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Acute Pyelonephritis: Symptomatic and Antibiotic Treatment

• Acute pyelonephritis: definition, causes and pathology
• Acute pyelonephritis: symptoms and diagnostic workup
• Acute pyelonephritis: treatment

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

Symptomatic Treatment of pyelonephritis:

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

Antibiotic Treatment for Pyelonephritis:

Appropriate antibiotics are fluoroquinolones, aminopenicillins in combination with beta-lactamase inhibitors, and cephalosporins. In children, cephalosporins are preferred. Because of high resistance rates of up to 40%, ampicillin or cotrimoxazole alone is inadequate. Duration of treatment: 7–14 days, depending on severity and improvement. Antibiotic treatment has to be changed depending on the urine culture results.

Oral Antibiotic Treatment in Adults:

For mild pyelonephritis, options are, e.g., ciprofloxacin 500 mg 1-0-1, amoxicillin/clavulanic acid 875/125 mg 1-0-1 or 1-1-1, or cefpodoxime 200 mg 1-0-1.

Intravenous Antibiotic Treatment in Adults:

Options are, e.g., piperacillin and tazobactam 4,5 g 1-1-1 i.v., 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 pyelonephritis, above mentioned antibiotics may be combined with gentamicin.

Antibiotic Treatment in Children:

Mild and uncomplicated pyelonephritis may be treated with oral cephalosporins alone. Dosage of oral cephalosporins: e.g., ceftibuten 9 mg/kg 1–0–0 or cefixime 4–8 mg/kg 1–0–1. Treating severe pyelonephritis is started intravenously: e.g., ceftriaxone 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., cefuroxime 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 scan, 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. A Nephrectomy is necessary for a non-functioning kidney with fungal infection.

Management of Infected Hydronephrosis:

Infected hydronephrosis is a potentially life-threatening emergency requiring immediate drainage of the upper urinary tract. Possible techniques are the insertion of a ureteral stent (MJ or DJ catheter) or percutaneous nephrostomy.

Lack of Clinical Improvement with Antibiotic Treatment

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. Consider escalation of antibiotic treatment with reserve antibiotics like imipenem or meropenem.

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

Indications for Nephrectomy

Nephrectomy is an option if urosepsis cannot be stabilized with the help of intensive medical care. Nephrectomy is necessary without delay in poor organ function or emphysematous pyelonephritis. Simple nephrectomy may be technically demanding due to adhesions to neighboring organs. Radical nephrectomy with removal of perirenal fat or subcapsular nephrectomy are technical alternatives.

References

DGU, DEGAM, and PEG, “S3 Leitlinie Epidemiologie, Diagnostik, Therapie, Prävention und Management unkomplizierter, bakterieller, ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten Aktualisierung 2024.” [Online]. Available: https://register.awmf.org/assets/guidelines/043-044l_S3_Epidemiologie-Diagnostik-Therapie-Praevention-Management-Harnwegsinfektione-Erwachsene-HWI_2024-09.pdf

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

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