eMedicine Specialties > Nephrology > Tubulointerstitial Diseases of the Kidney

Pyelonephritis, Acute: Treatment & Medication

Author: William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
Coauthor(s): Judith Green-McKenzie, MD, MPH, Associate Professor of Emergency Medicine, Director of Clinical Practice and Associate Director of Occupational Medicine, Department of Emergency Medicine, University of Pennsylvania School of Medicine, University Hospital; Christopher Edwards, MD, Staff Physician, Department of Emergency Medicine, University of Pennsylvania Medical School; Amy J Behrman, MD, Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine; Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine
Contributor Information and Disclosures

Updated: Jan 7, 2009

Treatment

Medical Care

  • Supportive care
    • Rest
    • Antipyretics as needed
    • Oral or parenteral pain medications as needed
    • Oral or parenteral antiemetics as needed
    • Urinary tract analgesics to relieve dysuria (up to 3 d)
    • Intravenous or oral fluids to maintain hydration status
  • Reasons for hospital admission
    • Cannot tolerate oral intake
    • Unstable social situation (eg, possibility of poor compliance or poor follow-up)
    • Unstable vital signs
    • Severe signs and symptoms
    • Pregnancy
    • Comorbid disorders that increase the complexity of management or the complication rate (eg, diabetes mellitus, chronic lung disease, congenital or acquired immunodeficiency syndrome)
  • Antibiotic selection
    • Antibiotic selection is typically empirical, because the results of blood or urine cultures are rarely available by the time a decision must be made.
    • Initial selection should be guided by local antibiotic resistance patterns. Urine culture collected at the initiation of therapy should be checked in 48 hours to determine antibiotic efficacy.
    • When using an oral-only regimen, the initial dose should be administered at the time of the evaluation.
    • See Medication for a list of other acceptable antibiotics that are not discussed here.
    • The etiology of community-acquired infections is usually E coli or other Enterobacteriaceae. Infections usually involve women aged 18-50 years and, infrequently, men of the same age. Accepted outpatient regimens include the following:
      • Administer ceftriaxone (1 g IV/IM) or gentamicin (single 24-h dose or divided q8h) or tobramycin (single 24-h dose or divided q8h) on day 1, followed by an oral fluoroquinolone from day 2 to days 10-14. For pediatric dosing, see Medication.1
      • Prescribe oral fluoroquinolone for 10-14 days.1,2
      • Prescribe amoxicillin-clavulanate potassium for 14 days.
      • Prescribe trimethoprim-sulfamethoxazole or trimethoprim or oral cephalosporin for 14 days. Use only if the organism is known to be sensitive.
      • If beta-lactam drugs and fluoroquinolones are contraindicated, administer aztreonam parenterally; as such, the patient will need to be admitted.  
    • The fluoroquinolone course can be shortened to a 7-day course, instead of 10-14 days, in healthy, young women with uncomplicated pyelonephritis; a similar course probably could be used in healthy, young men without any complicating comorbidity, particularly if there is a prompt response to therapy.3,4
    • Studies have demonstrated the efficacy of levofloxacin (750 mg/d for 5 d) in the treatment of uncomplicated pyelonephritis and complicated UTI.2,1 This same regimen has also been demonstrated to be safe and efficacious in comparison with ciprofloxacin (400-500 mg bid for 10-14 d).2
    • Growing data suggest that oral antibiotic therapy alone versus parenteral antibiotic only or initial parenteral antibiotic therapy followed by oral antibiotic therapy are all equally efficacious, although most of the studies are small.5  
    • Some clinicians believe that initiating therapy with an intravenous or intramuscular dose of medication reduces the risk of therapeutic failure; other clinicians believe that an oral course is sufficient. Data exist to support both assertions. One prospective study supports using oral therapy alone in patients who can tolerate oral intake, lack signs of sepsis, and do not show signs of obstruction or renal suppuration on urinary tract ultrasonography findings. Another study (prospective, randomized, unblinded) in a controlled, hospital setting compared oral versus intravenous ciprofloxacin for the initial management of severe pyelonephritis. Both regimens were equally efficacious. If the patient can tolerate oral medication, there is no indication for admission, and the patient can be monitored closely to ensure good compliance. An oral antibiotic therapy only regimen appears to have increasing efficacy. 
    • If enterococci are suggested based on Gram stain results, then ampicillin or vancomycin can replace fluoroquinolone. If any doubt exists as to the diagnosis, then coverage of both Enterobacteriaceae and enterococci is acceptable.
    • Enterococci have a higher incidence in hospitalized and other institutionalized patients. Ampicillin or amoxicillin should be included in the regimen. If the patient is allergic to penicillin, then vancomycin should be substituted.
    • Admit patients who appear toxic, if they are not already hospitalized. Refer to Sepsis, Bacterial if this diagnosis is being considered. If complicated acute pyelonephritis is suggested, use one of the following regimens:
      • Treat patients parenterally until they improve clinically. Complete the course of therapy with an oral agent selected based on culture results.
      • Acceptable regimens include the following: (1) ampicillin and an aminoglycoside, (2) cefepime, (3) imipenem, (4) meropenem, (5) piperacillin-tazobactam, or (6) ticarcillin-clavulanate. If the patient is allergic to penicillin, substitute vancomycin.
      • Vancomycin or linezolid are options if enterococci are a consideration.

