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Acute complicated cystitis and pyelonephritis

Author: Thomas M Hooton, MDSection Editor: Stephen B Calderwood, MDDeputy Editor: Allyson Bloom, MD

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Sep 2017. | This topic last updated: Feb 09, 2016.

INTRODUCTION — Urinary tract infections (UTIs) include cystitis (infection of the bladder) andpyelonephritis (infection of the kidney). Most episodes of cystitis and pyelonephritis are generallyconsidered to be uncomplicated in otherwise healthy nonpregnant adults. A complicated urinary tractinfection, whether localized to the lower or upper tract, is associated with an underlying condition thatincreases the risk of failing therapy.

Issues related to acute complicated cystitis and pyelonephritis will be reviewed here. Issues relatedto acute uncomplicated cystitis and pyelonephritis in women are discussed separately, as are issuesrelated to UTIs in pregnant women, in men, and in the setting of indwelling urethral catheters. (See"Urinary tract infections and asymptomatic bacteriuria in pregnancy" and "Acute uncomplicatedcystitis and pyelonephritis in men" and "Catheter-associated urinary tract infection in adults" and"Acute uncomplicated cystitis and pyelonephritis in women".)

Urinary tract infections in renal transplant patients are also discussed in detail elsewhere. (See"Urinary tract infection in renal transplant recipients".)

UNCOMPLICATED VERSUS COMPLICATED INFECTION — A complicated urinary tract infection,whether localized to the lower or upper tract, is associated with an underlying condition thatincreases the risk of failing therapy, including the following:

Infection with a uropathogen with broad-spectrum antimicrobial resistance is also consideredcomplicated, although there are no data to suggest that such infections are more likely to fail if an

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Poorly controlled diabetes mellitus●Pregnancy●Hospital-acquired infection●Acute kidney injury or chronic kidney disease●Suspected or known urinary tract obstruction●Presence of an indwelling urethral catheter, stent, nephrostomy tube, or urinary diversion●Functional or anatomic abnormality of the urinary tract●Renal transplantation●Other immunocompromising condition (eg, chronic high-dose corticosteroid use, use of otherimmunosuppressive agents, neutropenia, advanced HIV infection, B or T leukocyte deficiency)

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antimicrobial to which the infecting pathogen is susceptible is used.

Acute complicated pyelonephritis is progression of upper urinary tract infection to emphysematouspyelonephritis, renal corticomedullary abscess, perinephric abscess, or papillary necrosis. (See"Emphysematous urinary tract infections" and "Renal and perinephric abscess".)

MICROBIOLOGY — The microbial spectrum of uncomplicated cystitis and pyelonephritis consistsmainly of Escherichia coli (75 to 95 percent), with occasional other species of Enterobacteriaceae,such as Proteus mirabilis and Klebsiella pneumoniae, and Staphylococcus saprophyticus [1,2]. Themicrobial spectrum of complicated UTI is broader and includes the above organisms as well asPseudomonas, Serratia, and Providencia species, in addition to enterococci, staphylococci, and fungi[3,4].

In addition, organisms causing complicated cystitis are more likely to be resistant to commonly usedoral antimicrobials recommended for uncomplicated cystitis [5]. Colonization and infection withantibiotic-resistant organisms develop because of the selective pressure exerted by exposure toantimicrobials or by contact transfer of resistant organisms between patients because of poorinfection control practices. The prevalence of drug resistance among pathogens causing complicatedurinary tract infections is growing. As an example, in one study, the prevalence of extended-spectrumbeta-lactamase (ESBL) producing E. coli among hospitalized patients with urinary tract infections inthe United States was estimated to have increased threefold from 2000 to 2009 [6].

In particular, a specific strain of E. coli, sequence type 131 (ST131), has emerged globally as a majorcause of fluoroquinolone-resistant and ESBL producing E. coli urinary tract infections [7]. As anexample, in a study of E. coli clinical isolates from extraintestinal sites, predominantly urine, collectedat Veterans Affairs (VA) laboratories across the United States, the ST131 clone accounted for themajority of fluoroquinolone-resistant and ESBL isolates and was calculated to account for 28 percentof all VA E. coli isolates nationwide [8].

