As practically all cases of pyelonephritis are due to bacterial infections, antibiotics are the mainstay of treatment. Mild cases may be treated with oral therapy, but generally intravenous antibiotics are required for the initial stages of treatment.
The type of antibiotic depends on local practice, and may include fluoroquinolones (e.g. ciprofloxacin), beta-lactam antibiotics (e.g. amoxicillin or a cephalosporin), trimethoprim (or co-trimoxazole).
Aminoglycosides are avoided due to their toxicity, but may be added for a short duration.
Intravenous fluids may be administered to compensate for the reduced oral intake, insensible losses (due to the raised temperature) and vasodilation and to maximize urine output.
If the patient is septic secondary to an obstructing stone, percutaneous nephrostomy is indicated for source control.
In recurrent infections, additional investigations may identify an underlying abnormality. Occasionally, surgical intervention is necessary to reduce chances of recurrence.
If no abnormality is identified, some studies suggest long-term preventative (prophylactic) treatment with antibiotics, either daily or after sexual intercourse.
In children at risk of recurrent UTIs, meta-analysis of the present literature indicates that not enough studies have been performed to conclude prescription of long-term antibiotics have a net positive benefit. Ingestion of cranberry juice has been studied as a prophylactic measure; while studies are heterogeneous, many suggest a benefit.
Some recommend other nutritional approaches to prevent recurrence of UTIs. Increasing fluid intake, consuming cranberry juice, blueberry juice, and fermented milk products containing probiotic bacteria, have been shown to inhibit adherence of bacteria to the epithelial cells of the urinary tract.
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