Surgical Care

Surgical intervention may be emergent if it occurs during active infection, or it may be elective if it occurs after recovery from infection. Emergent surgery is performed to preserve kidney function or to save the life of the patient. Elective surgical intervention reduces or prevents future morbidity.

Elective surgery is performed to reverse conditions that predispose the kidney to recurrent infections and renal damage. These conditions include congenital anomalies, fistulae involving the urogenital tract, prostatic hypertrophy, renal calculi, and vesicoureteral reflux.

An emergent surgical condition may be indicated by a patient with fever or positive blood culture results persisting longer than 48 hours, a patient with a deteriorating condition, or a patient who appears toxic for longer than 72 hours. The etiology may not be immediately evident, but an unexpected change in the clinical picture warrants immediate evaluation for potential surgical intervention. The following is a list of conditions that are in the differential diagnosis of surgical conditions relative to patients presenting with acute pyelonephritis who do not respond to standard therapy.

  • Renal cortical abscess (renal carbuncle)
    • This is an uncommon condition that is usually caused by the hematogenous spread of S aureus. It occurs 3 times more commonly in men than in women. Microabscesses develop in the cortex and coalesce to form a circumscribed abscess that may or may not communicate with the collecting system. This process takes days to months. Patient presentation includes fever, chills, back pain, abdominal pain, flank mass, and urinary symptoms if the collecting system is involved.
    • Blood culture results are usually negative. Diagnosis is best made using CT scan, although ultrasonography can be useful in distinguishing among an abscess, a cyst, and a tumor. Treatment includes parenteral antibiotics for 10-14 days, incision and drainage, enucleation of the carbuncle, nephrectomy, or any combination of these therapies. If parenteral antibiotic therapy is successful, oral therapy is instituted for an additional 2-4 weeks.
  • Renal corticomedullary abscess
    • This condition is usually associated with a urinary tract abnormality such as vesicoureteral reflux or obstruction. It is commonly caused by Enterobacteriaceae.
    • The pathology represents a spectrum of disease, as follows:
      • Acute focal bacterial nephritis (eg, acute lobar nephroma, focal pyelonephritis) that affects a single renal lobe with interstitial inflammation represented by marked polymorphonuclear leukocytes
      • Acute multifocal bacterial nephritis with a similar process throughout the kidney that produces liquefaction and abscess formation
      • XGP with chronic parenchymal infection, granulomatous tissue, and perirenal fibrosis (see Xanthogranulomatous pyelonephritis below)
      • Emphysematous pyelonephritis with severe, necrotizing infection (discussed separately below)
    • Men and women are equally affected by these conditions, although XGP affects women more often than men. The presentation of the first 3 described entities includes fever, chills, abdominal pain, flank pain, nausea, vomiting, urinary symptoms (may be absent), flank mass (60%), hepatomegaly (30%), draining sinus in the flank (rare), leukocytosis, bacteriuria/pyuria (normal urine in 30%), and bacteremia (acute forms of disease).
    • CT scan is the preferred imaging method. Treatment includes parenteral antibiotics for 48 hours (usually successful), incision and drainage, and nephrectomy. If antibiotic therapy is successful, oral therapy is instituted for an additional 2 weeks.
  • Emphysematous pyelonephritis
    • Emphysematous pyelonephritis is a severe, necrotizing form of acute multifocal bacterial nephritis with extension of the infection through the renal capsule. This leads to the presence of gas within the kidney substance and in the perinephric space. Persons with diabetes (with or without obstruction) account for 85-100% of cases, although some cases have occurred in patients who had obstruction without diabetes. Females outnumber males (2-6:1).
    • Emphysematous pyelonephritis occurs on the left side in approximately two thirds of cases. The etiology is usually Enterobacteriaceae (E coli, 60%), with some reported cases of Streptococcus species and Candida species. A triad of diabetes, obstruction, and remote or recent pyelonephritis should raise clinical suspicion. Patient presentation includes fever, chills, abdominal pain, nausea, vomiting, flank pain, flank mass (50%), crepitation (over thigh or flank), urinary symptoms, and pyuria.
