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id.pyelonephritis.core.v1PRODUCTION
id.pyelonephritis.core.v1

Acute pyelonephritis (uncomplicated → complicated)

infectious_diseaseacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Frame

Detailed

Adult acute pyelonephritis. Pediatric pyelo and prostatitis covered by sibling engines

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Patient inputs (13)

Fever ≥38°C is core; drives sepsis screen

Tachycardia component of SIRS / qSOFA

Pregnancy → admit, avoid fluoroquinolones, narrower antibiotic options

Resistance risk; informs empiric choice + IDSA 2025 4-step framework

Complicated phenotype; stent / nephrolithiasis → urology

Emphysematous pyelo / abscess risk

Pyuria + bacteriuria + nitrites supports diagnosis

Anchors targeted therapy + susceptibility

Hypotension → urosepsis pathway + SSC bundle

Baseline renal + obstructive AKI screen + dose adjustment

Imaging if no improvement at 48-72h, recurrent pyelo, suspected obstruction / abscess / emphysematous

Bacteremia in 15-30%; required when admitting / sepsis features

Sepsis bundle when SIRS positive

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Severity triggers (8)

8 need judgement
  • informationallife_threateningurosepsis_with_shock
    Pyelonephritis + hypotension on adequate fluids + lactate >2 (SSC 2021; Sepsis-3 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningobstructive_uropathy_with_infection
    Hydronephrosis on imaging + pyelonephritis (especially with stone) (AUA/CUA/SUFU 2019; EAU 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningemphysematous_pyelonephritis
    Gas in renal parenchyma on CT (often diabetic) (EAU 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_pyelonephritis
    Acute pyelonephritis in pregnant patient (IDSA 2011 Gupta; NICE 2018 NG109)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereno_improvement_at_72h
    Persistent fever or symptoms at 72 h on appropriate antibiotic (AUA/CUA/SUFU 2019; EAU 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremdro_esbl_or_cre_pathogen
    Culture-confirmed ESBL- or CRE-producing Enterobacteriaceae pyelonephritis (EAU 2024; IDSA AMR 2024; IDSA 2025 cUTI 4-step framework)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverekidney_transplant_pyelonephritis
    Acute pyelonephritis in kidney transplant recipient — admit regardless of severity (AST-IDSA transplant ID; EAU 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemdro_risk_pattern
    Recent hospitalisation, recent broad-spectrum antibiotics, prior ESBL/Pseudomonas, indwelling urinary device (IDSA 2011 Gupta; EAU 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Outpatient uncomplicated pyelonephritis
axis: pyelonephritis_outpatient_uncomplicated
Selected axis "Outpatient uncomplicated pyelonephritis" by default fallback (first axis)
  • ciprofloxacin
    first line
    fluoroquinolone
    triggers: uncomplicated, tolerates_PO, no_FQ_resistance_risk
    IDSA/ESCMID 2010 + IDSA 2025: 5-7 d course non-inferior to 10-14 d (CMI 2025 meta-analysis)
    rxcui 2551
  • levofloxacin
    first line
    fluoroquinolone
    triggers: uncomplicated, tolerates_PO
    750 mg × 5 d short-course (Peterson 2008)
    rxcui 82122
  • trimethoprim-sulfamethoxazole
    first line
    sulfonamide
    triggers: susceptibility_confirmed
    IDSA/ESCMID 2010 — 14 d if susceptible
    rxcui 10831
  • ceftriaxone
    add on
    3rd_gen_cephalosporin
    triggers: local_FQ_resistance_>=10pct, pregnancy, severe_initial
    Single 1 g IV/IM bridge before oral; preferred in pregnancy
    rxcui 2193

outpatient playbook — drug actions (6)

