Written by Amanda Matthews
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This retrospective study found no difference in rates of treatment failure at 14 days in patients treated with cephalosporins compared to fluoroquinolones/TMP-SMX for outpatient pyelonephritis.
Which antibiotic is best?
This was a multicenter, retrospective, observational cohort study of 11 U.S. emergency departments. Patients aged 18 years or older who presented with a primary or secondary diagnosis of uncomplicated or complicated pyelonephritis in the ED and were ultimately discharged home on oral antibiotics were included. Complicated pyelonephritis included patients who were male or had an anatomical condition or immunocompromising condition that increased risk of treatment failure. 909 patients met inclusion criteria (647 received cephalosporins, 204 received fluoroquinolones or TMP-SMX). Primary outcome was outpatient treatment failure at 14 days.
Cephalexin was the most commonly prescribed cephalosporin. Average treatment duration was 9 days for the cephalosporin group and fluoroquinolone group and 7 days for the TMP-SMX group. IV antibiotics were administered while in the ED for 60.4% of the cephalosporin group and 46.6% of the other antibiotic group. The most common IV antibiotic was ceftriaxone in both cohorts (86.8%). The odds of treatment failure at 14 days were not statistically different in patients who received a fluoroquinolone/TMP-SMX compared to cephalosporin (adjusted OR 1.275, 95%CI 0.86 to 1.9]). This was adjusted for gender, complicated infection, previous use of IV or PO antibiotics, and urinary tract abnormality.
How will this change my practice?
The outpatient pyelonephritis treatment I have historically used was a one-time dose of IV ceftriaxone and then 14 days of PO cefdinir, which I have continued to use now that I practice at different hospitals. This study does not offer any conflicting evidence against that protocol, so I will continue to use it as my go-to for patients with pyelonephritis who are stable enough to go home.
Source
Cephalosporins for Outpatient Pyelonephritis in the Emergency Department: COPY-ED Study. Ann Emerg Med. 2025 Mar;85(3):240-248. doi: 10.1016/j.annemergmed.2024.10.013. Epub 2024 Nov 20. PMID: 39570254
