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

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