  1. 1. ciprofloxacin
    500 mg PO BID (or 1 g ER daily) • PO • 5-7 d
    trigger: Uncomplicated, tolerating PO, no FQ resistance risk
    IDSA 2011 Gupta + IDSA 2025 cUTI 4-step + CMI 2025 short-course meta — 5-7 d non-inferior to 10-14 d for uncomplicated APN
  2. 2. levofloxacin
    750 mg PO daily • PO • 5 d
    trigger: Alternative FQ
    Peterson 2008 short-course 5 d high-dose levofloxacin non-inferior to 10 d ciprofloxacin
  3. 3. ceftriaxone single IV/IM bridge
    1 g IV/IM × 1 • IV/IM • single (then PO step-down per susceptibility)
    trigger: Local FQ resistance ≥ 10% OR pregnancy OR severe initial presentation
    IDSA 2011 Gupta bridge-then-step-down strategy when FQ unsuitable
  4. 4. trimethoprim-sulfamethoxazole
    1 DS PO BID • PO • 14 d
    trigger: Susceptibility confirmed AND local resistance < 10% AND not 1st-trimester pregnancy AND not severe renal impairment
    IDSA 2011 Gupta — 14 d if susceptible
  5. 5. amoxicillin-clavulanate
    875/125 mg PO BID • PO • 14 d
    trigger: Pregnancy or beta-lactam preference; susceptibility confirmed
    EAU 2024 alternative; less potent for pyelo than FQ but pregnancy-safe
  6. 6. PO step-down per susceptibility (after IV ceftriaxone or inpatient course)
    cipro 500 mg PO BID OR levofloxacin 750 mg PO daily OR amox-clav 875 mg PO BID OR TMP-SMX DS BID (susceptibility-driven) • PO • complete to 7-14 d total depending on phenotype
    trigger: Day 2-3 culture review; afebrile + improving + tolerating PO
    IDSA 2011 Gupta + IDSA 2025 cUTI — culture-driven de-escalation at 48-72 h

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Flank pain + fever; Costovertebral angle tenderness with systemic symptoms; Pyuria/bacteriuria with fever, tachycardia, or rigors.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute pyelonephritis (uncomplicated → complicated)** (id.pyelonephritis.core.v1).
Phenotype framing: Lower UTI, perinephric abscess, renal stone with obstruction, prostatitis, PID, herpes zoster, MSK flank pain
Scope: Adult acute pyelonephritis. Pediatric pyelo and prostatitis covered by sibling engines

No severity triggers fired against current inputs.

Plan

Regimen axis: **Outpatient uncomplicated pyelonephritis**.
1. ciprofloxacin (fluoroquinolone, first line) — IDSA/ESCMID 2010 + IDSA 2025: 5-7 d course non-inferior to 10-14 d (CMI 2025 meta-analysis)
2. levofloxacin (fluoroquinolone, first line) — 750 mg × 5 d short-course (Peterson 2008)
3. trimethoprim-sulfamethoxazole (sulfonamide, first line) — IDSA/ESCMID 2010 — 14 d if susceptible
4. ceftriaxone (3rd_gen_cephalosporin, add on) — Single 1 g IV/IM bridge before oral; preferred in pregnancy

Setting playbook (outpatient) — Manage uncomplicated pyelonephritis (and PO step-down from ED/inpatient) with oral antibiotic, structured 24-72 h follow-up with culture-driven de-escalation, completion of 7-14 d total course depending on phenotype, pregnancy-specific surveillance, recurrent-UTI prevention counselling, and urology referral when anatomic / obstructive factors emerge (IDSA 2011 Gupta + EAU 2024 + AUA/CUA/SUFU 2019 + CMI 2025 short-course)
5. ciprofloxacin 500 mg PO BID (or 1 g ER daily) PO 5-7 d — Uncomplicated, tolerating PO, no FQ resistance risk (IDSA 2011 Gupta + IDSA 2025 cUTI 4-step + CMI 2025 short-course meta — 5-7 d non-inferior to 10-14 d for uncomplicated APN)
6. levofloxacin 750 mg PO daily PO 5 d — Alternative FQ (Peterson 2008 short-course 5 d high-dose levofloxacin non-inferior to 10 d ciprofloxacin)
7. ceftriaxone single IV/IM bridge 1 g IV/IM × 1 IV/IM single (then PO step-down per susceptibility) — Local FQ resistance ≥ 10% OR pregnancy OR severe initial presentation (IDSA 2011 Gupta bridge-then-step-down strategy when FQ unsuitable)
8. trimethoprim-sulfamethoxazole 1 DS PO BID PO 14 d — Susceptibility confirmed AND local resistance < 10% AND not 1st-trimester pregnancy AND not severe renal impairment (IDSA 2011 Gupta — 14 d if susceptible)
9. amoxicillin-clavulanate 875/125 mg PO BID PO 14 d — Pregnancy or beta-lactam preference; susceptibility confirmed (EAU 2024 alternative; less potent for pyelo than FQ but pregnancy-safe)
10. PO step-down per susceptibility (after IV ceftriaxone or inpatient course) cipro 500 mg PO BID OR levofloxacin 750 mg PO daily OR amox-clav 875 mg PO BID OR TMP-SMX DS BID (susceptibility-driven) PO complete to 7-14 d total depending on phenotype — Day 2-3 culture review; afebrile + improving + tolerating PO (IDSA 2011 Gupta + IDSA 2025 cUTI — culture-driven de-escalation at 48-72 h)