    • CT scan is the preferred imaging method to use in the diagnosis and to help localize the gas pattern to the collecting system, intrarenal, or perinephric. Plain radiographs (85%) and ultrasonography can help detect renal emphysema but do not help in localization. Considerable mortality is associated with this entity. When gas is within the kidney only, the mortality rate is 60% (antibiotic therapy with surgical drainage); when gas extends to the perinephric space, the mortality rate is 80% (antibiotic therapy only); when nephrectomy is performed, the mortality rate is 20%.
  • Perinephric abscess
    • The suppurative material of the abscess is located between the renal capsule and the surrounding renal fascia. The material is secondary to chronic or recurrent pyelonephritis, rupture or extension of a suppurative process from within the kidney, or dissemination (blood, lymph) or direct extension from other sites of infection. Although it is usually confined to the perinephric space, it may extend to the colon, flank, groin, lung (empyema, nephrobronchial fistula), paracervical area, peritoneal cavity, psoas muscle, skin surface, or subphrenic space.
    • Development is insidious. Patient presentation includes fever, chills, unilateral flank pain (70%), dysuria (40%), nausea, vomiting, weight loss (25%), flank tenderness, CVA tenderness, abdominal tenderness (60%), referred pain (ie, hip, thigh, or knee), flank or abdominal mass (<50%), pyuria (70%), sterile urine (40%), and bacteremia (40%). One third of patients are diagnosed upon admission; another third are diagnosed at autopsy. This diagnosis is not usually readily apparent; a high index of clinical awareness is necessary.
    • CT scan is the preferred diagnostic study. Ultrasound findings may be falsely negative in 36% cases. MRI may help define extension better than CT scan. The mortality rate is 20-50%, but this rate can be decreased with early recognition, surgical drainage, and antimicrobial therapy (not adequate alone). Antibiotics should include an aminoglycoside and an antistaphylococcal agent. If Pseudomonas species are considered or demonstrated, an antipseudomonal beta-lactam antibiotic should be added. For enterococci, an aminoglycoside and ampicillin are recommended. Other organisms that have been reported include tuberculosis and fungi. Nephrectomy may be necessary.
  • Obstructing calculus
    • Obstructing calculi may pass with time, hydration, and analgesia.
    • In the presence of acute infection, they must be removed immediately using cystoscopy or open surgical procedure.
  • Renal papillary necrosis
    • Most patients with renal papillary necrosis have diabetes. Patient presentation is similar to that for pyelonephritis.
    • The imaging study of choice is retrograde pyelography. Confirmatory evidence is histologic verification of voided medullary tissue, which may occur only at autopsy. Treatment is admission for intravenous antibiotics (see Medical Care). If the response is not good, CT-guided drainage or surgical drainage with debridement is indicated.
  • Xanthogranulomatous pyelonephritis
    • This rare form of pyelonephritis is almost always associated with chronic obstruction (ie, staghorn calculus [75% cases], another calculus, stricture, or tumor). In adults, the female-to-male ratio is 3:1; in children, it is 1.1:1.
    • It is a chronic infection that finally manifests acutely with fever and flank pain or tenderness, and it may be complicated by a flank mass, cutaneous fistula, septic arthritis, or hematochezia if extension has occurred beyond the renal capsule. Kidney function is absent (71%) or poor (25%) in almost all cases. Diagnosis is difficult preoperatively.
    • The imaging study of choice is CT scan. Ultrasound images may suggest the diagnosis in the presence of an enlarged kidney and a staghorn calculus.
    • The treatment of choice is nephrectomy after the patient is stabilized. See Xanthogranulomatous Pyelonephritis for more information.
  • Staghorn calculus: Infectious stones, urease stones, or triple-phosphate stones composed of magnesium ammonium phosphate or struvite and apatite account for 10-15% of all urinary stones. They develop secondary to the action of urea-splitting organisms (see Pathophysiology) and can grow rapidly and branch out.
    • If left untreated, they will destroy the kidney and may cause the death of the patient. Complications include azotemia, hydropyonephrosis, perinephric abscess, pyelonephritis (severe or end-stage), sepsis, and XGP.
    • The treatment of choice is to remove the whole stone. Fragments left behind remain infected and will grow again.