CLINICAL MANIFESTATIONS — Clinical manifestations of acute complicated cystitis may consist ofdysuria, frequency, urgency, suprapubic pain and/or hematuria [9]. Symptoms and signs of cystitiscan be subtle in the very young and very old. Cystitis is considered complicated in the circumstancesoutlined above. (See 'Uncomplicated versus complicated infection' above.)

Clinical manifestations of acute complicated pyelonephritis consist of the above symptoms(symptoms of cystitis may or may not be present) together with fever (>38ºC), chills, flank pain,costovertebral angle tenderness, and nausea/vomiting [10]. In some cases, the presentation maymimic pelvic inflammatory disease. Patients with acute complicated pyelonephritis may present withsepsis, multiple organ system dysfunction, shock, and/or acute renal failure. In some cases,complicated pyelonephritis may be associated with weeks to months of insidious, nonspecific signsand symptoms such as malaise, fatigue, nausea, or abdominal pain.

Acute complicated pyelonephritis is progression of upper urinary tract infection to renalcorticomedullary abscess, perinephric abscess, emphysematous pyelonephritis, or papillary necrosis.Risk factors for progression to complicated pyelonephritis include urinary tract obstruction, urologicdysfunction, antibiotic resistant pathogen(s), and diabetes (particularly for emphysematouspyelonephritis and papillary necrosis). (See 'Uncomplicated versus complicated infection' above and"Renal and perinephric abscess" and "Emphysematous urinary tract infections".)

Chronic pyelonephritis is an uncommon cause of chronic tubulointerstitial disease due to recurrentinfection, such as infection in association with a chronically obstructing kidney stone (possiblyproducing xanthogranulomatous pyelonephritis) or vesicoureteral reflux. Affected patients can


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present with weeks to months of insidious symptoms. (See "Clinical presentation, diagnosis, andcourse of primary vesicoureteral reflux" and "Xanthogranulomatous pyelonephritis".)

DIAGNOSTIC EVALUATION — The diagnosis of complicated cystitis or pyelonephritis begins withassessment of the clinical history, guided by the clinical manifestations above. Physical examinationshould include assessment for fever, costovertebral angle tenderness, and abdominal examination. Apelvic examination is indicated if factors suggesting vaginitis or urethritis are present. Pregnancytesting is also appropriate in women of childbearing age.

Patients with acute cystitis or pyelonephritis who have persistent symptoms after 48 to 72 hours ofappropriate antimicrobial therapy or recurrent symptoms within a few weeks of treatment should haveevaluation for complicated infection as discussed in the following sections.

Laboratory studies — Laboratory diagnostic tools consist of urinalysis (either by microscopy or bydipstick) and urine culture with susceptibility data [11]. Pyuria is present in almost all patients withcomplicated UTI; its absence suggests an alternative diagnosis. White cell casts suggest a renalorigin for pyuria. However, pyuria and bacteriuria may be absent if the infection does notcommunicate with the collecting system or if the collecting system is obstructed.

Urine cultures with susceptibility testing should be obtained prior to therapy to evaluate forantimicrobial resistance. Urine Gram stain may be helpful for guiding the choice of empiric therapypending culture results, particularly in the setting of enterococcal UTI.

Issues related to interpretation of urine culture colony counts are discussed separately. (See"Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in adults", sectionon 'Definition of a positive culture'.)

Radiographic imaging — Patients with persistent clinical symptoms after 48 to 72 hours ofappropriate antibiotic therapy for acute uncomplicated urinary tract infection should undergoradiologic evaluation of the upper urinary tract. In addition, radiologic evaluation is warranted forpatients with pyelonephritis who are severely ill or who also have symptoms of renal colic or historyof renal stones, diabetes, history of prior urologic surgery, immunosuppression, repeated episodes ofpyelonephritis, or urosepsis [12-14].

Computed tomography (CT) scan and ultrasonography are useful modalities to evaluate for thepresence of an underlying anatomic abnormality, to detect a process that may delay response totherapy (such as calculus, papillary necrosis, or obstruction), or to diagnose a complication ofinfection such as a renal or perinephric abscess [12-15].

