Drug | Recommendation |
Use for mild-to-moderate acute uncomplicated pyelonephritis caused by Enterococcus or to complete a 14d course of therapy for same which began with parenteral ampicillin. Employ only after susceptibility data returns. | |
For infections caused by Enterococcus spp., this parenteral agent (with or without an aminoglycoside) can be used initially for severe cases of acute uncomplicated pyelonephritis. Use PO amoxicillin to complete a 14d course of treatment. | |
May be considered as an alternative agent for susceptible pathogens. One observational, non-randomized study showed it to be non-inferior to ceftriaxone for acute pyelonephritis vis-a-vis clinical response, length of hospital stay, and 30-day readmission rates for cystitis or pyelonephritis. | |
Active against most Enterobacteriaceae and can be used to commence outpatient therapy followed by oral therapy. However, there is no demonstrated long term post-antibiotic effect as noted with aminoglycosides. | |
Active against most Gram-negative organisms including P. aeruginosa. Attains good levels in urine. | |
When compared with levofloxacin for the treatment of patients with pyelonephritis or complicated lower UTI, this agent was more likely to be associated with microbiological cure and was non-inferior in achieving clinical cure. | |
Moxifloxacin | This fluoroquinolone is not a good choice for UTIs as it attains poor urine levels with mostly hepatic excretion. |
Not recommended for acute pyelonephritis as it does not attain therapeutic levels in renal parenchyma. | |
Fluoroquinolones (FQ) are the first line empiric treatment for acute pyelonephritis. | |
Fluoroquinolones (FQ) are the first line empiric treatment for acute pyelonephritis. | |
An effective modality along when given IV or IM or given as a first dose in outpatient treatment. In light of the proven post antibiotic effect of aminoglycosides, this regimen may be preferable when combined parenteral and oral outpatient treatment is used. Single dose therapy has not been associated with adverse impact on the kidneys. All aminoglycosides are associated with the risk of ototoxicity beginning with the first dose. | |
An effective modality along when given IV or IM or given as a first dose in outpatient treatment. In light of the proven post antibiotic effect of aminoglycosides, this regimen may be preferable when combined parenteral and oral outpatient treatment is used. Single dose therapy has not been associated with adverse impact on the kidneys. All aminoglycosides are associated with the risk of ototoxicity beginning with the first dose. | |
Use of amikacin should be limited to those patients with organisms found to be resistant to other aminoglycosides. | |
Do not use oral preparation for severe pyelonephritis because of limited systemic absorption. Drug has been used for AUP at higher dosings by IV preparation [12-16 g IV per day in 3 or 4 divided doses]. |
Pathogen | 1st Line Agent | 2nd Line Agent |
Enterobacteriaceae including Escherichia coli | Outpatient Regimens: Levofloxacin | Outpatient Regimens: TMP/SMX Cephalexin Cefpodoxime Cefixime |
Enterobacteriaceae including Escherichia coli | Inpatient regimen (until afebrile x 48h, then outpatient regimen) Levofloxacin Ceftriaxone ± gentamicin | |
Staphylococcus saprophyticus | Outpatient regimens: Inpatient regimens (Give IV until afebrile X 48h, then PO for total 14d): Levofloxacin Ceftriaxone ± gentamicin | Outpatient regimens: Amoxicillin/clavulanate |
Comment: Provides the clinical practice guideline formulated by a panel of international experts convened by the IDSA and ESCMID to update the previous guideline from 1999. Co-sponsors include the American Congress of Ob/GYN, American Urological Association, Associatrion of Medical Microbiologty and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine. This guideline focuses on uncomplicated acute bacterial cystitis and acute pyelonephritis in pre-menopausal, non-pregnant jwomen with no known urological abnormalities or co-morbidities.
Comment: Non-randomized, observational study suggesting that cefazolin may be an acceptable choice for susceptible isolates. While over half of patients treated with cefazolin received at least one dose of an additional antibiotic, this study suggests there may be a role for this narrow-spectrum agent in treating acute pyelonephritis.
Comment: RCT of patients with complicated lower UTI or pyelonephritis. Ceftolazone-tazobactam was non-inferior to levofloxacin in achieving clinical cure and was superior in achieving microbiological cure. Composite (clinical + microbiological) cure rates were superior for ceftolazone-tazobactam when considering patients whose pathogens were resistant to levofloxacin or were ESBL-positive.
Comment: Contemporary study confirming that 7 days of ciprofloxacin provides adequate therapy for acute uncomplicated pyelonephritis; unlike earlier studies, this one included among middle-aged women and women with more severe illness. The work also suggests that 14 days of therapy should not be used, in part to minimize needless antibiotic therapy and the increased risk for antibiotic resistant organisms with prolonged therapy.
Comment: The authors provide a concise review of host-pathogen interactions occurring in both uncomplicated and complicated urinary tract infections. Excellent diagrams are provided to accompany the text explaining uropathogenic E. coli virulence factors (fimbriae, toxins, flagella, iron acquisition systems, proteins that function in immune evasion. Host defenses are discussed including the role of urine flow and cell exfoliation, innate and adaptive immune responses, and genetics.
Comment: A concise discussion of S. saprophyticus, its role in UTI , risk factors, pathogenesis and research questions and issues that are outstanding. This novobiocin resistant organism is resistant to nitrofurantoin but sensitive to the fluoroquinolones.
Rating: Important
Comment: This is a report of a prospective cohort study to determine the utility of blood cultures in combination with urine cultures in the management of new-onset community acquired acute uncomplicated pyelonephritis (APN). Data were collected from 583 cases. In 97.6% of cases the urine and blood isolates matched. Clinical outcome did not differ among patients with concordant and non-concordant isolates from the 2 sites (blood and urine).
Rating: Important
Comment: Excellent, concise review of acute uncomplicated UTIs in women including acute bacterial cystitis (ABC), uncomplicated acute pyelonephritis (AUP), recurrent UTIs (rUTI). The review reiterates that UAP in an otherwise healthy, nonpregnant woman can be treated in the outpatient setting with a 14-day course of TMP-SMX (provided that local rates of E. coliresistance to this drug is <20%). Amoxicillin-clavulanate orally is an alternative for Gram positive organisms. Women with risk factors for complicated disease, including diabetes, should initially be treated in hospital.
Rating: Important
Comment: Well-written report on a large case series. The conclusions of the authors -- effective, decreases nephrotoxicity, cost-effective by decreasing ancillary service costs. However, this is a case-series and not a controlled trial. Comparison is general experience with multiple daily dose regimens.
Comment: Extensive review of the issue. Notes high serum levels achieve concentration dependent killing; post-antibiotic effect seen yields continued bacterial growth suppression below MIC.
Rating: Important
Comment: Although the paper was written as a guideline for evaluating antimicrobials, it provides a very good and concise overview of the clinical and laboratory aspects of UTIs including acute pyelonephritis.
Rating: Important
Comment: Double-blind randomized study of 214 post-menopausal women with uncomplicated pyelonephritis given ciprofloxacin 500 mg PO twice daily (7 days) vs TMP-SMX 1 DS PO twice daily x 14d. Ciprofloxacin had better clinical response (96% vs 83%) and bacteriologic response (99% vs 89%).
Rating: Important
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