Pyelonephritis medical therapy

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

Medical Therapy

• 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.

Uncomplicated pyelonephritis

Acute Bacterial Uncomplicated Pyelonephritis Preferred Regimen ▸ Fluoroquinolones Ciprofloxacin 500 mg PO bid ×7 days Levofloxacin 750 mg PO q24 × 5 days Ofloxacin 400 mg Po bid Moxifloxacin 400 mg PO q24h Alternative Regimen(14 day regimen) ▸ TMP-SMX 160/800 mg PO bid OR ▸ Oralβ-lactam Amoxicillin-clavulanate 875/125 mg po q12h or 500/125 mg po tid or 1000 /125 mg po bid Cefdinir 300 mg po q12h or 600 mg po q24 Cefaclor 250-500 mg po q8h Cefpodoxime-proxetil 100-200 mg po q12h Cephalexin250-500 mg po q6h not studied well but effective.

• 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.
  
• 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.
  
• 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.
  

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 a cephalosporin), trimethoprim (or co-trimoxazole) or nitrofurantoin. Aminoglycosides are avoided due to their toxicity, but may be added for a short duration.

If the patient is unwell and septic, 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.

Hospitalized patients

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 antimicrobials should be used based on susceptibility resullts and local resistance data.

Acute Pyelonephritis-Hospitaliztion Preferred Regimen(14 days)‡ ▸ IV Fluoroquinolones Ciprofloxacin400 mg IV q12h Levofloxacin 750 mg IV q24h; Gatifloxacin 400 mg IV q24h OR ▸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 OR ▸Ceftriaxone 1-2 gm IV q24h OR ▸Piperacillin-tazobactam 3.375 gm IV q4-6h Alternative Regimen(14 day)‡ ▸ Ticarcillin-clavulanate 3.1 gm IV q6h OR ▸Ampicillin-sulbactam 3 gm IV q6h OR ▸Piperacillin-tazobactam 3.375 gm IV q4-6h OR ▸Ertapenem 31 gm IV q24h OR ▸Doripenem 500 mg IV q8h (1 hr infusion for 10 days)

‡Treat IV until 24-48 patient afebrile, then start 2 weeks course of PO regimen in the first table(uncomplicated pyelonephritis).

• Treat with ampicillin/sulbactam with or without an aminoglycoside if a gram positive cocci is the casitive organism.

Complicated pyelonephritis

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.

Complicated nephritis Preferred Regimen(2-3 weeks)† ▸ 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 OR ▸Piperacillin-tazobactam 3.375 gm IV 6h OR ▸ Ticarcillin-clavulanate 3.1 gm IV q6h OR ▸Carbapenems: Doripenem 500 mg IV q8h (1 hr infusion for 10 days) OR Imipenem 0.5 gm IV q12h (max 4 gm/day OR Meropenem 1 gm IV q8h Alternative Regimen(2-3 weeks)† ▸ IV Fluoroquinolones: Ciprofloxacin 400 mg IV q12h OR Levofloxacin 750 mg IV/po x 5 days OR Gatifloxacin 400 mg IV q24h OR ▸Ceftazidime 2 gm IV q8h OR ▸Cefepime 2 gm IV q12h