Acute Pyelonephritis Medication

Antibiotic therapy is essential in the treatment of acute pyelonephritis and prevents progression of the infection. Urine culture and sensitivity testing should always be performed, and empirical therapy should be tailored to the infecting uropathogen.^[10]

Patients presenting with complicated pyelonephritis should be managed as inpatients and treated empirically with broad-spectrum parenteral antibiotics. Depending on patient presentation, antibiotic therapy can be completed with oral therapy. Antibiotics are administered for at least 10-14 days. On the basis of patient presentation, longer duration of therapy may be needed.

Class Summary

Sulfonamides such as trimethoprim-sulfamethoxazole(TMP-SMX) have bacteriocidal activity and are used in the treatment of pyelonephritis.

Trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)

This drug combination is designed to take advantage of the synergy between trimethoprim and sulfonamides. TMP-SMX activity covers common urinary tract pathogens, both aerobic gram-positive and gram-negative bacteria, except Pseudomonas aeruginosa.

Oral trimethoprim-sulfamethoxazole (160 mg/800 mg [1 double-strength tablet] twice-daily for 14 days) is an appropriate choice for therapy if the uropathogen is known to be susceptible. This agent has been given an A-I rating in the 2010 IDSA guidelines for treating pyelonephritis.^[10]

Class Summary

Fluoroquinolones are acceptable agents for the treatment of pyelonephritis because they are highly effective against gram-negative and gram-positive bacteria. A major concern with fluoroquinolones is the development of resistance among uropathogens and other organisms. Oral fluoroquinolones are a treatment option for patients not requiring hospitalization where the prevalence of resistance of community uropathogens does not exceed 10%.^[10] According to the IDSA 2010 guidelines, if the prevalence of fluoroquinolone resistance exceeds 10%, an initial 1-time intravenous dose of a long-acting parenteral antimicrobial or a consolidated 24-hour dose of an aminoglycoside, is recommended.^[10] Fluoroquinolones should be avoided during pregnancy.

Ciprofloxacin (Cipro, Cipro XR)

Oral ciprofloxacin is recommended for patients who do not need hospitalization. Dosing recommendations include 500 mg twice daily for 7 days, with or without an initial 400-mg dose of intravenous ciprofloxacin.^[10] Patients can also be given a once-daily regimen of ciprofloxacin extended release at a dosage of 1000 mg for 7 days.

Levofloxacin (Levaquin)

Levofloxacin is also recommended as an oral antibiotic for patients with pyelonephritis not requiring hospitalization. Recommended dose includes the administration of levofloxacin 750 mg for 5 days.

Class Summary

Oral beta-lactams are not as effective for treating pyelonephritis. Based on the IDSA 2010 guidelines, however, if they are used, they should be administered with a single dose of ceftriaxone (Rocephin) 1 g IV ora consolidated 24-hour dose of an aminoglycoside.^[10]

Cefaclor

Cefaclor is indicated for the treatment of pyelonephritis, caused by Escherichia coli, Proteus mirabilis, Klebsiella species, and coagulase-negative staphylococci. Cefaclor, 500 mg 3 times a day for 7 days, is recommended for outpatient treatment of pyelonephritis.

Class Summary

Third-generation cephalosporins are broad-spectrum and have bactericidal activity. These drugs are the most active against serious gram-negative pathogens and have some activity against gram-positive pathogens.

Ceftriaxone (Rocephin)

Ceftriaxone is a parenteral regimen that can be administered once daily in patients with pyelonephritis requiring hospitalization. For patients with mild to moderate pyelonephritis, a dosage of 1 g every 24 hours is recommended.

Cefotaxime (Claforan)

Cefotaxime has bactericidal activity. It is indicated for the treatment of genitourinary infections caused by Escherichia coli, Enterococcus species, and Klebsiella species, among others. For moderate to severe infections, the usual dose is 1-2 g IV or IM every 8 hours.

