Acute Pyelonephritis Treatment & Management

Approach Considerations
• Ambulatory younger non pregnant, women who present with signs and symptoms
of uncomplicated acute pyelonephritis may be candidates for outpatient therapy.
o Treated initially in the emergency department (ED) with vigorous oral or IV
fluids, antipyretic pain medication, and a dose of parenteral antibiotics.
▪ parenteral analgesics are often necessary to reduce morbidity from
symptoms.
• Outpatient therapy for selected patients is as safe as inpatient therapy for a
comparable group of patients and is much less expensive.
• Admission is usually appropriate for patients who are severely ill, pregnant, or
elderly or who have comorbid disorders that increase the complexity of
management or the complication rate (eg, diabetes mellitus, chronic lung disease,
congenital or acquired immunodeficiency).
• Emergency surgery may be indicated in a patient:
o fever or positive blood culture results persisting longer than 48 hours,
whose condition deteriorates or in a patient who appears toxic for longer
than 72 hours.
▪ These patients may have an abscess, emphysematous
pyelonephritis, or an obstructing calculus.

Antibiotic Selection
• Empirical, because the results of blood or urine cultures are rarely available by the
time a decision must be made.
• Should be guided by local antibiotic resistance patterns.
• Culture results from specimens collected before the initiation of therapy should
be checked in 48 hours to determine antibiotic efficacy.
• Pathogen in community-acquired infections is usually E coli or other
Enterobacteriaceae.
o Acceptable regimens may include fluoroquinolones, cephalosporins,
penicillins, extended-spectrum penicillins, carbapenems, and
aminoglycosides.
• If enterococci are suggested on the basis of Gram stain results
o Ampicillin or vancomycin can replace the fluoroquinolone.
o Higher incidence of enterococcal infections in hospitalized and other
institutionalized patients.

Created by Peter Inocando

 Outpatient Treatment
First-line therapy
First-line empiric therapy is with one of the fluoroquinolones listed below:
• Ciprofloxacin (Cipro) 500 mg PO q12h for 7d
• Ciprofloxacin extended-release (Cipro XR, Proquin XR) 1000 mg PO q24h for 7d
• Levofloxacin (Levaquin) 750 mg PO q24h for 5d

If fluoroquinolone resistance in the community is known to be >10%, then include a single

dose of one of the following:
• Ceftriaxone (Rocephin) 1 g IV
• Gentamicin 7 mg/kg IV
• Tobramycin 7 mg/kg IV
• Amikacin 20 mg/kg IV

Second-line therapy
• Trimethoprim/sulfamethoxazole 160/800 mg (Bactrim DS, Septra DS) 1 tablet PO
BID for 14d.
• If trimethoprim is used when the susceptibility is not known, an initial single IV dose
of one of the following may also be given:
o Ceftriaxone 1 g IV
o Gentamicin 7 mg/kg IV
o Tobramycin 7 mg/kg IV
o Amikacin 20 mg/kg IV

Treatment During Pregnancy

• Inpatient admission is warranted for any pregnant patient with pyelonephritis.
• Avoid fluoroquinolones and aminoglycosides in pregnant patients.
• Therapy should be given for 24-48h or until severe symptoms improve. Duration of
therapy should be 10-14d, inclusive of initial IV therapy.

First-line treatment
• Ampicillin-sulbactam (Unasyn) 1.5 g IV q6h
• Piperacillin-tazobactam (Zosyn) 3.375 g IV q6h
• Cefotaxime (Claforan) 1-2 g IV q8h
• Ceftriaxone (Rocephin) 1 g IV q24h
• Ceftazidime (Fortaz, Tazicef) 2 g IV q8h

Created by Peter Inocando

 Inpatient Treatment
• IV therapy should be given for 24-48 h or until severe symptoms improve. Duration
of therapy, inclusive of initial IV therapy
o Ciprofloxacin: 7 d
o Levofloxacin: 5 d
o Beta-lactams: 10-14 d

First-line therapy (fluoroquinolones)

• Ciprofloxacin (Cipro) 400 mg IV q12h
• Levofloxacin (Levaquin) 750 mg IV q24h

Second-line therapy (preferred if patient is critically ill or pregnant)

• Extended-spectrum cephalosporins or penicillins:
o Ampicillin-sulbactam (Unasyn) 1.5 g IV q6h
o Piperacillin-tazobactam (Zosyn) 3.375 g IV q6h
o Cefotaxime (Claforan) 1-2 g IV q8h
o Ceftriaxone (Rocephin) 1 g IV q24h
o Ceftazidime (Fortaz, Tazicef) 2 g IV q8h
o All of the above can be administered with or without an aminoglycoside
(except in pregnant patients)
• Carbapenems:
o Ertapenem (Invanz) 1 g IV q24h
o Doripenem (Doribax) 500 mg IV q8h
• Monobactam (penicillin allergy):
o Aztreonam (Azactam) 2g IV q6h

Third-line therapy (aminoglycosides)

o Gentamicin 3 mg/kg/day IV/IM in three divided doses or 7 mg/kg/day pulsed
dosing
o Tobramycin 3 mg/kg/day IV/IM in three divided doses or 7 mg/kg/day
pulsed dosing
o Amikacin 10 mg/kg/day IV/IM in three divided doses or 20 mg/kg/day pulsed
dosing
o All of the above can be administered with or without ampicillin 500 mg
IM/IV q6h

Created by Peter Inocando

Regimens for complicated cases
• With complicated acute pyelonephritis, treat patients parenterally until defervescence
and improvement in the clinical condition warrants changing to oral antibiotics.
• Complete the course of therapy with an oral agent selected on the basis of culture results.
Acceptable regimens include the following:
o Ampicillin and an aminoglycoside
o Cefepime
o Imipenem
o Meropenem
o Piperacillin-tazobactam
o Ticarcillin-clavulanate
o Ceftazidime-avibactam
o Meropenem-vaborbactam
• If the patient is allergic to penicillin, vancomycin should be substituted. Vancomycin or
linezolid are options if enterococci are a consideration.

IV fluids
• If oral intake is not tolerated, intravenous hydration is warranted. Intravenous fluids
should include 1 L of 5% dextrose in saline

Follow-up
• Initial follow-up visit should take place in 24 - 48 hours.
o Continue supportive care by prescribing antiemetics, antipyretics, analgesics,
and urinary tract analgesics as needed.
• Complete a 14-day course of oral antibiotics
o Young, healthy female, the course of treatment can be shortened to 7 days from
14 days, if the antibiotic being used is a fluoroquinolone.
o Healthy young males should complete a 14-day course.
• Obtain follow-up urine culture results in any patient with a complicated UTI
• Patient should not return to work for 2 weeks, so as to allow time for the infection to be
eliminated and for the patient to recover physical strength.

Created by Peter Inocando