Acute Pyelonephritis

In contrast to patients that present with lower UTIs, those that present with pyelonephritis usually have high-grade fever (greater than 38.3°C [100.9°F]) and severe flank pain. Select patients with pyelonephritis may be treated in the outpatient setting; however, patients whose infection is severe enough to cause vomiting, decreased food intake, and dehydration may need to be treated in an inpatient hospitalized setting. These patients will usually receive IV antibiotics at first before being switched to oral therapy depending on susceptibility testing.

Table 79-2 Commonly Used Antimicrobial Agents for the Treatment of UTIs

AgcJH

CimrTunu

Oral rhiTipy ftantiffim AmoddiPn AmOjtilllfr dMitofc actf Cephaknpo<trx

CeiiKftmnl

Coflüime

Cefpodoxime Cefuroxime

Oevtatotin Cjupjhiddlne ifiiwifiiflef Düxyiytline Minocycline Tetracycline

Hvt^uirtSiirtfl Ciprolki xatm LewjfltuVitirt Norfloxacin

CHIciSUtn AfTiyiiönWiiJ irlnitiivxifim-inirameitKMSic«e

WjnoiuanMii

Azithromycin

Fcifomycln

Piriitleril Therapy

AfflfrldyifflOSiJij Anndn GeffianiHn Tobramycin flenifiiuns Ainpkillai ftnipkilSr sulbatMri TtaicPin-ctawJarnti Pipowiilin tyaKlHn-larobactam

Cephaloiparim Firsr .second . qhinJ-.and fourth-generation

CdrtKlpfiif.'ni OfH^penem Erlaperunn inpipcncm-tiljstjiiii Mefdfwvm

Ine ra*üng resistance h« limiieciimcMiifiinr-usi iflicwe cynüü empire hKuci-jpecriiim aciKvicy. AmadclBln-davJanic atkl isrropirkosy prifawddl» 10 «asnnce. AiripBHirt lulttdiug o< clttteiut «nfcKHOHf swi(ivt (Ope^V:lllln tWOfil bK»vailabiliiy approximately

I Ivre are riL> in,if:.M a<tvaniagei,cf ihi^actonrioverothei oral .vienrün (he trearmiru nf U1 Is, and ihey me usually moe expensive. They may be useful in cases of resistance to amaxiciHn jnd timelhopim-JulfjUMStuXiZOk' Ih(*L Willi ■ft POC JC(rve ifUlrtH enrcrococci

TIiCsl- jginrs tWhe LHiW cftctllvü feu initiJl OtiiwxJes of UTI; iMMMf, «MfclMK« OA JCvfitüu rJfÄily. ^volct (Wint) pregnancy

The newer quinobnes have a greater spec trum a) k tivity These agents are effec tive ft* pyelonephritis Avoid in|>rti>iTjnty JfiO MoxifkWji.il 1» not IrsrcdOiio KrlimiKicI urinjtiy faCNiliOfi liiri (.tnnliiiuriuri Li tiii;!iiy effwiivc at>)iiTii mo« acio(*i efiterk iwtKiiafiCttn P. otKuQifxao. High minary tract tissue levels, anfi mine fcwK W ac h*veit, Wihith may tie implant In compllcaieit UTI ireatmum AlsOdfGClirt! ispiophyÜxisiOf rciLurntfH iivfectiow. Gonc-idlly well tolerated JikJ lewiölt. I« use n«y Iw petlyJifl In patiems*i|ti wHjillfigi«

Tiirv jpi 's effective in uoMinem arid ptnpfgiaxfs in patterns with igcuirwn kmcr tract U1 Is. Siuuid neu be used in patkiiNs Uilh kw «LimjletJCrG (Icii lluri 40 töiii mL/minl'dui lo limited uiiitii»w:tNlia(HiP4,arttf potential increased "isk 01 neuiQjMltiy Commonly used tor s«juaily (rarisnnHieci<Jiseai«ii£.. Chlamydia infettionsj rächet than (or tjfs irh)le-dose therapy foi uncomplicated IfTl

