Pyelonephritis Empiric Therapy
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Patients who are suspected of having pyelonephritis should have a urine culture and susceptibility test performed. [1] Empiric therapy should be adjusted based on the infecting uropathogen. [2, 1]
Empiric therapy regimens described below include the following:
First-line empiric therapy is with one of the fluoroquinolones listed below:
If fluoroquinolone resistance in the community is known to be >10%, then include a single dose of one of the following:
Second-line empiric therapy is with 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:
Patients with pyelonephritis who require hospitalization should be treated with one of the IV antimicrobial regimens listed below. The treatment of choice should be based on local resistance data, and the drug regimen should be tailored according to susceptibility results. IV therapy should be given for 24-48 h or until severe symptoms improve. Duration of therapy, inclusive of initial IV therapy, should be as follows:
First-line therapy is with one of the following fluoroquinolones:
Extended-spectrum cephalosporins or penicillins:
Carbapenems:
Monobactam (penicillin allergy):
See the list below:
Inpatient admission is warranted for any pregnant patient with pyelonephritis. Avoid fluoroquinolones and aminoglycosides in pregnant patients.
Antibiotic selection should be based on urine culture sensitivities, if known. Often, therapy must be initiated on an empirical basis, before culture results are available. This requires clinical knowledge of the most common organisms and their practice-specific or hospital-specific sensitivities to medications.
Institution-specific drug resistances should also be considered before a treatment antibiotic is chosen. For instance, with E coli infection alone, resistance to ampicillin can be as high as 28%-39%. Resistance to trimethoprim-sulfamethoxazole has been described as 31%, and resistance to first-generation cephalosporins may be as high as 9-19%.
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 is with one of the extended-spectrum cephalosporins or penicillins listed below:
Overview
Which tests should be performed prior to initiating pyelonephritis empiric therapy?
In what settings is pyelonephritis empiric therapy administered?
Which medications are used in first-line outpatient pyelonephritis empiric therapy?
Which medications are used in second-line outpatient pyelonephritis empiric therapy?
What medications are used for inpatient pyelonephritis empiric therapy?
Which medications are used in first-line inpatient pyelonephritis empiric therapy?
Which medications are used in second-line inpatient pyelonephritis empiric therapy?
What medications are used in third-line inpatient pyelonephritis empiric therapy?
How is pyelonephritis treated during pregnancy?
Which medications are used for first-line pyelonephritis empiric therapy during pregnancy?
Pasiechnikov S, Buchok O, Sheremeta R, Banyra O. “Empirical Treatment in Patients with Acute Obstructive Pyelonephritis”. Infect Disord Drug Targets. 2015. 15 (3):163-70. [Medline].
[Guideline] Gupta K, et al. 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. 2011 Mar. 52(5):e103-20. [Medline].
Antibiotic therapy for acute uncomplicated pyelonephritis in women. Take resistance into account. Prescrire Int. 2014 Dec. 23 (155):296-300. [Medline].
Mony Fraer, MD, MHCDS, FACP, FASN Associate Professor, Division of Nephrology, Department of Medicine, University of Iowa Hospitals and Clinics; Staff Physician, Iowa City Veterans Affairs Medical Center
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic
Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio
Disclosure: Nothing to disclose.
Kelley Struble, DO Fellow, Department of Infectious Diseases, University of Oklahoma College of Medicine
Kelley Struble, DO is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.
Pyelonephritis Empiric Therapy
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