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Acute Pyelonephritis: Treatment

• Acute pyelonephritis (1/3): definition, causes and pathology
• Acute pyelonephritis (2/3): symptoms and diagnostic work-up
• Acute pyelonephritis (3/3): treatment

Review literature: (Fihn, 2003) (Nickel, 2001) (Roberts, 1999) (DGU S3-Guideline urinary tract infections).

Treatment of Acute Pyelonephritis

Symptomatic Treatment of pyelonephritis:

• Bed rest
• Analgesics with antipyretic effect, e.g. metamizol, for children paracetamol
• Increased fluid intake or intravenous therapy with crystalloid fluid depending on symptoms.

Antibiotics for Pyelonephritis:

Appropriate antibiotics are fluoroquinolones, aminopenicillin in combination with beta-lactamase inhibitor and cephalosporins. In children, cephalosporins are preferred.

Antibiotic Treatment in Adults:

• Duration of treatment: 7–14 days depending on severity and improvement
• Ciprofloxacin 500 mg p.o. 1-0-1 or 400 mg 1-0-1 i.v. Since the oral bioavailability is high, intravenous administration is necessary only in case of vomiting.
• Amoxicillin and clavulanic acid 2.2 g 1-1-1 i.v.
• Third or fourth generation cephalosporin, e.g. ceftriaxone 1–2 g every 24 h or cefotaxime 1–2 g every 12 h i.v.
• In severe disease, an antibiotic combination may be appropriate: e.g. cephalosporin or amoxicillin/clavulanic acid combined with gentamicin 3 mg/kg 1-0-0 i.v.
• Antibiotic treatment may have to be switched depending on the results of the urine culture

Antibiotic Treatment in Children:

Mild uncomplicated pyelonephritis may be treated with oral cephalosporins alone. Dosage of oral cephalosporins: e.g. ceftibuten 9 mg/kg 1–0–0 or cefixim 4–8 mg/kg 1–0–1. Treatment of severe pyelonephritis is started intravenously: e.g. ceftriaxon 50 mg/kg i.v. once a day or cefepime 50 mg/kg every 8–12 h i.v. If the child is afebrile, treatment is switched to oral therapy.

In Pregnancy:

Antibiotics of first choice are cephalosporins of the second, third and fourth generation, e.g. cefuroxim 1,5 g every 12 h, ceftriaxone 1--2 g every 24 h or cefotaxime 1--2 g every 12 h i.v. Ampicillin is an option if results of the urine culture show sensitivity. In severe pyelonephritis, above mentioned antibiotics may be combined with gentamicin.

Treatment of Fungal Pyelonephritis:

Antifungal treatment is possible with fluconazole 5–10 mg/kg p.o. 1-0-0 or amphotericin B 0.6 mg/kg i.v. 1-0-0. The exclusion of fungal balls with intravenous urography, CT or retrograde pyelography is important. Fungal pyelonephritis with upper tract obstruction should be treated with percutaneous nephrostomy, which enables antegrade nephrostomy irrigation with amphotericin or fluconazole. Nephrectomy is necessary in a non-functioning kidney with fungal infection.

Management of Infected Hydronephrosis:

Lack of Clinical Improvement

If the patient does not improve within 48–72 hours, an abdominal CT should be done to search for a renal abscess, hydronephrosis or other possible diseases (see differential diagnosis). Repeat urine culture and check for the results of antibiotic testing.

Relapsing pyelonephritis after antibiotic treatment (10%) makes another antibiotic treatment for 14 days necessary. In some cases, long term antibiotic treatment is sound.

Nephrectomy

Nephrectomy should be kept in mind, if urosepsis cannot be stabilized with the help of intensive medical care. Nephrectomy is necessary without delay especially in poor organ function or emphysematous pyelonephritis. Lumbar nephrectomy may be technically demanding due to adhesions to neighbouring organs. Transperitoneal nephrectomy with removal of Gerota's fascia or subcapsular nephrectomy are technical alternatives.

References

DGU S-3 Guideline Urinary tract infections

Epidemiologie, Diagnostik, Therapie und Management unkomplizierter bakterieller ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten
AWMF, 2010, Register-Nr. 043/044

Dalla-Palma und Pozzi-Mucelli 2000 DALLA-PALMA, L. ; POZZI-MUCELLI, F.:

[The imaging of chronic renal infections].
In: Radiologe
40 (2000), Nr. 6, S. 537–46

Fihn 2003 FIHN, S. D.:

Clinical practice. Acute uncomplicated urinary tract infection in women.
In: N Engl J Med
349 (2003), Nr. 3, S. 259–66

Kawashima u.a. 2000 KAWASHIMA, A. ; SANDLER, C. M. ; GOLDMAN, S. M.:

Imaging in acute renal infection.
In: BJU Int
86 Suppl 1 (2000), S. 70–9

Nickel 2001 NICKEL, J. C.:

The management of acute pyelonephritis in adults.
In: Can J Urol
8 Suppl 1 (2001), S. 29–38

Roberts 1999 ROBERTS, J. A.:

Management of pyelonephritis and upper urinary tract infections.
In: Urol Clin North Am
26 (1999), Nr. 4, S. 753–63

  Deutsche Version: Therapie der Pyelonephritis