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Fluoroquinolones (Levaquin 500 mg po qd or Cipro 500 mg po bid or Floxin 400 mg po bid) x 2 weeks.
Alternative: Augmentin 875/125 mg po q12h or 500/125 mg po tid x 2 weeks or Keflex 500 mg po qid
x 2 weeks.
Moderately ill but unable to tolerate po medications:
Ampicillin 1-2 gm IV q 6-8h and gentamicin.
Gentamicin, q d dosing at 5 mg/kg is preferred or 1.5 mg/kg loading and 1.0 mg/kg IV/IM q 8 h.
Alternative: cefotaxime 1.0 gm q12h IV up to 2.0 gm q4h IV or ceftriaxone 2.0 gm qd IV.
Once patient is clinically improved, treat with quinolones (as above) x 2 weeks.
Severely ill: Treat 2-3 weeks with same IV regimen as above. Do not progress to oral dosing.
Give IV fluids if there is dehydration and nausea.
Of the quinolones, Levaquin has a broader spectrum of coverage for UTI.
If quinolones are not available, use Septra DS tid until afebrile, then bid for 2 weeks.
Nitrofurantoin is not useful for deep tissue infections such as pyelonephritis.
Patients who are penicillin allergic should be treated with vancomycin 15 mg/kg q12h IV when ampicillin
is indicated.
Pyelonephritis with complicating factors (recurrent UTIs or post-menopausal)
After initial treatment, begin suppression regimen until seen by urology: Macrodantin 50 mg po bid, Septra
DS 1⁄2 po qhs, Cipro 250 mg po q hs or Keflex 250 mg po q hs.
Empiric:
Failure of symptoms and urinalysis to improve suggests resistance to the antibiotic being used. Antibiotics
should be changed if there is no improvement after 3-4 days. Patients with a fever can be expected to take
several days to become afebrile.
Recurrence of urinary tract infection within weeks of completing the initial course of antibiotics suggests an
inadequate duration of treatment or reinfection. A longer course of antibiotics, possibly with the addition of
2-3 months of suppression is indicated.
Urine culture data is extremely valuable in both cases.
Patient Education
General: Hydrate well to ensure urination every 2 hours. Cranberry juice is a good fluid choice. Complete
all antibiotics.
Follow-up Actions
Evacuation/Consultation Criteria: Evacuate unstable patients ASAP. Refer patients with pyelonephritis for
urologic evaluation electively. Patients with cystitis that does not resolve within 3 days of initiating treatment
should be referred for evaluation.