Editing Pyelonephritis (section)

==Management==
In people suspected of having pyelonephritis, a urine culture and [[antibiotic sensitivity]] test is performed, so therapy can eventually be tailored on the basis of the infecting organism.<ref name=Fer2018/> As most cases of pyelonephritis are due to bacterial infections, antibiotics are the mainstay of treatment.<ref name=Fer2018/> The choice of antibiotic depends on the species and antibiotic sensitivity profile of the infecting organism, and may include [[Quinolone antibiotic|fluoroquinolones]], [[cephalosporin]]s, [[aminoglycoside]]s, or [[trimethoprim/sulfamethoxazole]], either alone or in combination.<ref name=Gupta2011/>

===Simple===
A 2018 systematic review recommended the use of norfloxacin as it has the lowest rate of side effects with a comparable efficacy to commonly used antibiotics.<ref name="Cattrall Robinson Kirby 2018 pp. 2285–2291">{{cite journal | vauthors = Cattrall JW, Robinson AV, Kirby A | title = A systematic review of randomised clinical trials for oral antibiotic treatment of acute pyelonephritis | journal = European Journal of Clinical Microbiology & Infectious Diseases | volume = 37 | issue = 12 | pages = 2285–2291 | date = December 2018 | pmid = 30191339 | doi = 10.1007/s10096-018-3371-y | doi-access = free | title-link = doi }}</ref>

In people who do not require hospitalization and live in an area where there is a low prevalence of [[Antibiotic resistance|antibiotic-resistant]] bacteria, a fluoroquinolone by mouth such as [[ciprofloxacin]] or [[levofloxacin]] is an appropriate initial choice for therapy.<ref name=Fer2018/> In areas where there is a higher prevalence of fluoroquinolone resistance, it is useful to initiate treatment with a single intravenous dose of a long-acting antibiotic such as [[ceftriaxone]] or an aminoglycoside, and then continuing treatment with a fluoroquinolone. Oral trimethoprim/sulfamethoxazole is an appropriate choice for therapy if the bacteria is known to be susceptible.<ref name=Fer2018/> If trimethoprim/sulfamethoxazole is used when the susceptibility is not known, it is useful to initiate treatment with a single intravenous dose of a long-acting antibiotic such as ceftriaxone or an aminoglycoside. Oral [[beta-lactam antibiotic]]s are less effective than other available agents for treatment of pyelonephritis.<ref name=Gupta2011/> Improvement is expected in 48 to 72 hours.<ref name=Fer2018/>

===Complicated===
People with acute pyelonephritis that is accompanied by high fever and [[leukocytosis]] are typically admitted to the hospital for intravenous hydration and intravenous antibiotic treatment. Treatment is typically initiated with an intravenous fluoroquinolone, an aminoglycoside, an [[extended-spectrum penicillin]] or cephalosporin, or a [[carbapenem]]. Combination antibiotic therapy is often used in such situations. The treatment regimen is selected based on local resistance data and the susceptibility profile of the specific infecting organism(s).<ref name=Gupta2011/>

