Spectrum: Local Antimicrobial Stewardship, for Prisma Health-Midlands

Acute Pyelonephritis

Note

In critically-ill patients with acute pyelonephritis (qSOFA ≥2), please refer to Prisma Health-Midlands Guidelines for Management of Gram-Negative Bloodstream Infections for recommendations on empirical antimicrobial therapy. Otherwise, continue below.

Gram Negative BSI

Are there risk factors for drug-resistant bacteria?

No

Yes - For P. aeruginosa

Any of the following:

  • Severely immune compromised host:

    • Chemotherapy
    • Neutropenia
    • Transplant recipient
    • Treatment with high dose steroids (20mg of prednisone equivalents daily for >2 weeks) or other immunosuppressive medications within one month

  • Currently hospitalized >5 days

  • β-lactam use within past 90 days

  • Colonization with P. aeruginosa in past 12 months

Yes - For ESBL-producing bacteria

Any of the following:

  • Colonization with ESBLs in past 12 months

  • ≥2 courses of β-lactams or fluoroquinolones in past 90 days

    • Prior course should be ≥24h; short-term perioperative antibiotics do no qualify as a course
    • >2 courses have to be ≥3 days apart; concurrent or sequential therapy is considered one course

Avoid

Oral 3rd generation cephalosporins

For example:

  • Cefdinir

  • Cefpodoxime

Highly discouraged due to low urinary concentrations and higher risk of treatment failure in comparison to fluoroquinolones and SMX/TMP

Nitrofurantoin and Fosfomycin

  • In patients with suspected or documented pyelonephritis

  • The antibiotics do not concentrate outside the urine, including the interstitial cells of the kidney