Guidelines Summary

The United Kingdom's National Institute for Health and Care Excellence (NICE) has issued guidelines on acute pyelonephritis in children, young people, and adults who do not have a urinary catheter in place. The recommendations cover management, self care, and choice of first-line antibiotic; for second-line therapy, NICE advises consulting with a local microbiologist.^[46]

For non-pregnant women and males aged 16 years and over, first-choice oral antibiotics are as follows:

Cephalexin
Amoxicillin/clavulanate (if culture confirms susceptibility)
Trimethoprim (if culture confirms susceptibility)
Ciprofloxacin (but consider safety issues; discontinue at the first signs of a serious adverse reaction, including tendon pain or inflammation)

First-choice intravenous (IV) antibiotics (eg, for patients who are vomiting, unable to take oral antibiotics, or severely unwell) are as follows (antibiotics may be combined if susceptibility or sepsis is a concern):

Amoxicillin/clavulanate (only in combination, and if culture confirms susceptibility)
Cefuroxime
Ceftriaxone
Ciprofloxacin (but consider safety issues)
Gentamicin
Amikacin

First-choice antibiotics for pregnant women aged 12 years and over are as follows:

Oral: Cephalexin
IV: Cefuroxime

For children < 3 months, the NICE guidelines recommend referral to a pediatric specialist for treatment with IV antibiotics. For children > 3 months and adolescents under 16 years of age, first-choice oral antibiotics are as follows:

Cephalexin
Amoxicillin/clavulanate (if culture confirms susceptibility)

First-choice IV antibiotics for children > 3 months and adolescents under 16 years of age are as follows:

Amoxicillin/clavulanate (only in combination, and if culture confirms susceptibility)
Cefuroxime
Ceftriaxone
Gentamicin
Amikacin