Consultations

Consultation is indicated if the infection is complicated. Most cases of acute pyelonephritis occur in adult women and are readily managed without consultation. The following are reasons for consulting various subspecialists.

  • A urologist may be consulted regarding patients with ureteral or urethral obstruction, urinary stones, urogenital abnormality, recurrent pyelonephritis, or for the first episode of pyelonephritis in an infant or child.
  • A renal specialist may be consulted regarding patients with acute renal failure or advanced chronic renal failure or for neonates or infants.
  • An infectious diseases specialist may be consulted regarding patients with an unusual or resistant pathogen, those who are immunocompromised, patients with persisting fever (>48 h) or toxicity (>72 h), or patients whose blood culture results are positive beyond 48 hours.
  • An obstetrician may be consulted for patients who are pregnant.

Diet

A regular diet is permitted as tolerated. Special dietary considerations, such as those associated with diabetes mellitus, should be honored. Hydration status is very important.

  • If oral intake is not tolerated, intravenous hydration is warranted. Intravenous fluids should include 1 L of 5% dextrose in saline to reverse any existing ketosis, regardless of whether ketones are detected in the urine. Additional intravenous hydration is accomplished with saline.
  • If admission is not indicated and the patient will be monitored in an outpatient setting, hydration status should be normalized with intravenous fluids; the physician should not assume that the patient can or will accomplish this with oral hydration alone.
  • When hydrating intravenously, exercise caution regarding conditions that might be adversely affected by improper amounts of fluid, saline, or glucose.

Activity

Rest is essential for recovery. Activity should be minimized. Patients who are treated in an outpatient setting should not return to work for 2 weeks in order to allow time for the infection to be eliminated. This time also allows the patient to recuperate physical strength. This recommendation can be tempered in special circumstances as warranted by the clinician.

Medication

Several classes of drugs may be required for the management of pyelonephritis. These pharmaceuticals include antibiotics, analgesics, antipyretics, and antiemetics. Only antibiotics and urinary tract analgesics are specifically addressed. Symptomatic management using analgesics, antipyretics, and antiemetics is accomplished by oral or parenteral means according to the clinical condition of the patient.

Nitrofurantoin is not used for the treatment of pyelonephritis or any other infection at the tissue level. It is included in this drug list because it is discussed in Special Concerns as asymptomatic bacteriuria therapy and postcoital therapy. It is also discussed in Deterrence/Prevention for uncomplicated UTI therapy and continuous therapy.

Norfloxacin lacks significant efficacy compared to the other fluoroquinolones listed below and is not recommended for the treatment of pyelonephritis. Moxifloxacin is another fluoroquinolone that is not recommended for pyelonephritis because tissue levels may not be sufficient to irrigate the infecting organism.

Other antibiotics reported to be effective in the management of acute pyelonephritis include parenteral penicillins, third-generation cephalosporins (eg, cefotaxime), oral fluoroquinolones (eg, enoxacin, lomefloxacin, ofloxacin), parenteral fluoroquinolones (eg, lomefloxacin), and aminoglycosides (eg, amikacin).

Antibiotics

Therapy should cover all likely pathogens in the context of this clinical setting. Antibiotic selection should be guided by blood or urine culture sensitivity results whenever feasible.


Ciprofloxacin (Cipro)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Adult

250-500 mg PO bid for 7-14 d

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy


Levofloxacin (Levaquin)

For pseudomonal infections and infections due to multidrug-resistant gram-negative organisms.

Adult

Inpatient: 500 mg/d IV until patient improves clinically, then switch to PO to complete 7-d course; if necessary, can be extended to 14 d
Outpatient: 500 mg PO/IV at time of diagnosis, followed by 500 mg/d PO to complete 7-d course; if necessary, can be extended to 14 d

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy


Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Adult

Uncomplicated infection: 250 mg IM once; not to exceed 4 g/d
Severe infection: 1-2 g IV qd or divided bid; not to exceed 4 g/d

Pediatric

<7 days: Not established
>7 days: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d

Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; caution in breastfeeding and allergy to penicillin


Gentamicin (Garamycin)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes.
Not the DOC. Consider if 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 dose based on CrCl and changes in volume of distribution. May be given IV/IM.

