Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

all patients

1st line – treatment of underlying cause

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ONGOING
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all patients
1st line – 

treatment of underlying cause

No specific treatment of chronic pyelonephritis is possible; however, patients should have underlying causes (e.g., infection, obstruction) treated appropriately to prevent further damage. In both children and adults, recurrent infections resulting from anatomical abnormalities are a major factor in the development of chronic pyelonephritis and renal failure. In chronic interstitial nephritis, the primary aetiological factors are vesicoureteral reflux and obstruction.[11]

Plus – nephrectomy and antibiotics

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ONGOING
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all patients
|
with xanthogranulomatous pyelonephritis
Plus – 

nephrectomy and antibiotics

Treatment recommended for ALL patients in selected patient group

Urgent urological consultation is essential in the management of these patients.

The main treatment of this chronic destructive inflammatory process is surgical.

Medical treatment does not cure this disease, but because most patients are diabetic, good glucose control and treatment of infection with gram-negative cover are recommended. Antibiotic treatment includes third-generation cephalosporins (e.g., ceftriaxone), extended-spectrum penicillins (e.g., ampicillin/sulbactam, piperacillin/tazobactam), aminoglycosides (e.g., gentamicin), and carbapenem antibiotics (e.g., imipenem/cilastatin, ertapenem). Fluoroquinolones (e.g., ciprofloxacin) should be considered if other treatments are not available or are contraindicated.

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[48]

Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).

Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

In the setting of increasing drug resistance in uropathogens, the following antibiotics are approved in some countries for use in adults with complicated urinary tract infection (UTI) caused by susceptible organisms who have limited or no alternative options: ceftazidime/avibactam, meropenem/vaborbactam, plazomicin, cefiderocol, and imipenem/cilastatin/relebactam.[49][50][51]​​​

Because of the destructive nature of the lesions, xanthogranulomatous pyelonephritis (XGP) may be mistaken for renal cell carcinoma on radiological images (e.g., CT scan). The correct diagnosis may not be made until the patient undergoes surgery.

The treatment of this rare infectious disease is surgical; this generally includes partial or, typically, total nephrectomy.[16][25]​ The disease rarely involves both kidneys.[52]​ Available evidence does not support serial progression from one kidney to the other. While surgery may represent optimal treatment, postoperative complications are common.[53]

Treatment course: 10-14 days. A repeat urine culture should be performed at least 48 hours after the last antibiotic dose in order to document resolution of the UTI.

Primary options

ceftriaxone: 1 g intravenously every 24 hours

OR

gentamicin: 5-7 mg/kg intravenously every 24 hours

More

OR

ampicillin/sulbactam: 3 g intravenously every 6 hours

More

OR

piperacillin/tazobactam: 3.375 g intravenously every 6-8 hours

More

OR

imipenem/cilastatin: 250-500 mg intravenously every 6-8 hours

More

OR

ertapenem: 1 g intravenously every 24 hours

Secondary options

ciprofloxacin: 400 mg intravenously every 12 hours

OR

ceftazidime/avibactam: 2.5 g intravenously every 8 hours

More

OR

meropenem/vaborbactam: 4 g intravenously every 8 hours

More

OR

plazomicin: 15 mg/kg intravenously every 24 hours

OR

cefiderocol: 2 g intravenously every 8 hours

OR

imipenem/cilastatin/relebactam: 1.25 g intravenously every 6 hours

More

Plus – percutaneous drainage, antibiotics, and supportive therapy

Back
ONGOING
|
all patients
|
with emphysematous pyelonephritis
Plus – 

percutaneous drainage, antibiotics, and supportive therapy

Treatment recommended for ALL patients in selected patient group

Urgent urological consultation is essential in the management of these patients.

If patients are haemodynamically stable, percutaneous drainage or stent placement to relieve obstruction may be the preferred option, together with antibiotics.[17][18][56] If no clinical improvement is noted within 24-48 hours, a repeat CT scan should be obtained, and nephrectomy considered.[1]

Most patients are acutely ill, and stabilisation in the emergency department with adequate fluid resuscitation and tissue oxygenation has been shown to decrease morbidity and improve mortality.[26]

Intravenous antibiotics are given for this severe infection; duration of treatment depends on clinical response to therapy. Antibiotic treatment includes third-generation cephalosporins (e.g., ceftriaxone), extended-spectrum penicillins (e.g., ampicillin/sulbactam, piperacillin/tazobactam), aminoglycosides (e.g., gentamicin), and carbapenem antibiotics (e.g., imipenem/cilastatin, ertapenem). Fluoroquinolones (e.g., ciprofloxacin) should be considered if other treatments are not available or are contraindicated.

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[48]

Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).

Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

In the setting of increasing drug resistance in uropathogens, the following antibiotics are approved in some countries for use in adults with complicated urinary tract infection (UTI) caused by susceptible organisms who have limited or no alternative options: ceftazidime/avibactam, meropenem/vaborbactam, plazomicin, cefiderocol, and imipenem/cilastatin/relebactam.[49][50][51]​​​

Treatment course: 10-14 days. A repeat urine culture should be performed at least 48 hours after the last antibiotic dose in order to document resolution of the UTI.

Primary options

ceftriaxone: 1 g intravenously every 24 hours

OR

gentamicin: 5-7 mg/kg intravenously every 24 hours

More

OR

ampicillin/sulbactam: 3 g intravenously every 6 hours

More

OR

piperacillin/tazobactam: 3.375 g intravenously every 6-8 hours

More

OR

imipenem/cilastatin: 250-500 mg intravenously every 6-8 hours

More

OR

ertapenem: 1 g intravenously every 24 hours

Secondary options

ciprofloxacin: 400 mg intravenously every 12 hours

OR

ceftazidime/avibactam: 2.5 g intravenously every 8 hours

More

OR

meropenem/vaborbactam: 4 g intravenously every 8 hours

More

OR

plazomicin: 15 mg/kg intravenously every 24 hours

OR

cefiderocol: 2 g intravenously every 8 hours

OR

imipenem/cilastatin/relebactam: 1.25 g intravenously every 6 hours

More

Consider – nephrectomy

Back
ONGOING
|
all patients
|
with emphysematous pyelonephritis
Consider – 

nephrectomy

Additional treatment recommended for SOME patients in selected patient group

Urgent urological consultation is essential in the management of these patients.

In the past, nephrectomy was recommended in all patients. However, patients who undergo urgent nephrectomy in the face of sepsis are significant surgical risks.

Patients who have no clinical improvement with drainage and antibiotics within 24-48 hours, or who are severely ill or septic, need nephrectomy.[1][59]

Operative treatment, such as nephrectomy and drainage, along with antibiotics has been shown to decrease the mortality rate.[59]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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