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Acute Pyelonephritis Medication

  • Author: Tibor Fulop, MD, FASN, FACP; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
 
Updated: Aug 11, 2015
 

Medication Summary

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 when results become available, empirical therapy should be tailored to the infecting uropathogen.[1]

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.

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Sulfonamides

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.

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Fluoroquinolones

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%.[1] 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.[1] 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. 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.

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Cephalosporins, Second Generation

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.[1]

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.

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Cephalosporins, Third Generation

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.

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Cephalosporins, Other

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.

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Penicillins, Amino

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. Amoxicillin-clavulanate possesses the properties of a broad-spectrum antibiotic and a beta-lactamase inhibitor.

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Penicillins, Extended-Spectrum

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.[1] 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.

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Carbapenems

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.[1] 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.

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Aminoglycosides

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, an aminoglycoside antibiotic that has gram-negative coverage, is used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Because of their potential nephrotoxicity, aminoglycosides  should be reserved as a last resort, for use in resistant or life-threatening infections. In addition, 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.

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Glycopeptides

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.

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Monobactams

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.

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Urinary Analgesics

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.

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Contributor Information and Disclosures
Author

Tibor Fulop, MD, FASN, FACP Professor of Medicine, Department of Medicine, Division of Nephrology, University of Mississippi Medical Center

Tibor Fulop, MD, FASN, FACP is a member of the following medical societies: American College of Physicians, American Society of Diagnostic and Interventional Nephrology, American Society of Hypertension, American Society of Nephrology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Fresenius Medical Care, Hungary.

Specialty Editor Board

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, International Society of Nephrology, American Society for Biochemistry and Molecular Biology, American Federation for Medical Research, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, Kentucky Medical Association, National Kidney Foundation, Phi Beta Kappa

Disclosure: Received grant/research funds from Dept of Veterans Affairs for research; Received salary from American Society of Nephrology for asn council position; Received salary from University of Louisville for employment; Received salary from University of Louisville Physicians for employment; Received contract payment from American Physician Institute for Advanced Professional Studies, LLC for independent contractor; Received contract payment from Healthcare Quality Strategies, Inc for independent cont.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology

Disclosure: Nothing to disclose.

Acknowledgements

Amy J Behrman, MD Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine

Amy J Behrman, MD is a member of the following medical societies: American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Christopher Edwards, MD Resident Physician, Department of Emergency Medicine, University of Pennsylvania School of Medicine

Christopher Edwards, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Judith Green-McKenzie, MD, MPH Associate Professor, Director of Clinical Practice, Occupational Medicine Residency Director, University of Pennsylvania School of Medicine

Judith Green-McKenzie, MD, MPH is a member of the following medical societies: American College of Occupational and Environmental Medicine, American College of Physicians, American College of Preventive Medicine, National Medical Association, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Eleanor Lederer, MD Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Dept of Veterans Affairs Grant/research funds Research

Chike Magnus Nzerue, MD Associate Dean for Clinical Affairs, Vice-Chairman of Internal Medicine, Meharry Medical College

Chike Magnus Nzerue, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Society of Nephrology, and National Kidney Foundation

Disclosure: Nothing to disclose.

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM Associate Professor, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

William H Shoff, MD, DTM&H Director, PENN Travel Medicine; Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Glaxo Smith Kline None None; Glaxo Smith Kline Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, 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 1. 52(5):e103-20. [Medline].

  2. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis. 2007 Aug 1. 45(3):273-80. [Medline].

  3. National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC). Kidney and Urologic Diseases Statistics for the United States. Available at http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/#urologic. Accessed: October 31, 2011.

  4. Mazaki-Tovi S, Vaisbuch E, Romero R, et al. Maternal plasma concentration of the pro-inflammatory adipokine pre-B-cell-enhancing factor (PBEF)/visfatin is elevated in pregnant patients with acute pyelonephritis. Am J Reprod Immunol. 2010 Mar 1. 63(3):252-62. [Medline].

  5. Kofteridis DP, Papadimitraki E, Mantadakis E, et al. Effect of diabetes mellitus on the clinical and microbiological features of hospitalized elderly patients with acute pyelonephritis. J Am Geriatr Soc. 2009 Nov. 57(11):2125-8. [Medline].

  6. Lumbiganon P, Laopaiboon M, Thinkhamrop J. Screening and treating asymptomatic bacteriuria in pregnancy. Curr Opin Obstet Gynecol. 2010 Apr. 22(2):95-9. [Medline].

  7. Arambašić J, Mandić S, Debeljak Ž, Mandić D, Horvat V, Šerić V. Differentiation of acute pyelonephritis from other febrile states in children using urinary neutrophil gelatinase-associated lipocalin (uNGAL). Clin Chem Lab Med. 2015 Jun 6. [Medline].

  8. Rafiei A, Mohammadjafari H, Bazi S, Mirabi AM. Urinary neutrophil gelatinase-associated lipocalin (NGAL) might be an independent marker for anticipating scar formation in children with acute pyelonephritis. J Renal Inj Prev. 2015. 4 (2):39-44. [Medline].

