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uro.pyelonephritis.v1PRODUCTION
uro.pyelonephritis.v1

Acute pyelonephritis (upper UTI; outpatient + inpatient + complicated + urosepsis)

urologyacuteadultpregnancy
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Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Adult or pregnant patient with fever + flank pain + N/V → acute pyelonephritis differential. Explicit pivots: men / pregnancy / immunocompromise / obstruction / DM with gas → complicated phenotype branch (IDSA 2010)

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Patient inputs (24)

Geriatric / pediatric workflows differ; aminoglycoside dose adjustment in elderly (IDSA 2010)

Diabetic + pyelo → emphysematous pyelo risk; CT if non-resolving fever; broad-spectrum + IR consult (EAU 2020)

Immunocompromised → complicated pathway; broaden empirics; ID consult low threshold (IDSA 2010)

Recent FQ → avoid empiric FQ; recent broad-spectrum → ESBL / Pseudomonas concern (Tamma 2019)

Obstruction → STAT decompression (PCN / stent); recurrent pyelo with stones → urology referral (AUA 2016)

Prior ESBL → empiric ertapenem; prior CRE → ID consult + tailored agent (Tamma 2019)

Indwelling catheter or recent instrumentation → complicated pathway + healthcare-associated empiric coverage (IDSA 2019 CAUTI)

Pregnancy + pyelo → admit; IV ceftriaxone; AVOID FQ (cartilage); fetal monitoring (IDSA 2010; USPSTF 2019)

Men with pyelo → always complicated workup (anatomic / prostate concern) (IDSA 2010)

Leuk-esterase + nitrite + WBC casts (pyelo) vs cystitis pattern; sterile pyuria → STI / TB / contamination pivot (IDSA 2010)

Always obtain in pyelo before abx; drives narrowing + duration (IDSA 2010)

Bacteremia in ~25% of pyelo; mandatory if febrile / septic appearance (SCC 2026; IDSA 2010)

Leukocytosis confirms inflammation; thrombocytopenia → sepsis severity (SCC 2026)

AKI staging + dose adjustment for renal-excreted abx (KDIGO AKI 2026)

qSOFA / sepsis bundle; ≥2 mmol/L → repeat q4–6h until cleared (SCC 2026)

Reproductive-age women — must check; drives regimen (USPSTF 2019)

Fever curve drives IV-to-PO step-down (typically afebrile × 24 h); persistent fever >72 h → imaging for abscess / obstruction (IDSA 2010)

Hypotension → urosepsis ICU; SCC 2026 bundle (SCC 2026)

Tachycardia component of qSOFA / SIRS / sepsis screen (SCC 2026)

Warfarin + TMP-SMX INR rise; methotrexate + sulfa toxicity; FQ + steroid → tendinopathy (FDA 2016)

For non-resolving fever at 72 h, abscess concern, or emphysema concern (gas in parenchyma) (EAU 2020)

Renal transplant or other SOT → ID + transplant team co-management; broaden empirics (IDSA)

First-line for obstruction; safe in pregnancy; no contrast (EAU 2020)

Tachypnea component of qSOFA (SCC 2026)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningurosepsis_with_obstruction
    Pyelo + sepsis (qSOFA ≥2 or hypotension) + obstruction on imaging — STAT decompression emergency (SCC 2026; AUA 2016; EAU 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningemphysematous_pyelo
    Diabetic patient with gas in renal parenchyma on CT — emphysematous pyelo; high mortality without source control (EAU 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereuncomplicated_inpatient_pyelo
    Severe symptoms, vomiting, ill-appearing, cannot tolerate PO, age >60 + comorbidities — admit (IDSA 2010)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecomplicated_pyelo
    Obstruction, immunocompromise, anatomic anomaly, pregnancy, men, recurrent, transplant — complicated phenotype (IDSA 2010; EAU 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererenal_perinephric_abscess
    Renal or perinephric abscess on CT or US — drainage indicated + 4–6 wk culture-directed antibiotics (EAU 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_pyelo
    Pregnant patient with pyelo — admit; IV ceftriaxone; AVOID FQ throughout (cartilage); fetal monitoring (USPSTF 2019; IDSA 2010)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverexanthogranulomatous_pyelo
    XGP — chronic destructive pyelo with obstruction + staghorn calculi; renal mass on CT (bear-paw sign); nephrectomy often required (EAU 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereesbl_or_mdr_pyelo
    Prior ESBL E. coli / Klebsiella culture OR healthcare-associated risk factors → ertapenem 1 g IV q24h; tailored if CRE (Tamma 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateuncomplicated_outpatient_pyelo
    Otherwise healthy adult with pyelo, PO-tolerant, FQ-eligible, local FQ R <10%, reliable follow-up — outpatient pathway (IDSA 2010 Gupta PMID 21292654)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateacute_lobar_nephronia
    Focal pyelo (mass-like enhancement on CT) — pre-abscess form; antibiotics 3–4 wk with close imaging surveillance for abscess evolution (EAU 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Acute pyelonephritis — IDSA 2010 outpatient + inpatient empiric + ESBL escalation + pregnancy regimen + Pseudomonas coverage
axis: pyelonephritis_empiric_and_targetedstep 1 - Outpatient FQ-eligible (uncomplicated, IDSA 2010)
Selected step "Outpatient FQ-eligible (uncomplicated, IDSA 2010)" — Otherwise healthy adult with pyelo, PO-tolerant, FQ-eligible (no FQ contraindication, no recent FQ exposure), local FQ resistance <10%, reliable follow-up
  • ciprofloxacin
    first line
    fluoroquinolone
    500 mg PO BID • PO • BID × 7 days
    triggers: outpatient_pyelo, local_FQ_resistance_lt_10pct, no_FQ_contraindication
    IDSA 2010 outpatient first-line if local R <10%; reserve in elderly per FDA Black Box for tendinopathy / aortic / CNS / dysglycemia (Gupta PMID 21292654)
    rxcui 2551
  • levofloxacin
    first line
    fluoroquinolone
    750 mg PO daily • PO • once daily × 5 days
    triggers: outpatient_pyelo, compliance_preference_qd_dosing
    IDSA 2010 outpatient alternative — 5-day high-dose comparable to 7-day cipro (Gupta PMID 21292654)
    rxcui 82122

