PO for 14 days.

• Note: If trimethoprim-sulfamethoxazole is used when the susceptibility is not known, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone OR a consolidated 24-h dose of an aminoglycoside, is recommended.
• Note: Oral β-lactam agents are less effective than other available agents for treatment of pyelonephritis. If an oral β-lactam agent is used, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone OR a consolidated 24-h dose of an aminoglycoside, is recommended.

• Condition 3: Patients require hospitalization (high fever, high white blood cell count, vomiting, dehydration, or evidence of sepsis)

• Preferred regimen: intravenous antimicrobial regimen, such as a Fluoroquinolone; an Aminoglycoside ± Ampicillin; an extended-spectrum Cephalosporin or extended-spectrum Penicillin ± an Aminoglycoside; Carbapenem

• Note: The choice between these agents should be based on local resistance data, and the regimen should be tailored on the basis of susceptibility results.