  9. Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008 Mar. 22(1):73-87, vi. [Medline].

  10. Martina MC, Campanino PP, Caraffo F, et al. Dynamic magnetic resonance imaging in acute pyelonephritis. Radiol Med. 2010 Mar. 115(2):287-300. [Medline].

  11. Silverman SG, Leyendecker JR, Amis ES Jr. What is the current role of CT urography and MR urography in the evaluation of the urinary tract?. Radiology. 2009 Feb. 250(2):309-23. [Medline].

  12. Talan DA, Stamm WE, Hooton TM, et al. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis pyelonephritis in women: a randomized trial. JAMA. 2000 Mar 22-29. 283(12):1583-90. [Medline].

  13. Sandberg T, Skoog G, Hermansson AB, Kahlmeter G, Kuylenstierna N, Lannergård A, et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012 Aug 4. 380(9840):484-90. [Medline].

  14. Pohl A. Modes of administration of antibiotics for symptomatic severe urinary tract infections (Review) [database online]. www.thecochranelibrary.com: The Cochrane Collaboration. 2008, Issue 3.

  15. van Nieuwkoop C, van't Wout JW, Spelt IC, et al. Prospective cohort study of acute pyelonephritis in adults: safety of triage towards home based oral antimicrobial treatment. J Infect. 2010 Feb. 60(2):114-21. [Medline].

  16. Nicolle L, Duckworth H, Sitar D, Bryski L, Harding G, Zhanel G. Pharmacokinetics/pharmacodynamics of levofloxacin 750 mg once daily in young women with acute uncomplicated pyelonephritis. Int J Antimicrob Agents. 2008 Mar. 31(3):287-9. [Medline].

  17. Peterson J, Kaul S, Khashab M, Fisher AC, Kahn JB. A double-blind, randomized comparison of levofloxacin 750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for the treatment of complicated urinary tract infections and acute pyelonephritis. Urology. 2008 Jan. 71(1):17-22. [Medline].

  18. Vouloumanou EK, Rafailidis PI, Kazantzi MS, Athanasiou S, Falagas ME. Early switch to oral versus intravenous antimicrobial treatment for hospitalized patients with acute pyelonephritis: a systematic review of randomized controlled trials. Curr Med Res Opin. 2008 Dec. 24(12):3423-34. [Medline].

  19. Harwood-Nuss AL, Etheredge W, McKenna I. Urological Emergencies. Harwood-Nuss A, Wolfson AB, eds. The Clinical Practice of Emergency Medicine. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001. 2227-61.

  20. Hansson S, Martinell J, Stokland E, Jodal U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am. 1997 Sep. 11(3):499-512. [Medline].

  21. Juliano TM, Stephany HA, Clayton DB, Thomas JC, Pope JC 4th, Adams MC, et al. Incidence of Abnormal Imaging and Recurrent Pyelonephritis After First Febrile Urinary Tract Infection in Children 2-24 Months. J Urol. 2013 Jan 22. [Medline].

 
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Nonobstructing distal left ureteral calculus 2 X 1 X 2 cm.
Multiple abscesses, upper pole of left kidney.
Bilateral hydronephrosis.
Table 1. Bacterial Etiology of Urinary Tract Infections
Bacteria % Uncomplicated % Complicated
Gram negative    
Escherichia coli 70-95 21-54
Proteus mirabilis 1-2 1-10
Klebsiella spp 1-2 2-17
Citrobacter spp < 1 5
Enterobacter spp < 1 2-10
Pseudomonas aeruginosa < 1 2-19
Other < 1 6-20
Gram positive    
Coagulase-negative staphylococci 5-10* 1-4
Enterococci 1-2 1-23
Group B streptococci < 1 1-4
Staphylococcus aureus < 1 1-23
Other < 1 2
Adapted from Hooton TM. The current management strategies for community-acquired urinary tract infection. Infect Dis Clin North Am. Jun 2003;17(2):303-32. [Medline].



