RISK FACTORS: Underlying urinary tract abnormalities, Indwelling catheter, Nephrolithiasis,
Diabetes mellitus, Immunocompromised conditions, Elderly, institutionalized women, Acute pyelonephritis within the prior year, Prostatic enlargement
GENERAL MEASURES
β’ Intravenous fl uids when needed
β’ Broad-spectrum antibiotics initially, tailoring therapy to culture and sensitivity results
β’ Analgesics and antipyretics
β’ Urinary analgesics (e.g., phenazopyridine 200 mg tid) for severe dysuria
SURGICAL MEASURES Percutaneous drainage of abscess if necessary
ACTIVITY As tolerated
DIET Encourage fluid
DRUG(S) OF CHOICE
Severe Illness: IV therapy until afebrile 48 hours and tolerating oral hydration and medications, then oral agents to complete 2 weeks
. IV agents (assuming normal creatinine clearance):
. Cefotaxime I g q 12 hours up to 2 g q 4 hours
. Ceftriaxone 1-2 g q day
. Cefoxitin 2 g q 8 hours
. Ciprofloxacin 400 mg q 12 hours
. Levofloxacin 500 mg q day
. Moxifloxacin 400 mg qd
. Gatifloxacin 400 mg qd
. Piperacillin-tazobactam 3.375 g q 6 hours
. Ticarcillin-clavulanate 3.1 g q 6 hours
. Gentamicin 3-5 mg/kg of body weight q day (with or without ampicillin I g q 6 hours). Consider once daily
dosing for synergy with ampicillin.
. Trimethoprim-sulfamethoxazole 160-800 mg q 12 hours (Note: Up to 30% E. coli resistant to ampicillin and trimethoprim/sulfamethoxazole in community acquired infections). If enterococcus suspected based on gram stain, ampicillin plus low-dose once daily gentamicin is a reasonable empiric choice, unless penicillin allergic, then use vancomycin. Do not use a third generation cephalosporin for suspect or proven enterococcal infection.
. Oral agents:
. Moxifloxacin 400 mg q day
. Ciprofloxacin 500 mg q 12 hours
. Ciprofloxacin ER 1000 mg q day
. Levofloxacin 500 mg q day
. Norfloxacin 400 mg q 12 hours
. Gatifloxacin 400 mg q day
. Cephalexin 500 mg qid
. Amoxicillin-clavulanate 875/125 mg q 12 hours or 500/125 mg tid
Contraindications:
. Allergies to penicillin, sulfa, or other agents listed
. Fluoroquinolones contraindicated in adolescents, children and pregnant women
. Nitrofurantoin does not achieve reliable tissue levels for pyelonephritis treatment
ALTERNATIVE DRUGS N/A
PATIENT MONITORING
β’ Response within 48 hours (95% of patients): discharge on oral agent (see above) after patient is afebrile for 48 hours to complete 2 weeks
β’ No response within 48 hours (5% of patients): reevaluate, review cultures; CT (spiral CT most sensitive), IVP
or ultrasound; adjust therapy as needed; may need urological consult
β’ Mild/moderate Illness - oral therapy for 2 weeks as outpatient: ciprofloxacin, gatifloxacin, levofloxacin,
norfloxacin, cephalexin, amoxicillin/clavulanate. (Up to 30% E. coli resistance to ampicillin and trimethoprim/
sulfamethoxazole in community acquired UTIs.) If enterococcus suspected based on urine gram stain, add amoxicillin to fl uoroquinolone pending culture and sensitivity.
β’ All patients: follow-up urine analysis 1 to 2 weeks after completing therapy; if persistent hematuria despite
eradication of infection, refer for urologic evaluation
β’ Women: routine follow-up cultures not recommended unless symptoms resolve but recur within 2 weeks;
obtain urine culture, sensitivity, gram stain and CT or renal ultrasound. If symptoms resolve but recur after
2 weeks, treat as sporadic episode of pyelonephritis, unless 2 or more recurrences, then urologic evaluation
necessary.
β’ Men, children, adolescents, patients with recurrent infections, patients with risk factors: repeat cultures 1 to
2 weeks after completing therapy; urologic evaluation after fi rst episode of pyelonephritis and with recurrences.
POSSIBLE COMPLICATIONS
β’ Kidney abscess
β’ Metastatic infection: skeletal system, endocardium, eye, meningitis with subsequent seizures
β’ Septic shock and death
β’ Chronic renal insufficiency
β’ Complications of antibiotics
EXPECTED COURSE/PROGNOSIS
95% respond in 48 hours