Management of Antibiotic-Resistant Acute Pyelonephritis

Ha Na Lee; Hana Yoon

doi:10.14777/uti.2017.12.03.95

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Lee and Yoon: Management of Antibiotic-Resistant Acute Pyelonephritis

Review

Urogenit Tract Infect 2017;12(3):95-102.

Published online: 19 January 2017

DOI: https://doi.org/10.14777/uti.2017.12.03.95

Management of Antibiotic-Resistant Acute Pyelonephritis

Ha Na Lee, Hana Yoon^1,

Department of Urology, Seoul Metropolitan Seonam Hospital, Seoul

¹Department of Urology, Ewha Womans University School of Medicine, Seoul, Korea

Correspondence to: Hana Yoon http://orcid.org/0000-0002-8553-0152 Department of Urology, Ewha Womans University School of Medicine, 1071 Anyangcheon-ro, Yang-cheon-gu, Seoul 07985, Korea Tel: +82-2-2650-5157, Fax: +82-2-2654-3682 E-mail: wowhana@ewha.ac.kr

Received 1 September 2017 Revised 30 September 2017 Accepted 7 October 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Pyelonephritis, Drug resistance, microbial, Urinary tract infections

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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
Target structure modifications	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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