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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 effects
• Adequate fluid intake

Antibiotic Treatment for Pyelonephritis

Appropriate antibiotics include fluoroquinolones, aminopenicillins combined with beta-lactamase inhibitors, or cephalosporins. Treatment lasts 7–14 days, depending on disease severity and response. Once susceptibility results are available, review the empiric initial treatment and adjust or de-escalate it as appropriate.

Oral Antibiotic Treatment in Adults

For mild pyelonephritis, options include ciprofloxacin 500 mg 1-0-1, cefpodoxime 200 mg 1-0-1, or amoxicillin/clavulanate for mild disease or when susceptibility has been confirmed.

Intravenous Antibiotic Treatment in Adults

For severe pyelonephritis, options include piperacillin/tazobactam 4.5 g 1-1-1 IV or a second-, third-, or fourth-generation cephalosporin, such as cefuroxime 1.5 g every 12 h, ceftriaxone 1–2 g every 24 h, or cefotaxime 1–2 g every 12 h IV. Carbapenems are indicated for urosepsis or suspected multidrug-resistant gram-negative pathogens. After clinical stabilization and receipt of susceptibility results, treatment may be de-escalated to an appropriate oral regimen.

Antibiotic Treatment in Children

Cephalosporins are first-line agents: ceftriaxone 50 mg/kg body weight IV once daily, cefepime 50 mg/kg body weight IV every 8–12 h, or ceftazidime 50 mg/kg body weight IV every 8 h. After the fever resolves, treatment may be switched to an oral cephalosporin, such as ceftibuten 9 mg/kg body weight 1-0-0 or cefixime 4–8 mg/kg body weight 1-0-1. Uncomplicated pyelonephritis may be treated with oral antibiotics from the outset.

Antibiotic Treatment in Pregnancy

First-line options are second-, third-, or fourth-generation cephalosporins, such as cefuroxime 1.5 g every 12 h, ceftriaxone 1–2 g every 24 h, or cefotaxime 1–2 g every 12 h IV. Intravenous ampicillin is an option when urine culture confirms susceptibility. When clinically necessary, the antibiotics listed above may be combined with IV gentamicin.

Treatment of Fungal Infection

Treatment options are fluconazole 5–10 mg/kg body weight 1-0-0 orally or amphotericin B 0.6 mg/kg body weight 1-0-0 IV. It is important to exclude fungal balls by intravenous urography, CT, or retrograde pyelography. If obstruction is present, place a percutaneous nephrostomy. If a nephrostomy is in place, antegrade irrigation with amphotericin or fluconazole is possible.

Management of Urinary Tract Obstruction

An infected obstructed kidney is a potentially life-threatening emergency because of the risk of urosepsis and requires immediate drainage of the urinary tract. Options include retrograde pyelography with insertion of a ureteral stent (MJ or DJ catheter) or percutaneous nephrostomy.

Lack of Clinical Improvement

If the patient does not improve within 48–72 h, reassess for abscess or obstruction, preferably with CT. Repeat urine cultures and susceptibility testing. Consider changing antibiotic treatment to a reserve agent such as imipenem or meropenem.

Nephrectomy

Nephrectomy is a salvage option for treatment-refractory sepsis, particularly in patients with poor organ function, extensive destructive and suppurative pyelonephritis, or emphysematous nephritis. Nephrectomy is often technically difficult because of adhesions.

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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