Pyelonephritis Empiric Therapy

Updated: Dec 01, 2015
  • Author: Mony Fraer, MD, FACP, FASN; Chief Editor: Thomas E Herchline, MD  more...
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Overview

Overview

Patients who are suspected of having pyelonephritis should have a urine culture and susceptibility test performed. [1]

Empiric therapy should be initiated based on the infecting uropathogen. [2, 1] Empiric therapy regimens include outpatient treatments, inpatient treatments, and treatment for pregnant patients, as described below.

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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 is thought to be >10%, then include a single dose of one of the following:

Second-line therapy

See the list below:

  • 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 the following may also be given: ceftriaxone (Rocephin) 1 g IV or  gentamicin 7 mg/kg IV or  tobramycin 7 mg/kg IV or amikacin 20 mg/kg IV
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Inpatient Treatment

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. Therapy should be given for 24-48 h or until severe symptoms improve. Duration of therapy should be 10-14 d, inclusive of initial IV therapy.

First-line therapy (fluoroquinolones)

See the list below:

  • Ciprofloxacin (Cipro) 400 mg IV q12h for 10-14d or
  • Levofloxacin (Levaquin) 750 mg IV q24h for 5d

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

Extended-spectrum cephalosporins or penicillins:

Carbapenems:

Monobactam (penicillin allergy):

Third-line therapy (aminoglycosides)

See the list below:

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

Treatment is with one of the extended-spectrum cephalosporins or penicillins listed below:

  • 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
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