Adult

Serious infection and normal renal function: 3 mg/kg/d IV q8h
Loading dose and maintenance dose: 1-2.5 mg/kg IV and 1-1.5 mg/kg IV, respectively, q8h
Extended dosing regimen for life-threatening infections: 5 mg/kg/d IV/IM q6-8h
Follow each regimen by at least a trough level drawn on the third or fourth dose (0.5 h before dosing); may draw a peak level 0.5 h after 30-min infusion

Pediatric

<5 years: 2.5 mg/kg/dose IV/IM q8h
>5 years: 1.5-2.5 mg/kg/dose IV/IM q8h or 6-7.5 mg/kg/d divided q8h; not to exceed 300 mg/d; monitor as in adults

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment


Ampicillin (Principen, Omnipen, Marcillin)

Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.

Adult

250-500 mg PO q6h; 500 mg to 1.5 g IM q4-6h; 500 mg to 3 g IV q4-6h; not to exceed 12 g/d

Pediatric

50-100 mg/kg/d PO divided q4-6h; 100-400 mg/kg/d IM/IV divided q4-6h

Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction


Amoxicillin (Amoxil, Trimox)

Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.

Adult

250-500 mg PO q8h; not to exceed 3 g/d

Pediatric

20-50 mg/kg/d PO divided q8h

Reduces efficacy of oral contraceptives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; may enhance chance of candidiasis


Vancomycin (Vancocin)

Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or did not respond to penicillins and cephalosporins or patients who have infections with resistant staphylococci. For penetrating abdominal injuries, combine with an agent active against enteric flora and/or anaerobes.
To avoid toxicity, current recommendation is to assay trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.

Adult

500 mg to 2 g/d IV divided tid/qid 7-10 d

Pediatric

40 mg/kg/d IV divided tid/qid 7-10 d

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure and neutropenia; red man syndrome is caused by IV infusion that is too rapid (dose given over a few min) but rarely happens when dose given as 2-h administration or as PO or IP administration; red man syndrome is not an allergic reaction


Cephalexin (Keflex)

First-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora; used for skin infections or prophylaxis in minor procedures.

Adult

250-1000 mg PO q6h for 10-14 d; not to exceed 4 g/d

Pediatric

25-50 mg/kg/d PO q6h; not to exceed 3 g/d

Coadministration with aminoglycosides increases nephrotoxic potential

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment


Nitrofurantoin (Macrobid, Macrodantin)

Synthetic nitrofuran that interferes with bacterial carbohydrate metabolism by inhibiting acetylcoenzyme A. Bacteriostatic at low concentrations (5-10 mcg/mL) and bactericidal at higher concentrations.

Adult

50-100 mg/dose PO q6h

Pediatric

<1 month: Not established
>1 month: 5-7 mg/kg/d PO divided q6h; not to exceed 400 mg/d
Long-term therapy: 1-2 mg/kg/d PO divided 12-24 h; not to exceed 100 mg/d

Anticholinergics may delay gastric emptying and increase absorption, increasing nitrofurantoin bioavailability; antacids made of magnesium salts may decrease effects by decreasing absorption; high doses of probenecid concurrently decrease renal clearance and increase toxicity

Documented hypersensitivity; renal insufficiency (CrCl <60 mL/min), anuria, or oliguria

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause severe and irreversible peripheral neuropathy that can be fatal; renal impairment, diabetes, electrolyte imbalance, anemia, and vitamin B deficiency increase risk for adverse effects; prolonged use of antibiotics may result in fungal or bacterial overgrowth of resistant or nonsusceptible organisms


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

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except P aeruginosa.

Adult

160 mg TMP/800 mg SMZ PO q12h for 10-14 d

Pediatric

<2 months: Do not administer
>2 months: 15-20 mg/kg/d, based on TMP, PO tid/qid for 14 d

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine

Documented hypersensitivity; megaloblastic anemia due to folate deficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, elderly persons, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in those with G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation


Norfloxacin (Noroxin)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Adult

400 mg PO bid for 3-21 d; not to exceed 800 mg/d

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy


Ampicillin and sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.
Used for treatment of pyelonephritis. Both ampicillin and sulbactam are excreted in the urine.