Medication

Johnson JR, Russo TA. Acute Pyelonephritis in Adults. N Engl J Med. 2018 Jan 4. 378 (1):48-59. [QxMD MEDLINE Link].
Belyayeva M, Jeong JM. Acute Pyelonephritis. 2023 Jan. [QxMD MEDLINE Link]. [Full Text].
[Guideline] 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. [QxMD MEDLINE Link]. [Full Text].
Chung VY, Tai CK, Fan CW, Tang CN. Severe acute pyelonephritis: a review of clinical outcome and risk factors for mortality. Hong Kong Med J. 2014 Aug. 20 (4):285-9. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Choong FX, Antypas H, Richter-Dahlfors A. Integrated Pathophysiology of Pyelonephritis. Microbiol Spectr. 2015 Oct. 3 (5):[QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Medina M, Castillo-Pino E. An introduction to the epidemiology and burden of urinary tract infections. Ther Adv Urol. 2019 Jan-Dec. 11:1756287219832172. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Jeon DH, Jang HN, Cho HS, Lee TW, Bae E, Chang SH, et al. Incidence, risk factors, and clinical outcomes of acute kidney injury associated with acute pyelonephritis in patients attending a tertiary care referral center. Ren Fail. 2019 Nov. 41 (1):204-210. [QxMD MEDLINE Link]. [Full Text].
Graversen HV, Nørgaard M, Nitsch D, Christiansen CF. Preadmission kidney function and risk of acute kidney injury in patients hospitalized with acute pyelonephritis: A Danish population-based cohort study. PLoS One. 2021. 16 (3):e0247687. [QxMD MEDLINE Link]. [Full Text].
Ozen C, Ertan P, Aras F, Gumuser G, Ozkol M, Horasan Dinc G. Evaluation of abnormal radiological findings in children aged 2 to 36 months followed by recurrent urinary tract infection: a retrospective study. Ren Fail. 2017 Nov. 39 (1):100-103. [QxMD MEDLINE Link].
Herrera-Bedoya M, Avendaño-Capriles CA, Zakzuk-Martinez E, Barrera J. Xanthogranulomatous Pyelonephritis and Its Differential Diagnoses: An In-Depth Case Review. Cureus. 2021 Oct. 13 (10):e19133. [QxMD MEDLINE Link]. [Full Text].
Lumbiganon P, Laopaiboon M, Thinkhamrop J. Screening and treating asymptomatic bacteriuria in pregnancy. Curr Opin Obstet Gynecol. 2010 Apr. 22(2):95-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[Guideline] Expert Panel on Urological Imaging, Smith AD, Nikolaidis P, Khatri G, Chong ST, De Leon AD, et al. ACR Appropriateness Criteria® Acute Pyelonephritis: 2022 Update. J Am Coll Radiol. 2022 Nov. 19 (11S):S224-S239. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Rathod SB, Kumbhar SS, Nanivadekar A, Aman K. Role of diffusion-weighted MRI in acute pyelonephritis: a prospective study. Acta Radiol. 2015 Feb. 56 (2):244-9. [QxMD MEDLINE Link].
Martina MC, Campanino PP, Caraffo F, et al. Dynamic magnetic resonance imaging in acute pyelonephritis. Radiol Med. 2010 Mar. 115(2):287-300. [QxMD MEDLINE Link].
Enikeev DV, Glybochko P, Alyaev Y, Enikeev M, Rapoport L. Imaging technologies in the diagnosis and treatment of acute pyelonephritis. Urologia. 2017 Aug 1. 84 (3):179-184. [QxMD MEDLINE Link].
Aoyagi J, Kanai T, Odaka J, Ito T, Saito T, Betsui H, et al. Non-enhanced magnetic resonance imaging versus renal scintigraphy in acute pyelonephritis. Pediatr Int. 2018 Feb. 60 (2):200-203. [QxMD MEDLINE Link].
Bosakova A, Salounova D, Havelka J, Kraft O, Sirucek P, Kocvara R, et al. Diffusion-weighted magnetic resonance imaging is more sensitive than dimercaptosuccinic acid scintigraphy in detecting parenchymal lesions in children with acute pyelonephritis: A prospective study. J Pediatr Urol. 2018 Jun. 14 (3):269.e1-269.e7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[Guideline] Lee RA, Centor RM, Humphrey LL, Jokela JA, Andrews R, Qaseem A. Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of Physicians. Ann Intern Med. 2021 Jun. 174 (6):822-827. [QxMD MEDLINE Link]. [Full Text].
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.
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. [QxMD MEDLINE Link].
Ren H, Li X, Ni ZH, Niu JY, Cao B, Xu J, et al. Treatment of complicated urinary tract infection and acute pyelonephritis by short-course intravenous levofloxacin (750 mg/day) or conventional intravenous/oral levofloxacin (500 mg/day): prospective, open-label, randomized, controlled, multicenter, non-inferiority clinical trial. Int Urol Nephrol. 2017 Mar. 49 (3):499-507. [QxMD MEDLINE Link]. [Full Text].
Fox MT, Melia MT, Same RG, Conley AT, Tamma PD. A Seven-Day Course of TMP-SMX May Be as Effective as a Seven-Day Course of Ciprofloxacin for the Treatment of Pyelonephritis. Am J Med. 2017 Jul. 130 (7):842-845. [QxMD MEDLINE Link].
