Pyelonephritis

A. Acute uncomplicated pyelonephritis presents with a mild cystitis-like illness and accompanying flank pain; fever, chills, nausea, vomiting, leukocytosis and abdominal pain; or a serious gram-negative bacteremia. The microbiologic features of acute uncomplicated pyelonephritis are the same as cystitis, except that S. saprophyticus is a rare cause.

B. The diagnosis should be confirmed by urinalysis with examination for pyuria and/or white blood cell casts and by urine culture. Urine cultures demonstrate more than 100,000 CFU/mL of urine. Blood cultures are positive in 20%. White cell casts are present on urinalysis.

C. Oral therapy should be considered in women with mild to moderate symptoms. Since E. coli resistance to ampicillin, amoxicillin and first-generation cephalosporins exceeds 30 percent in most locales, these agents should not be used for the treatment of pyelonephritis. Resistance to trimethoprim-sulfamethoxazole exceeds 15 percent; empiric therapy with ciprofloxacin (Cipro), 250 mg twice daily, or ofloxacin (Floxin), 200 mg twice daily, should be considered.

D. Patients who are too ill to take oral antibiotics should initially be treated parenterally with a third-generation cephalosporin, aztreonam, a broad-spectrum penicillin, a quinolone or an aminoglycoside. Once these patients have improved clinically (usually by day 3), they can be switched to oral therapy.

E. The total duration of therapy need is usually 14 days. Patients with persistent symptoms after three days of appropriate antimicrobial therapy should be evaluated by renal ultrasonography or computed tomography for evidence of urinary obstruction. In the small percentage of patients who relapse after a two-week course, a repeated six-week course is usually curative.

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