Non-pharmacologic actions:
- Hydration counselling — 2-3 L/day if cardiorenal function permits (NICE 2018 NG109)
- Return precautions (fever > 72 h, vomiting, worsening pain, confusion, decreased UOP) — IDSA 2011 Gupta
- Phone/video check at 24-72 h to confirm clinical improvement (IDSA 2011 Gupta)
- Preventive counselling for recurrent UTI: post-coital voiding, front-to-back wiping, avoid spermicides, consider topical estrogen in postmenopausal women (AUA/CUA/SUFU 2019)
- Low-dose prophylaxis option discussion for recurrent UTI (nitrofurantoin 50-100 mg qHS, TMP-SMX SS qHS, or post-coital regimen) — AUA/CUA/SUFU 2019; not for index APN episode
- Vaccination check: PCV20 per ACIP 2024 (recurrent / high-risk hosts); annual influenza; COVID-19 per current guidance; HPV in age-eligible women — ACIP 2024
- Urology referral if recurrent APN, obstructive uropathy, anatomic abnormality, male APN (prostatitis-overlap workup), or pediatric overflow (AUA/CUA/SUFU 2019; EAU 2024)

AVOID / contraindication checks:
- Fluoroquinolone pregnancy block (IDSA 2011 Gupta; EAU 2024)
- Fluoroquinolone tendonitis aortic dissection warning (FDA 2018 boxed warning)
- Tmpsmx block if renal impairment severe (IDSA 2011 Gupta)

Monitoring

Regimen monitoring:
- phone check at 48-72h (IDSA 2011 Gupta)
- return if persistent fever at 72h for imaging (AUA/CUA/SUFU 2019; EAU 2024)

Setting (outpatient) monitoring:
- Phone/video check 24-72 h to confirm clinical improvement and adherence (IDSA 2011 Gupta)
- Culture susceptibility review at day 2-3 + culture-driven de-escalation (IDSA 2011 Gupta + IDSA 2025 cUTI)
- Re-image (renal US or CT) if persistent fever at 72 h OR new flank pain / hematuria / sepsis features (AUA/CUA/SUFU 2019; EAU 2024)
- Pregnancy-specific surveillance: weekly urine culture through pregnancy after APN; consider suppressive prophylaxis (nitrofurantoin 50-100 mg qHS until 36 wk) — IDSA 2011 Gupta + ACOG
- Repeat creatinine at 1-2 weeks if AKI during admission (KDIGO 2026 post-AKI surveillance) — routes to neph.aki.core.v1
- Renal imaging at 4-6 weeks if recurrent OR complicated OR no improvement (AUA/CUA/SUFU 2019; EAU 2024)

Follow-up plan: Test of cure not routinely needed unless pregnant or relapse; prevention counseling; recurrent UTI workup if ≥2 episodes/year
- Close-out criterion: follow-up plan documented

Monitoring phase: Resolution of fever within 48-72h; if not — re-image and broaden empirics; trend creatinine + WBC; vancomycin AUC if used

Disposition

Current setting: outpatient — Manage uncomplicated pyelonephritis (and PO step-down from ED/inpatient) with oral antibiotic, structured 24-72 h follow-up with culture-driven de-escalation, completion of 7-14 d total course depending on phenotype, pregnancy-specific surveillance, recurrent-UTI prevention counselling, and urology referral when anatomic / obstructive factors emerge (IDSA 2011 Gupta + EAU 2024 + AUA/CUA/SUFU 2019 + CMI 2025 short-course)

