Journal List > Urogenit Tract Infect > v.12(3) > 1084233

Lee and Yoon: Management of Antibiotic-Resistant Acute Pyelonephritis

Abstract

Acute pyelonephritis (APN) is a common urinary tract infection that affects a large proportion of women. Although antimicrobial therapy is a successful treatment in most cases, empirically, antibiotic resistance has emerged as a serious issue, including high resistance rate of fluoroquinolone and the advent of extended-spectrum -lactamase (ESBL)-producing organisms. Several agents can be considered for the management of antibiotic resistant APN. Fosfomycin trometamol is effective in treating ESBL-producing bacterial infection. Oral trimethoprim/sulfamethoxazole, -lactam agents, such as cephalosporin, and fluoroquinolone can be regarded as appropriate agents if pathogen is susceptible. Carbapenem, such as imipenem, meropenem, and doripenem, is one of the best and widely used agents for treating antibiotic resistant APN. However, there have recently been concerns regarding the increased rates of resistance to carbapenems. Daptomycin, linezolid, and tigecycline can be considered as solutions to antibiotic resistant organisms. Antibiotic resistant APN should be treated as other systemic infections to prevent antibiotic overuse with proper treatment duration considering carbapenem-saving strategy.

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Table 1.
Mechanisms for achieving antibiotic resistance
Mechanism Antibiotics Representative pathogens
Permeability and efflux mechanism modifications -Lactams Pseudomonas species
Fluoroquinolone Staphylococcus aureus
  Coagulase-negative Staphylococci
  Citrobacter freundii
Target structure modifications Fluoroquinolone Escherichia coli
TMP-SMX MRSA
Inactivation of antibiotics -Lactam S. aureus
  Proteus species
  Enterobacter species such as C. freundii and Serratia species
Aminoglycoside Staphylococcus
  Enterococcus species
  Pseudomonas species

TMP-SMX: trimethoprim-sulfamethoxazole, MRSA: methicillin-resistant Staphylococcus aureus.

Table 2.
Initial empiric therapy oral antibiotics for acute uncomplicated pyelonephritis
Antibiotics Dose Duration (d)
Ciprofloxacin 500-750 mg bid 7-10
Levofloxacin 500 mg qd 7-10 (or 750 mg qd for 5 d)
Alternatives (clinical but not microbiological    
equivalent efficacy compared with fluoroquinolones)    
Cefodoximeproxetil 200 mg bid 10
Ceftibuten 400 mg qd 10
Only if pathogen is susceptible    
Co-amoxiclav 0.5/0.125 g tid 14

Bid: twice a day, qd: once a day, tid: three times a day.

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