Ceftazidime (Fortaz, Tazicef)

Ceftazidime has broad-spectrum activity against gram-negative organisms, including Pseudomonas, and lower efficacy against gram-positive organisms. It is approved for the treatment of complicated and uncomplicated cystitis caused by Pseudomonas aeruginosa; Enterobacter species; Proteus species, including Proteus mirabilis and indole-positive Proteus; Klebsiella species; and E coli.

Class Summary

Cefepime is a fourth-generation drug, which possesses the gram-negative activity of the third-generation agents and the gram-positive activity of the first-generation drugs.

Cefepime (Maxipime)

Cefepime is a fourth-generation cephalosporin. It is indicated for the treatment of uncomplicated and complicated cystitis, including (1) pyelonephritis caused by E coli or Klebsiella pneumoniae when the infection is severe or (2) pyelonephritis caused by E coli, Klebsiella pneumoniae, or Proteus mirabilis when the infection is mild to moderate, including cases associated with concurrent bacteremia with these microorganisms.

Class Summary

Aminopenicillins have a broad spectrum of are bactericidal activity against gram-positive and gram-negative organisms.

Ampicillin

Penicillins such as ampicillin can be administered in combination with aminoglycosides for patients with pyelonephritis who require hospitalization. Ampicillin has bactericidal activity against susceptible organisms.

Amoxicillin-clavulanate (Augmentin, Augmentin XR)

Oral beta-lactams are not as effective for treating pyelonephritis. If they are used, they should be administered with a single dose of ceftriaxone, 1 g IV, or a consolidated 24-hour dose of an aminoglycoside.^[10] Amoxicillin-clavulanate possesses the properties of a broad-spectrum antibiotic and a beta-lactamase inhibitor.

Class Summary

Extended-spectrum penicillins have a broad spectrum of bactericidal activity. They are used mainly in the treatment of patients with pyelonephritis requiring hospitalization.^[10] The extended-spectrum penicillins are also an option for pregnant patients with pyelonephritis.

Piperacillin-tazobactam (Zosyn)

Piperacillin-tazobactam is useful as empirical therapy before the identification of causative organisms, because of its broad spectrum of bactericidal activity against gram-positive and gram-negative organisms. The dosing recommendation for severe pyelonephritis is 3.375 g IV every 6 hours.

Ampicillin-sulbactam (Unasyn)

Ampicillin has a broad spectrum of bactericidal activity against many gram-positive and gram-negative aerobic and anaerobic bacteria. The presence of sulbactam in the ampicillin-sulbactam formulation effectively extends the spectrum of ampicillin to include many bacteria normally resistant to it and to other beta-lactam antibiotics. Ampicillin-sulbactam, 1.5 g IV every 6 hours, can be used for the treatment of pyelonephritis.

Ticarcillin-clavulanate (Timentin)

Ticarcillin has broad-spectrum bactericidal activity against many gram-positive and gram-negative bacteria. Clavulanate is a beta-lactam agent and is structurally related to the penicillins. Clavulanate possesses the ability to inactivate a wide range of beta-lactamase enzymes commonly found in microorganisms that are resistant to penicillins and cephalosporins. General dosing recommendation is administering 3.1 g IV every 4-6 hours.

Class Summary

Carbapenem antibiotics are broad-spectrum antibiotics that are structurally related to beta-lactam antibiotics. Carbapenems can be used in the treatment of patients with pyelonephritis requiring hospitalization.^[10] The extended-spectrum penicillins are also an option for pregnant patients with pyelonephritis.

Doripenem (Doribax)

Doripenem is approved for the treatment of complicated cystitis, including pyelonephritis that is caused by E coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, and Acinetobacter baumannii. The usual dosage is 500 mg IV every 8 hours. The duration of therapy can range from 10-14 days. Duration includes a possible switch to an appropriate oral therapy after at least 3 days of parenteral therapy, once clinical improvement has been demonstrated. Duration can be extended up to 14 days in patients with concurrent bacteremia.