* S saprophyticus



Table 2. Outpatient Treatment for Pyelonephritis
First-line therapy
  • ciprofloxacin (Cipro) 500 mg PO BID for 7d or
  • ciprofloxacin extended-release (Cipro XR) 1000 mg PO daily for 7d or
  • levofloxacin (Levaquin) 750 mg PO daily for 5d
  • If fluoroquinolone resistance is thought to be >10%, administer a single dose of ceftriaxone (Rocephin) 1g IV or  a consolidated 24-hour dose of an aminoglycoside (gentamicin 7 mg/kg IV or  tobramycin 7 mg/kg IV or amikacin 20 mg/kg IV)
Second-line therapy
  • trimethoprim/sulfamethoxazole* 160 mg/800 mg (Bactrim DS, Septra DS) 1 tablet PO BID for 14d
  • If trimethoprim/sulfamethoxazole 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  a consolidated 24-h dose of an aminoglycoside (gentamicin 7 mg/kg IV or  tobramycin 7 mg/kg IV or amikacin 20 mg/kg IV)
Alternative therapy
  • Oral beta-lactams are not as effective for treating pyelonephritis; however, if they are used, administer with a single dose of ceftriaxone (Rocephin) 1 g IV or  a consolidated 24-h dose of an aminoglycoside (gentamicin 7 mg/kg IV or  tobramycin 7 mg/kg IV or amikacin 20 mg/kg IV)
  • amoxicillin-clavulanate (Augmentin) 500 mg/125 mg PO BID for 14d or
  • amoxicillin-clavulanate (Augmentin) 250 mg/125 mg PO TID for 3-7d or
  • cefaclor 500 mg PO TID for 7d
*Should generally be avoided in elderly patients because of the risk of affecting renal function.
Table 3. Inpatient Treatment for Acute Pyelonephritis
First-line therapy
  • ciprofloxacin (Cipro) 400 mg IV q12h for 10-14d or
  • levofloxacin (Levaquin) 250 mg IV q24h for 10d or
  • levofloxacin (Levaquin) 750 mg IV q24h for 5d
Second-line therapy
Extended-spectrum cephalosporins or penicillins:



  • ampicillin 500 mg IM/IV q6h or
  • ampicillin-sulbactam (Unasyn) 1.5 g IV q6h or
  • piperacillin-tazobactam (Zosyn) 3.375 g IV q6h or
  • ticarcillin-clavulanate (Timentin) 3.1 g IV 4-6h or
  • cefotaxime (Claforan) 1-2 g IV q8h or
  • ceftriaxone (Rocephin) 1 g IV q24h or
  • ceftazidime (Fortaz, Tazicef) 2 g IV q8h
  • All of the above can be administered with or without an aminoglycoside (except in pregnant patients); see Aminoglycosides, below
Carbapenems:



  • meropenem (Merrem) 500 mg IV q8h or
  • ertapenem (Invanz) 1 g IV q24h or
  • doripenem (Doribax) 500 mg IV q8h
Monobactam (penicillin allergy):



  • aztreonam (Azactam) 1 g IV q8-12h
Alternative therapy
Aminoglycosides (because of their potential nephrotoxicity, aminoglycoside antibiotics should be reserved for patients with serious and potentially life-threatening infections, and their dosage and blood levels should be carefully monitored to minimize the risk of nephrotoxicity):
  • gentamicin 3 mg/kg/day IV/IM in 3 divided doses or 7 mg/kg/day pulsed dosing or
  • tobramycin 3 mg/kg/day IV/IM in 3 divided doses or 7 mg/kg/day pulsed dosing or
  • amikacin 10 mg/kg/day IV/IM in 3 divided doses or 20 mg/kg/day pulsed dosing
Table 4. Treatment of Pyelonephritis During Pregnancy
Mild to moderate pyelonephritis
  • ceftriaxone (Rocephin) 1 g IV q24h or
  • cefepime (Maxipime) 1 g IV q12h or
  • cefotaxime (Claforan) 1-2 g IV q8h or
  • ceftazidime (Fortaz, Tazicef) 2 g IV q8h or
  • ampicillin 1-2 g IV q6h plus  gentamicin IV 1.5 mg/kg q8h
Severe pyelonephritis
If patient is immunocompromised and/or has incomplete urinary drainage:
  • ticarcillin-clavulanate (Timentin) 3.1 g IV q6h or
  • ampicillin-sulbactam (Unasyn) 1.5 g IV q6h or
  • piperacillin-tazobactam (Zosyn) 3.375 g IV q6h
Table 5. Pediatric Urinary Tract Infections
  Neonates Infants 6 weeks to 3 years of age Children 3-6 years of age Children 6-11 years of age
UTI frequency (%) 1 1.5-3 1.5-3 1.2
Female-to-male ratio 1:1.5 10:1 10:1 30:1
Route of infection Blood Ascending Ascending Ascending
Signs and symptoms Failure to thrive, fever, hypothermia, irritability, jaundice, poor feeding, sepsis, vomiting Diarrhea, failure to thrive, fever, irritability, poor feeding, strong-smelling urine, vomiting Abdominal pain, dysuria, enuresis, fever, gross hematuria, meningismus, strong-smelling urine, urinary urgency, urinary frequency, vomiting Dysuria, enuresis, fever, flank pain or tenderness, urinary urgency, urinary frequency
Predominant organism Klebsiella species E coli E coli, Proteus species in older boys E coli
Management Admit for intravenous ampicillin and gentamicin and further evaluation Admit for intravenous ampicillin and gentamicin and further evaluation Follow adult guidelines, but avoid fluoroquinolones, which are theoretically contraindicated due to potential effects on the musculoskeletal system Follow adult guidelines, but avoid fluoroquinolones, which are theoretically contraindicated due to potential effects on the musculoskeletal system
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