Acute Pyelonephritis in Adults: Rapid Evidence Review
Am Fam Physician. 2020 Aug 1;102(3):173-180.
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Acute pyelonephritis is a bacterial infection of the kidney and renal pelvis and should be suspected in patients with flank pain and laboratory evidence of urinary tract infection. Urine culture with antimicrobial susceptibility testing should be performed in all patients and used to direct therapy. Imaging, blood cultures, and measurement of serum inflammatory markers should not be performed in uncomplicated cases. Outpatient management is appropriate in patients who have uncomplicated disease and can tolerate oral therapy. Extended emergency department or observation unit stays are an appropriate option for patients who initially warrant intravenous therapy. Fluoroquinolones and trimethoprim/sulfamethoxazole are effective oral antibiotics in most cases, but increasing resistance makes empiric use problematic. When local resistance to a chosen oral antibiotic likely exceeds 10%, one dose of a long-acting broad-spectrum parenteral antibiotic should also be given while awaiting susceptibility data. Patients admitted to the hospital should receive parenteral antibiotic therapy, and those with sepsis or risk of infection with a multidrug-resistant organism should receive antibiotics with activity against extended-spectrum beta-lactamase–producing organisms. Most patients respond to appropriate management within 48 to 72 hours, and those who do not should be evaluated with imaging and repeat cultures while alternative diagnoses are considered. In cases of concurrent urinary tract obstruction, referral for urgent decompression should be pursued. Pregnant patients with pyelonephritis are at significantly elevated risk of severe complications and should be admitted and treated initially with parenteral therapy.
Acute pyelonephritis, a serious and relatively common bacterial infection of the kidney and renal pelvis, accounts for approximately 250,000 office visits and 200,000 hospital admissions annually in the United States.1–3
WHAT'S NEW ON THIS TOPIC
As of 2014, Escherichia coli resistance to trimethoprim/sulfamethoxazole and fluoroquinolones in the United States exceeded 35% and 10%, respectively.
A systematic review of 8 randomized controlled trials (N = 2,515) demonstrated equivalent clinical success rates in treating uncomplicated acute pyelonephritis with a 5- to 7-day course of fluoroquinolones compared with a 14-day course.
In the male subgroup of a 2017 randomized controlled trial, a 7-day course of ciprofloxacin was inferior to a 14-day course with respect to short-term cure rates with no differences in long-term outcomes.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
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