During the course of antibiotic treatment, serial white blood cell count and temperature are closely monitored. Typically, the intravenous antibiotics are continued until the person has no fever for at least 24 to 48{{nbsp}}hours, then equivalent antibiotics by mouth can be given for a total of two-week duration of treatment.<ref name=Starlin2005>{{cite book|last1=Cabellon|first1=MCL|editor-last=Starlin|editor-first=R|title=The Washington Manual: Infectious Diseases Subspecialty Consult|edition=1st|chapter=Chapter 8: Urinary Tract Infections|pages=95–108|publisher=Lippincott Williams & Wilkins|location=Philadelphia|year=2005|isbn=978-0-7817-4373-0|chapter-url=https://books.google.com/books?id=DdabV2chPzMC&pg=PA105|url-status=live|archive-url=https://web.archive.org/web/20130527045956/http://books.google.com/books?id=DdabV2chPzMC&lpg=PA105|archive-date=27 May 2013}}</ref> Intravenous fluids may be administered to compensate for the reduced oral intake, insensible losses (due to the raised temperature) and [[vasodilation]] and to optimize urine output. [[Percutaneous nephrostomy]] or ureteral stent placement may be indicated to relieve obstruction caused by a stone. Children with acute pyelonephritis can be treated effectively with oral antibiotics ([[cefixime]], [[ceftibuten]] and [[Augmentin|amoxicillin/clavulanic acid]]) or with short courses (2 to 4{{nbsp}}days) of intravenous therapy followed by oral therapy.<ref name=Strohmeier2014>{{cite journal | vauthors = Strohmeier Y, Hodson EM, Willis NS, Webster AC, Craig JC | title = Antibiotics for acute pyelonephritis in children | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 7 | pages = CD003772 | date = July 2014 | pmid = 25066627 | pmc = 10580126 | doi = 10.1002/14651858.CD003772.pub4 | hdl-access = free | hdl = 2123/22283 }}</ref> If intravenous therapy is chosen, single daily dosing with aminoglycosides is safe and effective.<ref name=Strohmeier2014/>

Fosfomycin can be used as an efficacious treatment for both UTIs and complicated UTIs including acute pyelonephritis. The standard regimen for complicated UTIs is an oral 3g dose administered once every 48 or 72 hours for a total of 3 doses or a 6 grams every 8 hours for 7 days to 14 days when fosfomycin is given in IV form.<ref name="Zhanel Zhanel Karlowsky 2020 pp. 1–11">{{cite journal | vauthors = Zhanel GG, Zhanel MA, Karlowsky JA | title = Oral and Intravenous Fosfomycin for the Treatment of Complicated Urinary Tract Infections | journal = The Canadian Journal of Infectious Diseases & Medical Microbiology | volume = 2020 | pages = 8513405 | date = 28 March 2020 | pmid = 32300381 | pmc = 7142339 | doi = 10.1155/2020/8513405 | doi-access = free | title-link = doi }}</ref>

Treatment of xanthogranulomatous pyelonephritis involves antibiotics as well as surgery. [[Nephrectomy|Removal of the kidney]] is the best surgical treatment in the overwhelming majority of cases, although polar resection (partial nephrectomy) has been effective for some people with localized disease.<ref name=Korkes2008/><ref name=Rosi1986>{{cite journal | vauthors = Rosi P, Selli C, Carini M, Rosi MF, Mottola A | title = Xanthogranulomatous pyelonephritis: clinical experience with 62 cases | journal = European Urology | volume = 12 | issue = 2 | pages = 96–100 | year = 1986 | pmid = 3956552 | doi = 10.1159/000472589 }}</ref> [[Watchful waiting]] with serial imaging may be appropriate in rare circumstances.<ref name=Lebret2007>{{cite journal | vauthors = Lebret T, Poulain JE, Molinie V, Herve JM, Denoux Y, Guth A, Scherrer A, Botto H | title = Percutaneous core biopsy for renal masses: indications, accuracy and results | journal = The Journal of Urology | volume = 178 | issue = 4 Pt 1 | pages = 1184–8; discussion 1188 | date = October 2007 | pmid = 17698122 | doi = 10.1016/j.juro.2007.05.155 }}</ref>

===Follow-up===
If no improvement is made in one to two days post therapy, inpatients should repeat a urine analysis and imaging. Outpatients should check again with their doctor.<ref name="Johnson Russo pp. 48–59">{{cite journal | vauthors = Johnson JR, Russo TA | title = Acute Pyelonephritis in Adults | journal = The New England Journal of Medicine | volume = 378 | issue = 1 | pages = 48–59 | date = January 2018 | pmid = 29298155 | doi = 10.1056/nejmcp1702758 | s2cid = 3919412 }}</ref>