TREATMENT OF ACUTE PYELONEPHRITIS: OUTPATIENT AND INPATIENT THERAPIES

Outpatient Therapy
Most pyelonephritis patients can be treated as outpatients. Compliant women with pyelonephritis who have only slight elevations in temperature and white blood cell count and who have no nausea or vomiting can be treated as outpatients with 7 to 14 days of oral antibiotics. Antibiotic treatment should be aimed at the same pathogens that cause acute cystitis (e.g., E. coli, S. saprophyticus). Fluoroquinolones are the drugs of choice for empirical therapy. Co-trimoxazole should be used only if the causative organism is known to be susceptible. If a gram-positive organism is causative, amoxicillin or amoxicillin-clavulanate can be used.16 Patients who do not improve with 48 to 72 hours of appropriate therapy should be investigated for obstruction or renal abscess with either renal ultrasonography or abdominal computed tomography (CT).
To avoid hospitalizations, some clinicians will observe patients for up to 24 hours on intravenous therapy to assess response to treatment. If the response is rapid, admission can be avoided. Another option in reliable patients is to give once-daily intravenous or intramuscular dosing (e.g., ceftriaxone, levofloxacin) in the outpatient setting. Other clinicians simply administer a single dose of parenteral antibiotics before starting oral antibiotics. All of these options are reasonable.
Inpatient Therapy
Hospital admission for intravenous antibiotics and fluids is required in patients who appear toxic or cannot ingest medications or adequate fluids. Several antibiotic regimens can be used in the inpatient setting. These include fluoroquinolones, an aminoglycoside (with, or without ampicillin), or a broad-spectrum cephalosporin (with or without an aminoglycoside). Once antibiotics and hydration are started, most patients improve within 72 hours. Once a patient’s condition has improved, treatment can be switched to oral antibiotics tailored to the pathogen’s antibiotic susceptibility.
As with outpatient therapy, renal ultrasonography or abdominal CT should be performed if a patient does not improve within 72 hours. Rarely, patients with renal parenchymal involvement will continue to mount low-grade fevers after several days of appropriate therapy. If these patients are otherwise improving (e.g., decreased pain, advancement of diet), it is reasonable to discharge them on oral antibiotics and follow them closely as outpatients.
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TREATMENT OF ACUTE PYELONEPHRITIS: OUTPATIENT AND INPATIENT THERAPIESOutpatient TherapyMost pyelonephritis patients can be treated as outpatients. Compliant women with pyelonephritis who have only slight elevations in temperature and white blood cell count and who have no nausea or vomiting can be treated as outpatients with 7 to 14 days of oral antibiotics. Antibiotic treatment should be aimed at the same pathogens that cause acute cystitis (e.g., E. coli, S. saprophyticus). Fluoroquinolones are the drugs of choice for empirical therapy. Co-trimoxazole should be used only if the causative organism is known to be susceptible. If a gram-positive organism is causative, amoxicillin or amoxicillin-clavulanate can be used.16 Patients who do not improve with 48 to 72 hours of appropriate therapy should be investigated for obstruction or renal abscess with either renal ultrasonography or abdominal computed tomography (CT).To avoid hospitalizations, some clinicians will observe patients for up to 24 hours on intravenous therapy to assess response to treatment. If the response is rapid, admission can be avoided. Another option in reliable patients is to give once-daily intravenous or intramuscular dosing (e.g., ceftriaxone, levofloxacin) in the outpatient setting. Other clinicians simply administer a single dose of parenteral antibiotics before starting oral antibiotics. All of these options are reasonable.
Inpatient TherapyHospital admission for intravenous antibiotics and fluids is required in patients who appear toxic or cannot ingest medications or adequate fluids. Several antibiotic regimens can be used in the inpatient setting. These include fluoroquinolones, an aminoglycoside (with, or without ampicillin), or a broad-spectrum cephalosporin (with or without an aminoglycoside). Once antibiotics and hydration are started, most patients improve within 72 hours. Once a patient’s condition has improved, treatment can be switched to oral antibiotics tailored to the pathogen’s antibiotic susceptibility.As with outpatient therapy, renal ultrasonography or abdominal CT should be performed if a patient does not improve within 72 hours. Rarely, patients with renal parenchymal involvement will continue to mount low-grade fevers after several days of appropriate therapy. If these patients are otherwise improving (e.g., decreased pain, advancement of diet), it is reasonable to discharge them on oral antibiotics and follow them closely as outpatients.*145/348/5*

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