Disposition criteria:
- Discharge from acute episode: well-appearing, tolerating PO, no obstruction on imaging if performed, follow-up booked at 7-14 d, recurrence prevention plan documented (IDSA 2011 Gupta + AUA/CUA/SUFU 2019)
- Continue outpatient prophylaxis pathway for recurrent UTI (≥ 2 episodes in 6 mo / ≥ 3 in 12 mo) — AUA/CUA/SUFU 2019
- Transition out of acute pyelo dossier: 4-6 week renal imaging negative for anatomic abnormality + no recurrence at 6 mo → return to standard primary care (AUA/CUA/SUFU 2019)

Escalation triggers (move to higher acuity):
- Persistent fever > 72 h on outpatient PO regimen → admit + image (CT/US) for abscess/obstruction (AUA/CUA/SUFU 2019; EAU 2024)
- Vomiting / cannot tolerate PO → ED (IDSA 2011 Gupta)
- Sepsis features (hypotension, lactate elevation, tachycardia, AMS) → ED + SSC 2026 Hour-1 bundle; routes to id.sepsis.core.v1
- Pregnancy with APN → admit (regardless of severity) per IDSA 2011 Gupta + EAU 2024
- New AKI (creatinine ≥ 1.5× baseline) → ED + reassess for obstruction; routes to neph.aki.core.v1
- Suspected obstruction (new flank pain + fever + hematuria, or hydronephrosis on US) → ED + urgent urology consult (AUA/CUA/SUFU 2019)
- Culture growing ESBL / CRE / Pseudomonas with clinical worsening → admit + ID consult; broaden coverage per resistance pattern (EAU 2024)
- Kidney transplant recipient with APN → admit + ID consult + transplant-nephrology coordination (regardless of severity) — AST-IDSA transplant ID; EAU 2024

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Pyelonephritis + hypotension on adequate fluids + lactate >2 (SSC 2021; Sepsis-3 2016)
- [LIFE_THREATENING] Hydronephrosis on imaging + pyelonephritis (especially with stone) (AUA/CUA/SUFU 2019; EAU 2024)
- [LIFE_THREATENING] Gas in renal parenchyma on CT (often diabetic) (EAU 2024)

Citations

- IDSA 2025 Complicated UTI + IDSA/ESCMID 2010 Uncomplicated Pyelonephritis (Gupta CID 2011) + IDSA cUTI 2010 (Hooton) + EAU Urological Infections 2024 + NICE NG109 (2024 review) + SSC 2026 (urosepsis) + AUA/CUA/SUFU 2019 (recurrent UTI / imaging) + KDIGO 2026 (obstructive AKI) [PMID:21292654](https://pubmed.ncbi.nlm.nih.gov/21292654/)
- Cited evidence (PMID 40228579) [PMID:40228579](https://pubmed.ncbi.nlm.nih.gov/40228579/)
- Cited evidence (PMID 22726802) [PMID:22726802](https://pubmed.ncbi.nlm.nih.gov/22726802/)
- Cited evidence (PMID 20175247) [PMID:20175247](https://pubmed.ncbi.nlm.nih.gov/20175247/)
- Cited evidence (PMID 25931244) [PMID:25931244](https://pubmed.ncbi.nlm.nih.gov/25931244/)

Last reconciled with current guidelines: 2026-05-22.
References
  • IDSA 2025 Complicated UTI + IDSA/ESCMID 2010 Uncomplicated Pyelonephritis (Gupta CID 2011) + IDSA cUTI 2010 (Hooton) + EAU Urological Infections 2024 + NICE NG109 (2024 review) + SSC 2026 (urosepsis) + AUA/CUA/SUFU 2019 (recurrent UTI / imaging) + KDIGO 2026 (obstructive AKI) — PMID:21292654
  • Cited evidence (PMID 40228579) — PMID:40228579
  • Cited evidence (PMID 22726802) — PMID:22726802
  • Cited evidence (PMID 20175247) — PMID:20175247
  • Cited evidence (PMID 25931244) — PMID:25931244