US guidance recommends short course antibiotic treatment in both men and women with uncomplicated pyelonephritis
Short course antibiotics are preferable to longer treatment durations for both men and nonpregnant women with uncomplicated pyelonephritis, according to new Best Practice Advice from the American College of Physicians (ACP).
The ACP notes that antimicrobial overuse is a major health care issue that contributes to antibiotic resistance.
It recommends short-course therapy in men and women either with a fluoroquinolone (5 to 7 days) or trimethoprim/sulfamethoxazole (14 days) based on antibiotic susceptibility, in line with 2010 Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases (IDSA/ESCMID) guidance for women.
The ACP recommendation on fluoroquinolones is underpinned by a meta-analysis that assessed shorter-course therapy for pyelonephritis in both men and women, and reported no significant difference overall in clinical failure with fluoroquinolones except in patients with complicated urinary tract infection (8 randomized controlled trials; N = 2515 patients); and three later randomized controlled trials that showed that a 5-day course was noninferior to a 10-day course for these patient groups.
This supports 2010 IDSA/ESCMID guidance on shorter-course antibiotic therapy for women with uncomplicated pyelonephritis, and extends it to include men.
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Acute pyelonephritis in adults commonly presents as acute-onset fever, chills, severe back or flank pain, nausea and vomiting, and costovertebral angle tenderness.
Urinalysis and urine culture confirm the diagnosis of pyelonephritis. Urine cultures, obtained prior to treatment, demonstrate bacteria, most often Escherichia coli.
The route and choice of empiric antibiotics depend on the severity of illness and the presumed bacterial sensitivities pending culture results.
Complications most often result from inappropriate (wrong drug or wrong dose) antibiotic use or antibiotic resistance, leading to recurrent or progressive infection.
Other common causes of complications are inadequate treatment of anatomic abnormalities (e.g., kidney stones or obstruction), preventing bacterial clearance.
Pyelonephritis, from the Greek "pyelo" (pelvis), "nephros" (kidney), and "-itis" (inflammation), describes a severe infectious inflammatory disease of the renal parenchyma, calices, and pelvis that can be acute, recurrent, or chronic. Acute infections may be caused by enteric bacteria (e.g., Escherichia coli) that ascend from the lower urinary tract or that spread hematogenously to the kidney. Most episodes are uncomplicated and are cured with no residual renal damage. Complicated infections can result from underlying medical problems (e.g., diabetes mellitus, HIV), genitourinary anatomic abnormalities, obstruction (e.g., benign prostatic hypertrophy, calculi), and/or multidrug-resistant pathogens. Urinary tract infection, or UTI, is a nonspecific term that refers to infection anywhere in the urinary tract, from the urethra to the bladder to the ureters to the kidneys. Pyelonephritis refers specifically to infections in the kidney.
Urinary tract infections in children is a specialized topic that is not covered here; please see the BMJ Best Practice topic: Urinary tract infections in children.
History and exam
- urinary tract infection
- diabetes mellitus
- stress incontinence
- foreign body in urinary tract (e.g., calculus, catheter)
- anatomic/functional urinary abnormality
- immunosuppressive state (e.g., HIV, transplantation, chemotherapy, corticosteroid use)
- frequent sexual intercourse
- mother with urinary tract infection history
- new sex partner
- spermicide use
- age between 18 and 50 years
- age >60 years
Lynda A. Frassetto, MD
Professor of Medicine
Division of Nephrology
University of California
LAF declares that she has no competing interests.
Dr Lynda A. Frassetto would like to gratefully acknowledge the assistance of Donna M. Frassetto. DMF declares that she has no competing interests.
John Lam, MD
Providence Saint Joseph Medical Center
Assistant Clinical Professor of Urology
Department of Urology
David Geffen School of Medicine at UCLA
JL declares that he has no competing interests.
Robert Mactier, MD, FRCP
Consultant Nephrologist/Lead Clinician
Glasgow Royal Infirmary
NHS Greater Glasgow and Clyde
RM declares that he has no competing interests.
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