CT scanning is generally the study of choice to detect anatomic or physiologic factors associatedwith complicated urinary tract infection; it is more sensitive than excretory urography or renalultrasound for detecting renal abnormalities predisposing to or caused by infection and in delineatingthe extent of the disease [16,17]. CT without contrast has become the standard radiographic studyfor demonstrating calculi, gas-forming infections, hemorrhage, obstruction, and abscesses [17].Contrast is needed to demonstrate alterations in renal perfusion. CT findings may include localizedhypodense lesions due to ischemia induced by marked neutrophilic infiltration and edema (image 1A-C) [16,18].

Renal ultrasound is appropriate in patients for whom exposure to contrast or radiation is undesirable[14]. Magnetic resonance imaging is not advantageous over CT except when avoidance of contrastdye or ionizing radiation is warranted [19]. (See "Pathogenesis, clinical features, and diagnosis ofcontrast-induced nephropathy" and "Prevention of contrast nephropathy associated with


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angiography".)

Resolution of radiographic hypodensities may lag behind clinical improvement by up to three months[16,18,20].

TREATMENT — Empiric antimicrobial therapy should be initiated promptly, taking into accountprevious antimicrobial use and results of recent urine cultures, with subsequent adjustment guided byantimicrobial susceptibility data. Anatomic abnormalities demonstrated by radiography should beaddressed with the involvement of urologic expertise when necessary.

Cystitis — Patients with complicated cystitis who can tolerate oral therapy may be treated with anoral fluoroquinolone such as ciprofloxacin (500 mg orally twice daily or 1000 mg extended releaseonce daily) or levofloxacin (750 mg orally once daily) for five to seven days. Short regimens areappropriate in patients with mild to moderate symptoms and rapid clinical response. Althoughresistance is increasing (most ESBL strains of E. coli are resistant to fluoroquinolones), thefluoroquinolones provide a broad spectrum of antimicrobial activity against most pathogens (includingPseudomonas aeruginosa), and achieve high levels in the urinary tract. Studies of complicated UTIhave shown that the fluoroquinolones are comparable or superior to other broad spectrum antibiotics,including parenteral regimens [21]. However, the newer fluoroquinolone moxifloxacin attains lowerurinary levels than other fluoroquinolones and is not recommended for the treatment of complicatedcystitis.

The choice of an empiric regimen also depends on previous antimicrobial use and results of anyrecent urine cultures [22]. Once susceptibility data are available, subsequent therapy should betailored as appropriate.

Nitrofurantoin, trimethoprim-sulfamethoxazole, fosfomycin and oral beta-lactams are poor choices forempiric oral therapy in complicated cystitis because of the high prevalence of resistance to theseagents among causative uropathogens. Use of these agents is acceptable if the isolate is known tobe susceptible. In the setting of diagnostic uncertainty regarding cystitis versus early pyelonephritis,use of trimethoprim-sulfamethoxazole is acceptable if the organism is known to be susceptible,though use of nitrofurantoin, fosfomycin and oral beta-lactams should be avoided.

Parenteral therapy may be warranted for treatment of patients who cannot tolerate oral therapy asoutlined above or for patients with infection that is suspected to be due to resistant organisms.Parenteral regimens that may be administered once daily include levofloxacin (500 mg), ceftriaxone(1 g), ertapenem (1 g), or an aminoglycoside (3 to 5 mg/kg of gentamicin or tobramycin) [23].Monitoring of aminoglycoside levels is warranted in the setting of unstable renal function. (See"Dosing and administration of parenteral aminoglycosides".)

In the case that a serious urinary tract infection is documented or suspected to be caused by anextended-spectrum beta-lactamase (ESBL) producing organism (based on prior cultures or other riskfactors), treatment options are generally limited to the carbapenem class (see "Extended-spectrumbeta-lactamases", section on 'Treatment options'). For patients who have mild cystitis due to ESBL-producing E. coli and low suspicion for pyelonephritis, nitrofurantoin and fosfomycin are reasonableoral options if the isolate is susceptible, although clinical data are limited [24-27].

