Acute Pyelonephritis or Complicated Urinary Tract Infection
- See investigation and treatment guidelines in Hospital HealthPathways.
- A urinary tract infection is complicated if the following apply:
- Pregnant (see Uncomplicated Acute Lower Urinary Tract Infections in Women for empiric treatment options for cystitis in pregnancy)
- Male (cystitis in men is treated as for women but for a longer course of 7 days. See Uncomplicated Acute Lower Urinary Tract Infections in Women)
- Recurrent UTIs (≥ 3 in one year, or 2 in 6 months)
- Failed antibiotic treatment (UTI symptom recurrence within 1 week or persistent symptoms)
- Recent urological or gynaecological instrumentation including intermittent self-catheterisation
- Presence of an indwelling urinary foreign body, e.g. catheter, stent, nephrostomy tube
- Risk for multidrug-resistant Gram-negative bacilli (MDR-GNB)
- recent admission to overseas healthcare facility
- multidrug-resistant Gram-negative bacilli positive
- travel to developing country in previous six months
- household contact with MDR-GNB
- residence or admission to any facility with high prevalence of MDR-GNB
- broad spectrum antimicrobial treatment
- Impaired immunity, e.g. diabetes
- Spinal cord impairment
- If upper urinary tract obstruction is present, an urgent Urology referral and drainage is required.
- For a post-op or post-procedure UTI – see Urinary Tract Infection / Pyelonephritis (Post-operative).
- Pregnant women and patients with severe renal failure require special consideration – see separate sections below.
Pathogens
- Common: E. coli
- Uncommon: Coliforms, P. aeruginosa, Enterococcus
- Consider risk factors for multidrug-resistant Gram-negative bacilli (MDR-GNB), such as extended spectrum beta-lactamase (ESBL) producers. If risk factors, ensure urine is sent for culture and susceptibility testing before initiating antimicrobial therapy. Meropenem is the preferred option for suspected ESBL-producing organisms.
- recent admission to overseas healthcare facility
- multidrug-resistant Gram-negative bacilli positive
- travel to developing country in previous six months
- household contact with MDR-GNB
- residence or admission to any facility with high prevalence of MDR-GNB
- broad spectrum antimicrobial treatment
Drug Treatment
- Consider early switch from IV to oral antimicrobials.
- A single IV dose of antimicrobial followed by oral therapy is usually sufficient. However, IV therapy may be continued until patient can take oral fluids.
- The empiric oral agents below are listed in order of preference.
- Susceptibilities from urine samples to guide oral treatment are usually available within 24 hours.
- For mild infection, duration of treatment is usually 10 days for a beta-lactam-based regimen, or 7 days for a ciprofloxacin-based regimen. Longer courses may be considered for patients slow to respond (maximum of 14 days for a beta-lactam-based regimen, and 10 days for a ciprofloxacin-based regimen).
Empiric
Non-pregnant Patients
gentamicin
HMLSchedNZFPMLnoids
|
Single dose of IV 5 mg/kg ideal body weight. Round dose to the nearest half vial (40 mg)
|
AND one of the following three agents (listed in order of preference):
OR
- Locals experts recommend a high dose is used based on local studies to ensure adequate concentrations against E. coli in the blood stream and kidney as well as in the bladder.
- fe = 0.9, dose is not normally reduced in patients with reduced CrCl for UTI treatment because urinary concentrations are important.
OR
If severe renal failure, i.e. CrCl or eGFR < 20 mL/min
followed, if sensitive, by
OR
Pregnant Patients
- Refer all pregnant patients with pyelonephritis to Obstetrics.
- Treatment duration is usually 10 – 14 days.
- fe = 0.5, dose is not normally reduced in patients with reduced CrCl for UTI treatment because urinary concentrations are important.
followed, if sensitive, by
- Locals experts recommend a high dose is used based on local studies to ensure adequate concentrations against E. coli in the blood stream and kidney as well as in the bladder.
- fe = 0.9, dose is not normally reduced in patients with reduced CrCl for UTI treatment because urinary concentrations are important.
OR, after 14 weeks’ gestation (not in the first trimester - folate antagonist):
Pathogens Known
E. coli
gentamicin
HMLSchedNZFPMLnoids
|
Single dose of IV 5 mg/kg ideal body weight. Round dose to the nearest half vial (40 mg)
|
- fe = 0.9, adjust dose if CrCl reduced.
- Avoid in pregnancy.
OR, in severe renal failure (CrCl or eGFR < 20 mL/min) or pregnancy:
followed, if sensitive, by (in order of preference):
- Locals experts recommend a high dose is used based on local studies to ensure adequate concentrations against E. coli in the blood stream and kidney as well as in the bladder.
- Reduce dose to 500 mg twice daily in severe renal failure (CrCl or eGFR < 20 mL/min)
OR
Enterococci
- fe = 0.7, dose is not normally reduced in patients with reduced CrCl for UTI treatment because urinary concentrations are important.
Penicillin allergy
Consult Infectious Diseases/Clinical Microbiology
Pseudomonas aeruginosa
gentamicin
HMLSchedNZFPMLnoids
|
Single dose of IV 5 mg/kg ideal body weight. Round dose to the nearest half vial (40 mg)
|
- fe = 0.9, adjust dose if CrCl reduced.
- Avoid in pregnancy.
followed by
- fe = 0.7, consider dose reduction if CrCl reduced.
- Inhibits CYP1A2 (strong) and 3A.
- Subject to OAT and OATP (transporter) inhibition.
- Avoid in pregnancy and breastfeeding.
Extended-spectrum beta-lactamase (ESBL) producing coliforms – consult Infectious Diseases/Clinical Microbiology, inform Infection Prevention, and give:
- Ertapenem IV 1 g every 24 hours may be considered for patients needing ongoing treatment on discharge. Discuss with Infectious Diseases.
- Meropenem rapidly and significantly reduces sodium valproate concentrations. Concomitant administration may precipitate seizures in patients with a pre-existing seizure disorder. Discuss alternative antibiotic options with Infectious Diseases/Clinical Microbiology.
- If still on meropenem beyond 48 hours, consider measuring a trough concentration. Consult Infectious Diseases for interpretation.
- fe = 0.7, start with full dose initially then consider extending dose interval and/or decreasing dose for subsequent doses if CrCl is reduced (< 30 mL/min). Consult pharmacist.
Topic Code: 99243