Last reviewed: 21 Aug 2021
Last updated: 15 Jun 2021
15 Jun 2021

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.

See Management: approach

See Management: treatment algorithm

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History and exam

Other diagnostic factors

  • nausea and vomiting
  • dysuria, frequency, or urgency
  • flank pain or costovertebral angle tenderness

Risk factors

  • 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)
  • pregnancy
  • frequent sexual intercourse
  • mother with urinary tract infection history
  • new sex partner
  • spermicide use
  • age between 18 and 50 years
  • age >60 years

Diagnostic investigations

1st investigations to order

  • urinalysis
  • Gram stain
  • urine culture
  • complete blood count
  • erythrocyte sedimentation rate
  • C-reactive protein
  • procalcitonin
  • blood culture

Investigations to consider

  • renal ultrasound
  • contrast-enhanced spiral computed tomography
  • magnetic resonance imaging

Treatment algorithm



Lynda A. Frassetto, MD

Professor of Medicine

Division of Nephrology

University of California

San Francisco



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.

Peer reviewers

John Lam, MD

Attending Urologist

Providence Saint Joseph Medical Center


Assistant Clinical Professor of Urology

Department of Urology

David Geffen School of Medicine at UCLA

Los Angeles



JL declares that he has no competing interests.

Robert Mactier, MD, FRCP

Consultant Nephrologist/Lead Clinician

Renal Unit

Glasgow Royal Infirmary

NHS Greater Glasgow and Clyde




RM declares that he has no competing interests.

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