Treatment of pyelonephritis

Treatment of pyelonephritis should be comprehensive, long-term, individual, aimed at eliminating the cause in each specific case.

Before starting treatment for pyelonephritis, it is necessary:

• eliminate factors that aggravate the course of the disease (urinary tract obstruction, diabetes mellitus, pregnancy, etc.);
• determine the type of pathogen, its sensitivity to antibiotics and chemotherapy drugs;
• clarify the state of urodynamics (absence or presence of disturbances in the passage of urine);
• determine the degree of activity of the infectious and inflammatory process;
• assess kidney function.

Acute pyelonephritis without signs of obstruction requires immediate treatment with antibacterial drugs. In case of obstructive pyelonephritis, treatment begins with restoring the passage of urine by installing a catheter, stent or performing a nephrostomy. Without restoring the passage of urine, the use of antibacterial drugs is dangerous (high risk of developing bacteremic shock).

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• Antibiotics for pyelonephritis

Treatment of chronic pyelonephritis is conventionally divided into two stages:

• treatment during an exacerbation (practically no different in its principles from the treatment of acute pyelonephritis);
• anti-relapse treatment.

Treatment tactics for pyelonephritis

Usually, treatment of pyelonephritis (after urine passage disorders have been excluded) begins before the results of bacteriological examination of the culture isolated from urine cultures and determination of its sensitivity to antibiotics (empirical antibacterial therapy). In the empirical approach, the determining factors are the localization, nature (acute or chronic) and severity of the infectious process. After receiving the results of the microbiological examination, the therapy should be adjusted.

Hospitalization is necessary for the treatment of severe and complicated pyelonephritis. Treatment usually begins with parenteral administration of antibiotics. After normalization of body temperature (within 3-5 days), treatment can be continued using antibacterial drugs for oral administration (step therapy). Regardless of the functional state of the kidneys, the first dose of drugs (saturation dose) is administered in full, then it is adjusted taking into account the kidney function.

There are first-line or choice agents, which are considered optimal, and second-line or alternative agents.

The duration of antibiotic treatment for acute pyelonephritis is 10-14 days, and for exacerbation of chronic pyelonephritis - 10-21 days. After completion of therapy, a control urine test is necessary, including bacteriological testing. If the infectious agent persists, a repeated course of antibiotic treatment is prescribed, taking into account the sensitivity of the pathogen to them. During treatment, it is necessary to drink at least 1.5 liters of fluid per day.

Treatment of pyelonephritis during pregnancy and lactation

In pregnant women with acute pyelonephritis or exacerbation of chronic pyelonephritis, antibiotic therapy should be carried out in a hospital setting.

Therapy begins with parenteral drugs. Subsequently, they switch to oral medication. The drugs of choice are ampicillin (not indicated in case of threatened miscarriage), amoxicillin + clavulanic acid, cephalosporins (cefotaxime, ceftriaxone, cefuroxime, etc.). In case of severe pyelonephritis and detection of Klebsiella or Pseudomonas aeruginosa, which are resistant to penicillins (including carbenicillin) and cephalosporins, the use of gentamicin is justified (in the third trimester).

Carbapenems are the reserve drugs.

Throughout pregnancy, treatment with tetracycline antibiotics and fluoroquinolones is contraindicated.

In milder cases of pyelonephritis, nalidixic acid preparations, 8-oxyquinoline derivatives (nitroxoline) and nitrofurans (furadonin, furazidin) can be used.

The duration of therapy should be at least 14 days (5 days parenteral administration of the drug, then orally), and, if necessary, a longer period.

In the group of patients at risk of developing gestational pyelonephritis, exacerbations of chronic pyelonephritis with asymptomatic bacteriuria, it is advisable to prescribe the herbal preparation Canephron N, 2 dragees or 50 drops 3 times a day in courses of 10 days each month of gestation or, if necessary, continuously.

During lactation, cephalosporins (cefaclor, ceftributen), nitrofurantoin, furazidin, and gentamicin may be prescribed.

The use of fluoroquinolones and cotrimoxazole is contraindicated.

Treatment of pyelonephritis in the elderly

In elderly patients, the incidence of urinary tract infections, including senile pyelonephritis, increases significantly due to complicating factors:

• prostate hyperplasia in men;
• reduction of estrogen levels in women during menopause.

This must be taken into account during drug or surgical treatment of the prostate in men and local intravaginal or periurethral use of hormonal creams containing estrogens (ovestin) in women.

Antibacterial treatment of pyelonephritis should be carried out in the presence of clinical signs of bacterial infection; do not strive for complete bacteriological cure, especially in relation to asymptomatic bacteriuria, since this is unlikely and requires long courses of therapy with the risk of drug complications.

Antibacterial treatment of pyelonephritis of a single kidney is carried out according to the generally accepted method. In this case, it is necessary to carefully consider the nephrotoxicity of drugs (avoid prescribing aminoglycosides, first-generation cephalosporins, carbapenems).