Adult

3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Pediatric

Not established

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reactions


Tobramycin (Nebcin)

Used in skin, bone and skin-structure infections caused by Staphylococcus aureus, P aeruginosa, E coli, and Klebsiella, Proteus, and Enterobacter species. Indicated in treatment of staphylococcal infections when penicillin or potentially less-toxic drugs are contraindicated and when bacterial susceptibility and clinical judgment justify its use. Dosing regimens are numerous and are adjusted on basis of CrCl and changes in volume of distribution.

Adult

Serious infections and normal renal function: 3 mg/kg IV/IM q8h
Extended dosing regimen for life-threatening infections: 5 mg/kg IV/IM q6-8h
Usual loading dose: 1-2.5 mg/kg IV; maintenance dose, 1-1.5 mg/kg IV q8h
Each regimen must be followed by at least trough level drawn on third or fourth dose 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion

Pediatric

<5 years with normal renal function: 2.5 mg/kg IV/IM q8h
>5 years: 1.5-2.5 mg/kg IV/IM q8h or 6-7.5 mg/kg/d IV/IM divided q8h; not to exceed 300 mg/d; adjustments for renal function as needed; monitor levels as in adults

Effects decrease when used concurrently with gentamicin

Documented hypersensitivity; mycobacterial, viral, and fungal infections of the eye; steroid combinations after uncomplicated removal of a foreign body from cornea should also avoid using this product

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Do not use in deep-seated ocular infections or in those that may become systemic; prolonged use of antibiotics, may result in bacterial or fungal overgrowth of nonsusceptible organisms


Aztreonam (Azactam)

A monobactam, not a beta-lactam, antibiotic that inhibits cell wall synthesis during bacterial growth. Active against gram-negative bacilli but very limited gram-positive activity and not useful for anaerobes. Lacks cross-sensitivity with beta-lactam antibiotics. May be used in patients allergic to penicillins or cephalosporins.
Duration of therapy depends on severity of infection and continued for at least 48 h after patient asymptomatic or evidence of bacterial eradication obtained. Doses smaller than indicated should not be used.
Transient or persistent renal insufficiency may prolong serum levels. After initial loading dose of 1 or 2 g, reduce dose by one half for estimated ClCr of 10-30 mL/min/1.73 m2. When only serum creatinine concentration available, the following formula (based on sex, weight, and age) can approximate ClCr. Serum creatinine should represent a steady state of renal function.
Males: ClCr = [(weight in kg)(140 - age)] divided by (72 X serum creatinine in mg/dL)
Females: 0.85 X above value
In patients with severe renal failure (ClCr <10 mL/min/1.73 m2), those supported by hemodialysis, usual dose of 500 mg, 1 g, or 2 g, is given initially.
Maintenance dose is one fourth of usual initial dose given at usual fixed interval of 6, 8, or 12 h.
For serious or life-threatening infections, supplement maintenance doses with one-eighth of initial dose after each hemodialysis session.
Elderly persons may have diminished renal function. Renal status is a major determinant of dosage in these patients. Serum creatinine may not be an accurate determinant of renal status. Therefore, as with all antibiotics eliminated by kidneys, obtain estimates of ClCr, and make appropriate dosage modifications. Insufficient data are available regarding IM administration to pediatric patients or dosing in pediatric patients with renal impairment. Administered IV only to pediatric patients with normal renal function.

Adult

500-1000 g q8-12h IV/IM

Pediatric

90-120 mg/kg/d divided q6-8h IV/IM

Tetracyclines may reduce effects

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal insufficiency


Meropenem (Merrem IV)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Effective against most gram-positive and gram-negative bacteria.
Has slightly increased activity against gram-negatives and slightly decreased activity against staphylococci and streptococci compared to imipenem.

Adult

1 g IV q8h

Pediatric

40 mg/kg IV q8h

Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Dosage adjustments (adult adjustments)
CrCl (mL/min) 10-50: 0.5-1 g q12h
CrCl <10: 0.5 g/d
Hemodialysis (HD): As for CrCl <10, with an extra 0.5 g after HD
Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication


Piperacillin and Tazobactam sodium (Zosyn)

Anti-pseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.

Adult

3/0.375 g (piperacillin 3 g and tazobactam 0.375 g) IV q6h

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels; high dose parenteral penicillins may result in increased risk of bleeding

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions


Ticarcillin and clavulanate potassium (Timentin)

Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth.
Anti-pseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positives, most gram-negatives, and most anaerobes.