Ertapenem (Invanz)

Ertapenem is approved for the treatment of complicated cystitis, including pyelonephritis caused by Escherichia coli including cases with concurrent bacteremia or Klebsiella pneumoniae. Usual dosage is 1 g IV every 24 hours for 10-14 days. Duration includes a possible switch to an appropriate oral therapy after at least 3 days of parenteral therapy, once clinical improvement has been demonstrated.

Meropenem (Merrem)

Meropenem is a bactericidal broad-spectrum carbapenem antibiotic that is effective against most gram-positive and gram-negative bacteria. It can be administered at a dose of 500 mg IV every 8 hours.

Imipenem-cilastatin (Primaxin)

Imipenem/cilastatin has bactericidal activity against a wide range of gram-negative and gram-positive organisms. It is an alternative treatment for pyelonephritis because infections resistant to other antibiotics (eg, cephalosporins, penicillin, aminoglycosides) have been shown to respond to treatment with imipenem-cilastatin. The general dosing recommendation is 500 mg IV every 6 hours.

Class Summary

Aminoglycosides are bactericidal antibiotics used primarily in the treatment of gram-negative infections. They are commonly used in combination with drugs such as ampicillin . For example, gentamicin is an aminoglycoside antibiotic that has gram-negative coverage. It is used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Aminoglycosides should be avoided during pregnancy.

Gentamicin

Gentamicin is not the drug of choice for acute pyelonephritis. Consider using it when penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous; adjust the dose based on the creatinine clearance and changes in volume of distribution. Gentamicin may be given intravenously or intramuscularly.

Tobramycin

Tobramycin has bactericidal activity against, and is used to treat infections caused by, E coli, Proteus species, Klebsiella species, Serratia species, Enterobacter species, and Citrobacter species. Tobramycin can be administered intravenously or intramuscularly. Dosage is based on weight and renal function.

Amikacin

Amikacin has bactericidal activity against gram-negative organisms. Clinical studies have shown that amikacin is clinically effective for serious complicated and recurrent cystitis. Amikacin can be administered intravenously or intramuscularly. Dosage is based on weight and renal function.

Class Summary

Glycopeptide antibiotics such as vancomycin have bactericidal activity and can be used as alternative therapy for patients with pyelonephritis.

Vancomycin (Vancocin)

Vancomycin is a potent antibiotic directed against gram-positive organisms and is active against Enterococcus species. Vancomycin is indicated for patients who cannot receive or did not respond to penicillins and cephalosporins or patients who have infections with resistant staphylococci.

Class Summary

Unlike the penicillins and cephalosporins, aztreonam is a monobactam. Monobactams such as aztreonam are bactericidal; however, they lack activity against gram-positive activity.

Aztreonam (Azactam)

Aztreonam is approved for the treatment of complicated and uncomplicated cystitis. It is approved for the treatment of pyelonephritis caused by Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Enterobacter cloacae, Klebsiella oxytoca, Citrobacter species, and Serratia marcescens. Aztreonam lacks cross-sensitivity with beta-lactam antibiotics and may be used in patients allergic to penicillins or cephalosporins. General dosing recommendations include administering 1 g IV every 8-12 hours.

Class Summary

Use of a urinary analgesic is indicated when a patient has dysuria to such an extent that it disrupts activities of daily living. These agents relieve pain, discomfort, and spasms of the bladder.

Phenazopyridine (Azo Standard, Azo Standard Maximum Strength, Baridium, Pyridium, UTI Relief)

Phenazopyridine is an azo dye excreted in urine, where it exerts a topical analgesic effect on urinary tract mucosa. Its use is compatible with antibacterial therapy and can help relieve pain and discomfort before antibacterial therapy controls infection.

It is used for symptomatic relief of pain, burning, urgency, frequency, and other discomfort arising from irritation of lower urinary tract mucosa caused by infection, trauma, surgery, endoscopic procedures, or passage of sounds or catheters. Its analgesic action may reduce or eliminate the need for systemic analgesics or narcotics.