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Outpatient Antibiotic for Pyelonephritis – Ciprofloxacin, TMP/SMX, or Cephalosporins?

September 27, 2018

Written by Vivian Lei

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Outpatient treatment failure for pyelonephritis occurred more often in patients treated with fluoroquinolones or trimethoprim-sulfamethoxazole (TMP-SMX) than in patient treated with cephalosporins.*

Why does this matter?
The last IDSA guideline for treatment of uncomplicated pyelonephritis was published in 2011. First-line agents are fluoroquinolones and TMP-SMX. However, antibiotic resistance has continued to increase to these first-line agents since the guidelines were released. What other options might exist?

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In this study, investigators performed a retrospective chart review of patients diagnosed with pyelonephritis in 6 community EDs between August 2017 and October 2017. Patients were excluded if they were male, were recently hospitalized, had kidney stones or recent catheterization, had received recent antibiotic use, were nursing home patients, or were immunocompromised. Treatment failure (defined as return within 30 days for relapsing symptoms or needing to change antibiotics based on cultures and sensitivities) occurred in 10 out of 43 patients (23%) treated with fluoroquinolones or TMP-SMX versus 0 out of 55 patients (0%) treated with cephalosporins (p<0.001).  Bacterial culture sensitivities showed significantly higher rates of resistance to TMP-SMX compared to the other antibiotic agents. Based on this study, oral cephalosporins may be a more appropriate antibiotic choice for uncomplicated pyelonephritis compared to current IDSA recommendations, with the caveat that local antibiograms may vary.

*Notable limitations of this study included lack of a standardized treatment regimen for pyelonephritis. 13 of 45 patients were prescribed an under-dosed regimen of a fluoroquinolone or TMP-SMX, as recommended by the IDSA. Additionally, more patients in the cephalosporin group received a dose of parenteral antimicrobial therapy before starting outpatient therapy (78% vs. 53%).

Pyelonephritis treatment in the community emergency department: Cephalosporins vs. first-lineagents. Am J Emerg Med. 2018 Aug 8. pii: S0735-6757(18)30652-1. doi: 10.1016/j.ajem.2018.08.016. [Epub ahead of print]

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Reviewed by Thomas Davis

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