Gentamicin jnd lobumyun are yencraly equity effective while Ictnamyun bat s'ightly Loner coverage of certain PiivrJumuriiii ipjj. Aw*j( in gemrtyKfHavGd fee multidrug iftistani tk*.(i?ria. Typitdliy used on j ihori cotirscof (hrriiiiffoioived by j switch to in o<jl iijrxn. Coneefn for iwicnwicity ¿nd otoroniciiy gerirally I vtiJt tise eipKiity in parienTi with: mpaired nenal function

These agents jiegeneidllyetktlw Tot StiSCepllLilc ÜKHitl.DHaitiVlid'ifwaruin pont illini Jie diliw again« oar[a«i itr-ains c^ fttvAtarriono! spj. riity jie very useful in rt"jlly Impiiied fMtk'nts iiiKe urir-'.L coiKisntrjiioii mm ismain ^^ujitor wtwnanirinlftogl)««idt ii iivuidetf soctfiid and third generation tiphalmpoifis luve j bujad spectiuifl it<.!ivityjgjir»h gum negüä» biitteiij, hut sns-not ai-jain1.! emerocccci. only cefTfl?i(iiriw> and tef^inv have activity aflalrfit cenain mrainsof f'ieutfdniiJiiiJi spp They are trief ul tor noscconnial inhscdonj anu urowoiii due io susiepdfcxe ofhogerwj

TI vjsu jgentt luwe biojd ¡.piK-trurri dLlivity, irxki^ i>y gum yoiitivKigrjiii negaiverand drumobk tütlürij. Gmpemm ii nt< active jyjinst PsiiKfoniWMl Al mjy I»IHocbtedM^tFi Candida sppLsupepinioctiOrij. Rjicty us*d tor inis

Wtíc»HjuwiO(aneí CfHultanacm Levtíkwatin

Monoboctam Aztreonarn

1 hew agents hwr> bff>,id ipec h um ac tlvlty agalnsl both gram negative and gram positive bat lerla. They piOwki.- high urine and [iisuetorttemraticitt ind a<e actively semcied in «.Tduted lenJTunaiois. Switch to cal therapy ivhefl eosswe due co< excellent bioavailability

Only jt tive .Kjainsr giam-negsrivetHCTCrii »^dueling some-strain« of A w^unon Cienerjliy useful tor nosocomial Infections when aminoglycosides are 1o be avoided and In p<ii>ents with iype l/tmmedialp hyjXNScfniiiwityijO pcnkiHim

May be Cflftiklwd in combination fc* empiric tlieiapy tuv?d pal*1"! ilsk faiIds fcr multidrug rtlisuni organisms and gram-positive cocci shown in urinalysis

(In. I, creatinine clearance.

Table 79-3 Overview of Outpatient, Oral Antimicrobial Therapy for Lower and Upper Tract UTIs

Gtytopepbdt

Indications

Antibiotic

Adult Dose'

Frequency Duration lower Fr«t UTIï

(jncompllcaiecl

CyrtiîjliCiinCd

BecunOnt inftitkjns—íonlinutKB, p<ûplïy(JxH

Upptr Tract UTlt

Acule pyctoncphrltis'

Trimeihflprim íulfameihOKJínle

Trimethoprim CtKcdwich Levoflowatin Norfloxacin

Nitrofurantoin macioeiystals Nil Nifui.aiil^ h rni:ri<)lYy<Ji.ilr Amoxicillin

AmortflinOlivulirtt acid FosfomoKln p i", ^niiii m ill. m r.i -Ijii'iy.i/i Ji"

Trimethoprim ("(wnfloMarlri ffclrilotiKlh I pv ofloxacin

Amcjxicillin-clavijlartc acid lr¡^^o[llof)fim-SL^fílne^^k))üaok■

Tiimerhoptim

Cipfófkuotiii tiitioluramoin

Cefaclor

Cephjleïin

Arno®ol¡mclawulantc acrd

Ciprofloxacin Levoflosacin lilime[IX)p'irn-iTitfar«ethojiiS>ie i D5r1abiets <v i üytawet 103 my íí£i mg 250 mg ■fflOmg 5Ûof lÛOmg 100 mg

