Treatment of pyelonephritis

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

Before you begin treatment of pyelonephritis, you must:

• Eliminate the factors that make the disease worse (urinary tract obstruction, diabetes mellitus, pregnancy, etc.);
• to establish the type of pathogen, its sensitivity to antibiotics and chemotherapy;
• clarify the condition of urodynamics (absence or presence of urinary passage disorders);
• determine the degree of activity of the infectious-inflammatory process;
• evaluate the function of the kidneys.

Acute pyelonephritis without signs of obstruction is subject to immediate treatment with antibacterial drugs. In obstructive pyelonephritis, treatment is begun by restoring the passage of urine through the installation of a catheter, a stent, or nephrostomy. Without restoration of the passage of urine, the use of antibacterial drugs is dangerous (high risk of bacteriemic shock).

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• Antibiotics for pyelonephritis

Treatment of chronic pyelonephritis is conditionally divided into two stages:

• treatment during the period of exacerbation (practically does not differ in its principles from the treatment of acute pyelonephritis);
• anti-relapse treatment.

Tactics of pyelonephritis treatment

Usually, the treatment of pyelonephritis (after excluding urinary passage disorders) begins before the results of bacteriological examination of culture isolated from urine cultures and the determination of its sensitivity to antibiotics (empirical antibacterial therapy). In the empirical approach, localization, character (acute or chronic) and the severity of the infectious process are the defining factors. After receiving the results of the microbiological study, therapy should be corrected.

For the treatment of severe and complicated pyelonephritis, hospitalization is necessary. Treatment, as a rule, begins with parenteral administration of antibiotics. After normalization of body temperature (within 3-5 days), it is possible to continue treatment with antibacterial drugs for oral administration (stepwise therapy). Regardless of the functional state of the kidneys, the first dose of drugs (a dose of saturation) is administered completely, in the future, it is adjusted taking into account the function of the kidneys.

Allocate funds of the 1 st row, or the means of choice, which are considered optimal, and funds of the second row, or alternative.

The duration of treatment with antibiotics for acute pyelonephritis is 10-14 days, with exacerbation of chronic pyelonephritis - 10-21 days. After the termination of therapy it is necessary to check urine, including bacteriological. When persisting an infectious agent, a repeated course of treatment with antibiotics is prescribed taking into account the sensitivity to the pathogen. During treatment, you must drink at least 1.5 liters of fluid per day.

Treatment of pyelonephritis in pregnancy and lactation

In pregnant women with acute pyelonephritis or exacerbation of chronic pyelonephritis, antibiotic therapy should be performed in hospital settings.

Therapy is started with preparations for parenteral administration. Later they switch to oral medication. The drugs of choice are ampicillin (not shown when a miscarriage threatens), amoxicillin + clavulanic acid, cephalosporins (cefotaxime, ceftriaxone, cefuroxime, etc.). With severe pyelonephritis and the identification of Klebsiella or Pseudomonas aeruginosa, which are resistant to penicillins (including carbenicillin) and cephalosporins, gentamicin (in the third trimester) is justified.

The preparations of the reserve are carbapenems.

Throughout pregnancy contraindicated treatment with antibiotics tetracycline and fluoroquinolones.

With a lighter course of pyelonephritis, nalidixic acid preparations, derivatives of 8-hydroxyquinoline (nitroxoline) and nitrofurans (furadonin, furazidine) can be used.

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

In the group of patients with risk of developing gestational pyelonephritis, exacerbations of chronic pyelonephritis with asymptomatic bacteriuria, it is advisable to prescribe phytopreparation kanefron H in 2 drops or 50 drops 3 times a day by courses of 10 days each month of gestation or, if necessary, continuously. 

During lactation, the appointment of cephalosporins (cefaclor, ceftributene), nitrofurantoin, furazidine, gentamicin.

Contraindicated the use of fluoroquinolones and cotrimoxazole.

Treatment of pyelonephritis in old age

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

• hyperplasia of the prostate in men;
• decrease in the level of estrogen in women during menopause.

This must be taken into account in the medical or surgical treatment of the prostate in men and the local intravaginal or periuretral application of hormonal creams containing estrogens (ovestins) in women.

Antibiotic treatment of pyelonephritis should be carried out in the presence of clinical signs of bacterial infection; do not seek complete bacteriological cure, especially with regard to asymptomatic bacteriuria, as this is unlikely and requires long-term 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 the appointment of aminoglycosides, cephalosporins of the 1st generation, carbapenems).