Adult

3.1 g IV q4-6h

Pediatric

75 mg/kg IV q6h

Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions


Imipenem and cilastatin (Primaxin)

For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated due to potential for toxicity.

Adult

Base initial dose on severity of infection, and administer in equally divided doses; dose may range from 250-500 mg q6h IV for a maximum of 3-4 g/d
Alternatively, 500-750 mg q12h IM or intra-abdominally

Pediatric

Infants >3 months and children <12 years: 15-25 mg/kg/dose IV q6h
Fully susceptible organisms: Not to exceed 2 g/d
Infections with moderately susceptible organisms: Not to exceed 4 g/d
>12 years: Administer as in adults

Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures

Documented hypersensitivity; known hypersensitivity to amide local anesthetics; children with CNS infections (increased seizure risk); children <30 kg with renal impairment (lack of data)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in renal insufficiency (adult adjustments)
CrCl (mL/min) 80-50: 0.5 g q6-8h
CrCl 50-10: 0.5 g q8-12h
Hemodialysis (HD): 0.25-0.5 g after HD, then q12h
Adjust dose in renal insufficiency; avoid use in children <12 y with CNS infections
Caution with history of seizures, hypersensitivity to penicillins, cephalosporins, or other beta lactam antibiotics

Urinary analgesics

Indicated when patient has dysuria to such an extent that it disrupts activities of daily living.


Phenazopyridine (Pyridium, Urodine, Urogesic)

Azo dye excreted in urine, where it exerts a topical analgesic effect on urinary tract mucosa. Compatible with antibacterial therapy and can help relieve pain and discomfort before antibacterial therapy controls infection. 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. Analgesic action may reduce or eliminate need for systemic analgesics or narcotics.

Adult

200 mg tid PO pc for 2 d

Pediatric

<6 years: Not established
6-12 years: 12 mg/kg/d divided tid PO for 2 d
>12 years: Administer as in adults

Documented hypersensitivity; renal insufficiency

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal insufficiency; yellowish tinge of skin or sclera may indicate accumulation because of impaired renal excretion (discontinue therapy); treatment of UTI with phenazopyridine should not exceed 2 d because no evidence exists indicating this is more beneficial than the antibiotic alone following 2 d of therapy; dye may stain clothing

More on Pyelonephritis, Acute

Overview: Pyelonephritis, Acute
Differential Diagnoses & Workup: Pyelonephritis, Acute
Treatment & Medication: Pyelonephritis, Acute
Follow-up: Pyelonephritis, Acute
References
[ CLOSE WINDOW ]

References

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Further Reading

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Keywords

infectious tubulointerstitial nephritis, kidney infection, renal infection, upper urinary tract infection, upper UTI, Escherichia coli, E coli, bacterial infection, gram-positive infection, uropathogens, urovirulent organisms, urinary obstruction, prostatic infection, calculi, urinary diversion procedure, infected cysts, urinary catheter, nephrostomy tubes, vesicoureteral reflux, neurogenic bladder, bladder abscess, renal abscess, perinephric abscess, diabetes mellitus, pregnancy complications, renal impairment, xanthogranulomatous pyelonephritis, XGP, malakoplakia, primary biliary cirrhosis, transplantation, neutropenia, AIDS, immunodeficiency, emphysematous pyelonephritis, sepsis

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Contributor Information and Disclosures

Author

William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
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 Consulting fee Consulting; Glaxo Smith Kline Honoraria Speaking and teaching

Coauthor(s)

Judith Green-McKenzie, MD, MPH, Associate Professor of Emergency Medicine, Director of Clinical Practice and Associate Director of Occupational Medicine, Department of Emergency Medicine, University of Pennsylvania School of Medicine, University Hospital
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.

Christopher Edwards, MD, Staff Physician, Department of Emergency Medicine, University of Pennsylvania Medical School
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.

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.

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, 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.

Medical Editor

Chike Magnus Nzerue, MD, Associate Dean for Clinical Affairs, 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eleanor Lederer, MD, Consulting Staff, Louisville VA Hospital; Professor of Medicine, Director of Nephrology Training Program, Kidney Disease Program, University of Louisville School of Medicine; Director, Metabolic Stone Clinic
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: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Roche Honoraria Consulting

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, 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, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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