The presence of gram-positive cocci on Gram stain is suggestive of enterococcal UTI, for whichampicillin (1 g every six hours) or amoxicillin (500 mg orally every eight hours) are the drugs ofchoice. Issues related to management of infection due to Enterococcus are discussed furtherseparately. (See "Treatment of enterococcal infections", section on 'Urinary tract infection'.)


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After clinical improvement is observed, parenteral therapy can be switched to oral therapy, guided byantimicrobial susceptibility data. The duration of treatment for acute complicated cystitis is five toseven days, depending upon the severity of infection and the agent chosen [23,28,29]. Shortregimens are reasonable in patients who are not severely ill and have a rapid clinical response. In astudy including 619 patients with acute pyelonephritis or complicated UTI, levofloxacin (750 mgintravenously or orally once daily for 5 days) was as effective as ciprofloxacin (400 mg intravenouslyand/or ciprofloxacin 500 mg orally twice daily for 10 days) [30].

Pyelonephritis — Patients with complicated pyelonephritis should be managed initially as inpatients.Broad-spectrum parenteral antibiotics should be used for empiric treatment of complicatedpyelonephritis as outlined in the Table (table 1). Patients with illness of moderate severity can betreated with third generation cephalosporins or fluoroquinolones unless there are concerns thatresistant organisms may be involved (eg, based on past urine culture results); patients with severeillness can be treated with broader agents, such as a combination beta lactam/beta lactamaseinhibitor or carbapenem. In the setting of normal baseline renal function, use of aminoglycosides isacceptable for patients with highly resistant organisms not susceptible to a beta lactam/betalactamase inhibitor or carbapenem. Previous antimicrobial use and results of any recent urinecultures should inform the choice of an empiric regimen [22]. Antimicrobial therapy subsequentlymust be tailored to individual patient circumstances with consideration of the results of susceptibilitytesting.

Underlying urinary tract anatomic or functional abnormalities (such as obstruction or neurogenicbladder) should be addressed in consultation with a urologist [5]. Antibiotics alone may not besuccessful unless such underlying conditions are corrected.

Antibiotics are generally administered for 7 to 14 days. For patients who are treated with afluoroquinolone and have a mild infection and quick clinical response, seven days may be adequate.In contrast, a longer course of therapy is indicated for patients with more severe infection, resistantorganisms, or abnormal anatomy or obstruction. Depending on patient circumstances, a duration oftherapy beyond 14 days may be warranted. As an example, guidelines from the American Society ofTransplantation recommend antibiotic therapy for 14 to 21 days for renal transplant recipients withpyelonephritis or sepsis associated with a urinary tract infection [31]. Treatment may be completedwith oral therapy if antimicrobial susceptibility data and clinical circumstances permit; acceptableagents include levofloxacin, ciprofloxacin, or trimethoprim-sulfamethoxazole.

The treatment of pyelonephritis in the setting of pregnancy is discussed elsewhere. (See "Urinarytract infections and asymptomatic bacteriuria in pregnancy", section on 'Management'.)

The treatment of complicated urinary tract infections in renal transplant recipients is also discussed infurther detail elsewhere. (See "Urinary tract infection in renal transplant recipients".)

Follow-up — Follow-up urine cultures are not needed in patients with acute cystitis or pyelonephritiswhose symptoms resolve on antibiotics.

Patients with persistent or recurrent symptoms within a few weeks of treatment for acute complicatedurinary tract infection should have a reevaluation for other conditions that may be causing thesymptoms, repeat urine culture, and empiric treatment with another antimicrobial agent. Treatmentshould be tailored to the susceptibility profile of the causative organism isolated. In addition, initial orrepeat radiographic imaging should be performed to evaluate for factors that might be compromisingclinical response.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The


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Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language,at the 5 to 6 grade reading level, and they answer the four or five key questions a patient mighthave about a given condition. These articles are best for patients who want a general overview andwho prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,more sophisticated, and more detailed. These articles are written at the 10 to 12 grade readinglevel and are best for patients who want in-depth information and are comfortable with some medicaljargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print ore-mail these topics to your patients. (You can also locate patient education articles on a variety ofsubjects by searching on "patient info" and the keyword(s) of interest.)

