The management of acute pyelonephritis in adults

Acute pyelonephritis should be classified clinically at the time of presentation into either uncomplicated or complicated categories. The diagnostic workup includes history, physical examination, urinalysis (including a Gram stain), and urine culture. Patients with suspected complicated pyelonephritis require the standard assessment plus blood cultures and urinary tract imaging, preferably a computed tomography (CT) scan. Patients with moderate, uncomplicated pyelonephritis can be managed as outpatients with either a fluoroquinolone (7-14 days) or trimethoprim/sulfamethoxazole (at least 14 days). Patients with severe, uncomplicated pyelonephritis can be considered for short-term hospitalization and initial administration of intravenous antibiotics. Therapy for patients with complicated pyelonephritis should include initial hospitalization, supportive therapies, administration of wide spectrum intravenous antibiotic therapy, and relief of aggravating conditions. Such maneuvers could consist of simple bladder catheterization, percutaneous nephrostomy drainage, or definitive surgery. Patients with complicated pyelonephritis require longer duration of culture-specific antibiotic dosing, careful monitoring, long-term follow-up, and possible definitive management of their underlying condition.