Treatment
- Oral or intravenous antibiotics
- oral antibiotics should be given first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics
- if intravenous antibiotics then review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible
Reassessment
- reassess if symptoms worsen at any time, or do not start to improve within 48 hours of taking the antibiotic, taking account of:
- other possible diagnoses
- any symptoms or signs suggesting a more serious illness or condition, such as sepsis
- previous antibiotic use, which may have led to resistant bacteria.
Antibiotics1 for non-pregnant women and men aged 16 years and over
First-choice oral antibiotic2
- cefalexin - 500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infections) for 7 to 10 days
- co-amoxiclav (only if culture results available and susceptible) - 500/125 mg three times a day for 7 to 10 days
- trimethoprim (only if culture results available and susceptible) - 200 mg twice a day for 14 days
- ciprofloxacin (consider safety issues3) - 500mg twice a day for 7 days
First choice intravenous antibiotics (if vomiting, unable to take oral antibiotics, or severely unwell). Antibiotics may be combined if susceptibilty or sepsis a concern 2, 4
- co-amoxiclav (only in combination or if culture results available and susceptible)
- 1.2 g three times a day Cefuroxime 750 mg to 1.5 g three or four times a day
- OR
- ceftriaxone
- ciprofloxacin (consider safety issues3)
- 400 mg twice or three times a day
- OR
- gentamicin
- Initially 5 mg/kg to 7 mg/kg once a day, subsequent doses adjusted according to serum gentamicin concentration5
- OR
- amikacin Initially
- 15 mg/kg once a day (maximum per dose 1.5 g once a day), subsequent doses adjusted according to serum amikacin concentration (maximum 15 g per course)
- 1 check British national formulary (BNF) for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment and breastfeeding, and administering intravenous antibiotics.
- 2 check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.
- 3 the European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system (press release October 2018), but they are an option in acute pyelonephritis, which is a severe infection.
- 4 review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.
- 5 Therapeutic drug monitoring and assessment of renal function is required (BNF, August 2018)
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