I WlJblit 100 mg SiHJ mg 4Q0 mg 250 mg WOmg

V, Si' tablet 100 mg 125 mg 50or 100 mg 35fl nig I2S mg fifing or 500 mg 500 mg 240 os 500 mg i DSrtaWer

Sing le den? Evety 12 hcmis Eveiy U hours fvwy I? houfs EvCiy ÍJ louis Eveiy 12 houis tvflly b hours Euety 12 heuu Seigle dose E'.^iy IÎ houis tvCiy 0 hem Smgledose

Ewfliy 12 houis Eveiy 12 bouts Fvny 17 hoirs Evíiy 12 hCuiS Eveiy 2* houis 3 how

Every J4 [very '¿A ÉvHyïi Every Ewty Jl Every îi houis jinn hours houis houn houis

Every 12 hewn EweryB hours Every 12 hours Every H houis

E^y 12 houis

1 rtav

3ct}yS

3days

J days 3 days 1 days 5-1 days Ítbyí 1 day 3 days 3 CbyS I day

7-10 days 7-10 days ï-10days 7-10 days 7-10 days 7-10 days

6 months A months 6 months ú months ii months 6 months

11 days 14 days 7 days 14 days u tvtys

■Mjjcuity of lisied antimicrobi^ orients require do»qe afljusiment In patients wlti sirjiiifieani lenaldysfuivmsn 'OS. double sirpi k irh (16(1 mi f n imeihcfirim,flW0 mg -suMjmethoaJ&Xtt SV. Single strengrh (Wmg liinne(hCfiiinV40O msg sulfanMllnsiMAile] TXMes listed for acute pydonepuiiis a« foro«i regimen*

Patients with pyelonephritis are traditionally given 14 days of therapy; however, there are limited data showing success in treating acute uncomplicated pyelonephritis for 7 to 10 days. More studies need to be conducted on treating for these shorter dur-

ations. Gram stain and culture are important in ensuring that appropriate antimicrobial coverage is selected. Stratification is used to manage patients with acute pyelonephritis. Women who present with mild cases of pyelonephritis (defined as low-grade fever and a normal to slightly elevated peripheral white blood count, without nausea or vomiting) may be treated as outpatients. Those women who exhibit more severe signs and symptoms will need to be admitted to an acute care setting for appropriate treatment. The same holds true for antibiotic selection in these patients. Those who are treated in an outpatient setting can be treated with trimethoprim-sulfamethoxazole, fluoroquinolones, or even ^-lactam/^-lactamase inhibitors, such as amoxicillin-clavulanic acid. In those patients that are admitted to the hospital, antibiotic therapy is usually broader in nature, especially in patients suspected of having bacteremia or urosepsis. These patients will typically receive IV therapy such as a

3 37 38

fluoroquinolone, or a ^-lactam plus an aminoglycoside. ' ' Special Populations Pregnant Women

Changes to the urinary tract in pregnant women predispose them to an increased incidence of bacteriuria, and subsequent UTIs that may follow. These changes include alterations in amino acid and other nutrient concentrations in the urine along with physiologic changes such as reduced bladder tone and dilation of the renal pelvis and

An association exists between maternal UTI during pregnancy and fetal death, mental retardation, and developmental delay.41 Due to this known association and since up to 7% of pregnant women will develop an asymptomatic bacteriuria that may progress to pyelonephritis, screening for UTI is necessary.24,42 In pregnant patients with significant bacteriuria, whether symptomatic or asymptomatic, treatment is recommended to avoid the complications discussed previously. In the majority of patients, a sulfonamide (not in the third trimester due to concerns for hyperbilirubinemia), amoxicillin-clavulanic acid, cephalexin, or nitrofurantoin are effective treatment options. Tetracyclines and fluoroquinolones should be avoided due to risk of teratogenicity and ability to inhibit cartilage and bone development, respectively. Follow-up usually consists of a urine culture 1 to 2 weeks after completion of therapy, and afterwards monthly until birth.

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