SUMMARY AND RECOMMENDATIONS

th th

th th

Beyond the Basics topics (see "Patient education: Urinary tract infections in adolescents andadults (Beyond the Basics)")

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A complicated urinary tract infection, whether localized to the lower or upper tract, is associatedwith an underlying condition that increases the risk of failing therapy. These conditions aresummarized above. (See 'Uncomplicated versus complicated infection' above.)

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The microbial spectrum of complicated cystitis and pyelonephritis includes organisms associatedwith uncomplicated UTIs (mainly Escherichia coli, with occasional other species ofEnterobacteriaceae, such as Proteus mirabilis and Klebsiella pneumoniae) as well asPseudomonas, Serratia, Providencia, enterococci, staphylococci, and fungi. In addition,organisms causing complicated cystitis are more likely to be resistant to commonly used oralantimicrobials recommended for uncomplicated cystitis. (See 'Microbiology' above.)

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In addition to clinical manifestations observed with uncomplicated urinary tract infection, patientswith complicated infection may present with sepsis, multiple organ system dysfunction, and/oracute renal failure. In some cases, complicated pyelonephritis may be associated with weeks tomonths of insidious, nonspecific signs and symptoms such as malaise, fatigue, nausea, orabdominal pain. (See 'Clinical manifestations' above.)

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A urine culture and antimicrobial susceptibility testing should be performed to guide treatment.Patients with persistent or recurrent symptoms within a few weeks of treatment for acutecomplicated urinary tract infection should also have reevaluation for other conditions that mightbe causing the symptoms. In addition, patients with pyelonephritis should undergo radiographicimaging if they are severely ill or have symptoms of or risk factors for complications of infection.Computed tomography (CT) scan and ultrasonography are useful modalities to evaluate for thepresence of an underlying anatomic abnormality, to detect a process that may delay response totherapy (such as calculus, papillary necrosis, or obstruction), or to diagnose a complication ofinfection such as a renal or perinephric abscess. (See 'Diagnostic evaluation' above and'Radiographic imaging' above.)

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For patients with complicated cystitis who can tolerate oral therapy we suggest empiric treatmentwith an oral fluoroquinolone such as ciprofloxacin (500 mg orally twice daily or 1000 mgextended release once daily) or levofloxacin (750 mg orally once daily) (Grade 2B). The durationrange is generally five to seven days. Parenteral therapy may be warranted for treatment ofpatients who cannot tolerate oral therapy or for patients with infection that is suspected to be dueto resistant organisms; reasonable regimens that may be administered once daily includelevofloxacin (500 mg), ceftriaxone (1 g), ertapenem (1 g) (drug of choice for known or suspected

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REFERENCES

Echols RM, Tosiello RL, Haverstock DC, Tice AD. Demographic, clinical, and treatmentparameters influencing the outcome of acute cystitis. Clin Infect Dis 1999; 29:113.

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Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis ofacute pyelonephritis. Clin Infect Dis 2007; 45:273.

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Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am 1987; 1:823.3.

Nicolle LE. Catheter-related urinary tract infection. Drugs Aging 2005; 22:627.4.

Nicolle LE. A practical guide to the management of complicated urinary tract infection. Drugs1997; 53:583.

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Zilberberg MD, Shorr AF. Secular trends in gram-negative resistance among urinary tractinfection hospitalizations in the United States, 2000-2009. Infect Control Hosp Epidemiol 2013;34:940.

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Lautenbach E. Editorial commentary: flying under the radar: the stealth pandemic ofEscherichia coli sequence type 131. Clin Infect Dis 2013; 57:1266.

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Colpan A, Johnston B, Porter S, et al. Escherichia coli sequence type 131 (ST131) subcloneH30 as an emergent multidrug-resistant pathogen among US veterans. Clin Infect Dis 2013;57:1256.

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Bent S, Nallamothu BK, Simel DL, et al. Does this woman have an acute uncomplicated urinarytract infection? JAMA 2002; 287:2701.