Wagenlehner FM, Sobel JD, Newell P, Armstrong J, Huang X, Stone GG, et al. Ceftazidime-avibactam Versus Doripenem for the Treatment of Complicated Urinary Tract Infections, Including Acute Pyelonephritis: RECAPTURE, a Phase 3 Randomized Trial Program. Clin Infect Dis. 2016 Jun 16. [QxMD MEDLINE Link].
Lowes, R. New Antibiotic Avycaz Wins FDA Approval. Medscape Medical News. February 26, 2015. Available at https://www.medscape.com/viewarticle/840500.
FDA approves new antibacterial drug. U.S. Food & Drug Administration. Available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm573955.htm. August 29, 2017; Accessed: May 27, 2023.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
FDA In Brief: FDA warns that fluoroquinolone antibiotics can cause aortic aneurysm in certain patients. U.S. Food & Drug Administration. Available at https://www.fda.gov/news-events/fda-brief/fda-brief-fda-warns-fluoroquinolone-antibiotics-can-cause-aortic-aneurysm-certain-patients. December 20, 2018; Accessed: May 27, 2023.
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. [QxMD MEDLINE Link].
Hobbs AL, Shea KM, Daley MJ, Huth RG, Jaso TC, Bissett J, et al. Are first-generation cephalosporins obsolete? A retrospective, non-inferiority, cohort study comparing empirical therapy with cefazolin versus ceftriaxone for acute pyelonephritis in hospitalized patients. J Antimicrob Chemother. 2016 Jun. 71 (6):1665-71. [QxMD MEDLINE Link].
Elbaz M, Zadka H, Weiss-Meilik A, Ben-Ami R. Effectiveness and safety of an institutional aminoglycoside-based regimen as empirical treatment of patients with pyelonephritis. J Antimicrob Chemother. 2020 Aug 1. 75 (8):2307-2313. [QxMD MEDLINE Link].
Kyriazopoulou E, Liaskou-Antoniou L, Adamis G, et al. Procalcitonin to Reduce Long-Term Infection-associated Adverse Events in Sepsis. A Randomized Trial. Am J Respir Crit Care Med. 2021 Jan 15. 203 (2):202-210. [QxMD MEDLINE Link]. [Full Text].
Haas CR, Li G, Hyams ES, Shah O. Delayed Decompression of Obstructing Stones with Urinary Tract Infection is Associated with Increased Odds of Death. J Urol. 2020 Dec. 204 (6):1256-1262. [QxMD MEDLINE Link].
Luk T, Edwards BD, Bates D, Evernden C, Edwards J. Nitrofurantoin-induced liver failure: A fatal yet forgotten complication. Can Fam Physician. 2021 May. 67 (5):342-344. [QxMD MEDLINE Link]. [Full Text].
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.
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. [QxMD MEDLINE Link].
[Guideline] Pyelonephritis (acute): antimicrobial prescribing. NICE. Available at https://www.nice.org.uk/guidance/ng111. 31 October 2018; Accessed: May 27, 2023.
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. [QxMD MEDLINE Link].
Cruz C, Spina L. Are Oral Antibiotics as Effective as a Combination of Intravenous and Oral Antibiotics for Kidney Infections in Children?. Ann Emerg Med. 2016 Jan. 67 (1):30-1. [QxMD MEDLINE Link]. [Full Text].
Chang UI, Kim HW, Wie SH. Use of cefuroxime for women with community-onset acute pyelonephritis caused by cefuroxime-susceptible or -resistant Escherichia coli. Korean J Intern Med. 2016 Jan. 31 (1):145-55. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Nonobstructing distal left ureteral calculus 2 X 1 X 2 cm.
Multiple abscesses, upper pole of left kidney.
Bilateral hydronephrosis.

of 3

Author

Tibor Fulop, MD, PhD, FACP, FASN Professor of Medicine, Department of Medicine, Division of Nephrology, Medical University of South Carolina College of Medicine; Attending Physician, Medical Services, Ralph H Johnson VA Medical Center

Tibor Fulop, MD, PhD, FACP, FASN is a member of the following medical societies: American Academy of Urgent Care Medicine, American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society for Apheresis, International Society for Hemodialysis, Magyar Orvosi Kamara (Hungarian Chamber of Medicine)

Disclosure: Nothing to disclose.

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, 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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Society of Nephrology<br/>Received income in an amount equal to or greater than $250 from: Healthcare Quality Strategies, Inc.

Chief Editor

Vecihi Batuman, MD, FASN Professor of Medicine, Section of Nephrology-Hypertension, Deming Department of Medicine, Tulane University School of Medicine

Vecihi Batuman, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, Southern Society for Clinical Investigation

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