Acute Pyelonephritis — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Complicated or uncomplicated
   Complicated or uncomplicated? Can it be treated orally as an outpatient? (Clinical diagnosis: fever, flank pain/CVA tenderness (flank pain is nearly always present), ± lower urinary tract symptoms, nausea/vomiting; urinalysis (pyuria/bacteriuria) supports it, send a urine culture in all patients (E. coli most common). Complicating factors: male, pregnancy, structural/functional urinary tract abnormality, stones, catheter, immunosuppression, diabetes, AKI, sepsis, obstruction.)
   • Uncomplicated, can take orals, no sepsis → Uncomplicated · outpatient oral
   • Complicated/sepsis/vomiting/pregnancy/obstruction → Complicated/sepsis → admit IV
2. [End] Uncomplicated · outpatient oral
   Mostly healthy non-pregnant women, tolerating orals, no sepsis: outpatient oral therapy — where local fluoroquinolone resistance is <10%, a fluoroquinolone (ciprofloxacin 500 mg bid × 7 d or levofloxacin 750 mg × 5 d); if resistance >10%, give an initial single dose of a long-acting parenteral agent (ceftriaxone 1 g/an aminoglycoside) first. Do not use nitrofurantoin/fosfomycin (inadequate renal tissue levels). Adjust by urine culture; no routine imaging/blood cultures in uncomplicated cases. Analgesia and antipyretics.
3. [End] Complicated/sepsis → admit IV
   Complicated/sepsis/persistent vomiting/outpatient failure/pregnancy/obstruction/elderly: admit for IV antibiotics — a fluoroquinolone, a third-generation cephalosporin (ceftriaxone), an aminoglycoside ± ampicillin, or a carbapenem (ESBL risk); de-escalate by culture, switch to oral once afebrile and improving, total 7–14 days. Imaging (CT/US) for: sepsis, suspected obstruction/stone, AKI, no improvement at 48–72 h — to find obstruction/abscess/emphysematous pyelonephritis; obstruction with infection needs emergency drainage (urology).

Source guidelines & references

• IDSA acute pyelonephritis/UTI guideline; AAFP acute pyelonephritis

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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