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Fairley KF, Carson NE, Gutch RC, et al. Site of infection in acute urinary-tract infection ingeneral practice. Lancet 1971; 2:615.

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Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatmentof acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the InfectiousDiseases Society of America and the European Society for Microbiology and InfectiousDiseases. Clin Infect Dis 2011; 52:e103.

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Sandberg T, Stokland E, Brolin I, et al. Selective use of excretory urography in women with12.

infection with an extended-spectrum beta-lactamase producing organism), or an aminoglycoside(3 to 5 mg/kg of gentamicin or tobramycin). Empiric treatment choice should also take intoaccount previous antimicrobial use and results of any recent urine cultures. After clinicalimprovement is observed, parenteral therapy can be switched to oral therapy, guided byantimicrobial susceptibility data, for a total of five to seven days, depending upon the severity ofinfection. (See 'Cystitis' above.)

Patients with complicated pyelonephritis should be managed initially as inpatients. Broad-spectrum parenteral antimicrobials should be used for empiric treatment of complicatedpyelonephritis as outlined in the table (table 1). Previous antimicrobial use and results of anyrecent urine cultures should inform the choice of an empiric regimen. If antimicrobialsusceptibility data and clinical circumstances permit, treatment may be completed with oraltherapy; acceptable agents include levofloxacin, ciprofloxacin, or trimethoprim-sulfamethoxazole.Antibiotics are generally administered for 7 to 14 days; depending on patient circumstances, alonger duration of therapy may be warranted. (See 'Pyelonephritis' above.)

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acute pyelonephritis. J Urol 1989; 141:1290.

Kanel KT, Kroboth FJ, Schwentker FN, Lecky JW. The intravenous pyelogram in acutepyelonephritis. Arch Intern Med 1988; 148:2144.

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http://www.guideline.gov/summary/summary.aspx?doc_id=13683&nbr=007017&string=pyelonephritis (Accessed on September 14, 2009).

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Johnson JR, Vincent LM, Wang K, et al. Renal ultrasonographic correlates of acutepyelonephritis. Clin Infect Dis 1992; 14:15.

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Meyrier A, Condamin MC, Fernet M, et al. Frequency of development of early cortical scarringin acute primary pyelonephritis. Kidney Int 1989; 35:696.

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Kawashima A, LeRoy AJ. Radiologic evaluation of patients with renal infections. Infect Dis ClinNorth Am 2003; 17:433.

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Tsugaya M, Hirao N, Sakagami H, et al. Computerized tomography in acute pyelonephritis: theclinical correlations. J Urol 1990; 144:611.

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Demertzis J, Menias CO. State of the art: imaging of renal infections. Emerg Radiol 2007;14:13.

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Soulen MC, Fishman EK, Goldman SM. Sequelae of acute renal infections: CT evaluation.Radiology 1989; 173:423.

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Hooper DC, Wolfson JS. Fluoroquinolone antimicrobial agents. N Engl J Med 1991; 324:384.21.

MacFadden DR, Ridgway JP, Robicsek A, et al. Predictive utility of prior positive urine cultures.Clin Infect Dis 2014; 59:1265.

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Stamm WE, Hooton TM. Management of urinary tract infections in adults. N Engl J Med 1993;329:1328.

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Rodríguez-Baño J, Alcalá JC, Cisneros JM, et al. Community infections caused by extended-spectrum beta-lactamase-producing Escherichia coli. Arch Intern Med 2008; 168:1897.

24.

Tasbakan MI, Pullukcu H, Sipahi OR, et al. Nitrofurantoin in the treatment of extended-spectrumβ-lactamase-producing Escherichia coli-related lower urinary tract infection. Int J AntimicrobAgents 2012; 40:554.

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Pullukcu H, Tasbakan M, Sipahi OR, et al. Fosfomycin in the treatment of extended spectrumbeta-lactamase-producing Escherichia coli-related lower urinary tract infections. Int J AntimicrobAgents 2007; 29:62.

