Treatment of pyelonephritis in adults.

Although prescribing an antibiotic for the treatment of pyelonephritis seems to be a relatively easy task, a close look at the available data is disturbing. Optimal therapies for the different clinical syndromes of pyelonephritis have not yet been defined. The high failure rate suggests that in pyelonephritis (bacteria protected in the medulla) as well as in bacterial endocarditis (bacteria sequestered in vegetations) and in infections in neutropenic patients (host defenses not necessarily operating in conjunction with antibiotics), it may be necessary to maintain bactericidal levels at the site of infection (infected medulla) to achieve cure. Pharmacodynamic studies suggest that TMP/SMX, quinolones, and aminoglycosides, which penetrate well the infected renal parenchyma and are not impaired by the local inflammatory process, should, with the exception of pyelonephritis in pregnancy, be preferred to beta-lactams as first-choice agents for the therapy of gram-negative pyelonephritis.