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Senol S, Tasbakan M, Pullukcu H, et al. Carbapenem versus fosfomycin tromethanol in thetreatment of extended-spectrum beta-lactamase-producing Escherichia coli-related complicatedlower urinary tract infection. J Chemother 2010; 22:355.

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Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines fromthe Infectious Diseases Society of America. Clin Infect Dis 2010; 50:625.

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The prevention and management of urinary tract infections among people with spinal cordinjuries. National Institute on Disability and Rehabilitation Research Consensus Statement.January 27-29, 1992. J Am Paraplegia Soc 1992; 15:194.

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Peterson J, Kaul S, Khashab M, et al. A double-blind, randomized comparison of levofloxacin750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for thetreatment of complicated urinary tract infections and acute pyelonephritis. Urology 2008; 71:17.

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Parasuraman R, Julian K, AST Infectious Diseases Community of Practice. Urinary tract31.


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infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:327.

Topic 16109 Version 29.0


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GRAPHICS

Ultrasonography of acute pyelonephritis

Renal ultrasonography in a patient with acute pyelonephritis showing ahypodense mass with internal echoes (outlined by the arrows).

Courtesy of Alain Meyrier, MD.

Graphic 62046 Version 4.0


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Computed tomography scan of acute pyelonephritis

Contrast-enhanced CT scan in a patient with acute pyelonephritis showing alarge, hypodense region in the right kidney. There is no discrete abscessformation in this setting.




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Computed tomography scan of bilateral acutepyelonephritis

Contrast-enhanced CT scan in bilateral acute pyelonephritis showing triangularhypodense streaks spreading from the pelvis to the renal cortex (arrows).




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Parenteral regimens for empiric treatment of complicated pyelonephritis

Antimicrobial agent Dose, interval

Mild to moderate pyelonephritis*

Ceftriaxone 1 g every 24 hours

Ciprofloxacin 400 mg every 12 hours

Levofloxacin 750 mg every 24 hours

Aztreonam 1 g every 8 to 12 hours

Severe pyelonephritis

Cefepime 2 g every 12 hours

Piperacillin-tazobactam 3.375 g every 6 hours

Ceftolozane-tazobactam 1.5 g every 8 hours

Ceftazidime-avibactam 2.5 g every 8 hours

Meropenem 500 mg every 8 hours

Imipenem 500 mg every 6 hours

Doripenem 500 mg every 8 hours

Previous antimicrobial use and results of any recent urine cultures should inform the choice of an empiricregimen.Doses are for patients with normal renal function.In the setting of pregnancy, the above agents are acceptable with the exceptions of ciprofloxacin,levofloxacin, and imipenem. The treatment of urinary tract infection due to enterococcus is discussedseparately.If methicillin-resistant S. aureus (MRSA) is known or suspected, see treatment regimens outlinedseparately in topics addressing MRSA management.

*Broader therapy with one of the agents listed for severe pyelonephritis may be warranted if there is suspicionfor infection with a resistant organism. ¶ Alternative in the setting of beta lactam allergy.Δ If Pseudomonas aeruginosa is suspected, higher doses of piperacillin-tazobactam (4.5 g every 6 hours) ormeropenem (1 g every 8 hours) can be used.


¶

Δ

Δ


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Contributor Disclosures

Thomas M Hooton, MD Consultant/Advisory Boards: Cubist [Complicated UTI(Ceftolozane/tazobactam)]; Danone [UTI management (Hydration therapy)]; GSK (Antimicrobial indevelopment); Ocean Spray (Cranberry products); Paratek Pharmaceuticals (Antimicrobial indevelopment). Equity Ownership/Stock Options: Fimbrion Therapeutics [UTI prevention(Development of mannosides)]. Stephen B Calderwood, MD Patent Holder: Vaccine TechnologiesInc [Vaccines (Cholera vaccines)]. Equity Ownership: Pulmatrix [Infectious diseases (Inhaledantimicrobials)]. Allyson Bloom, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found,these are addressed by vetting through a multi-level review process, and through requirements forreferences to be provided to support the content. Appropriately referenced content is required of allauthors and must conform to UpToDate standards of evidence.

Conflict of interest policy


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