outpatient playbook — drug actions (4)

  1. 1. ciprofloxacin
    500 mg PO BID × 7 d • PO • BID
    trigger: Outpatient pyelo, local FQ R <10%, no FQ contraindication, PO tolerant
    IDSA 2010 outpatient first-line (Gupta PMID 21292654)
  2. 2. levofloxacin
    750 mg PO daily × 5 d • PO • once daily
    trigger: Compliance preference; FQ-eligible
    IDSA 2010 outpatient alternative — 5-day high-dose
  3. 3. IV ceftriaxone bridge
    1 g IV × 1 dose • IV • single dose
    trigger: Local FQ R >10% OR FQ contraindicated; outpatient-eligible otherwise
    IDSA 2010 — IV loading dose ensures empiric coverage, then oral step-down
  4. 4. TMP-SMX (susceptible-only)
    160/800 mg PO BID × 14 d • PO • BID
    trigger: Culture-confirmed susceptibility; FQ contraindicated
    IDSA 2010 alternative — 14-day course only if susceptible

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Fever + flank pain ± N/V ± dysuria — classic acute pyelonephritis (IDSA 2010 Gupta PMID 21292654); Costovertebral angle tenderness on exam (IDSA 2010); Dysuria + fever — pyelo concern over cystitis (IDSA 2010).

Objective

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

Assessment

**Acute pyelonephritis (upper UTI; outpatient + inpatient + complicated + urosepsis)** (uro.pyelonephritis.v1).
Phenotype framing: Pyelo vs renal colic (no fever; severe colic + hematuria) vs perinephric abscess vs basal pneumonia (referred pain) vs intra-abdominal (cholecystitis, appendicitis); pregnancy: chorio vs HELLP vs preterm labor differential (IDSA 2010)
Scope: Adult or pregnant patient with fever + flank pain + N/V → acute pyelonephritis differential. Explicit pivots: men / pregnancy / immunocompromise / obstruction / DM with gas → complicated phenotype branch (IDSA 2010)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute pyelonephritis — IDSA 2010 outpatient + inpatient empiric + ESBL escalation + pregnancy regimen + Pseudomonas coverage** — step "Outpatient FQ-eligible (uncomplicated, IDSA 2010)".
1. ciprofloxacin 500 mg PO BID PO BID × 7 days (fluoroquinolone, first line) — IDSA 2010 outpatient first-line if local R <10%; reserve in elderly per FDA Black Box for tendinopathy / aortic / CNS / dysglycemia (Gupta PMID 21292654)
2. levofloxacin 750 mg PO daily PO once daily × 5 days (fluoroquinolone, first line) — IDSA 2010 outpatient alternative — 5-day high-dose comparable to 7-day cipro (Gupta PMID 21292654)

Setting playbook (outpatient) — Stable, FQ-eligible, PO-tolerant, reliable follow-up → oral ciprofloxacin × 7 d OR levofloxacin × 5 d if local FQ R <10%; OR initial IV ceftriaxone 1 g + oral step-down; 48–72 h re-check (IDSA 2010)
3. ciprofloxacin 500 mg PO BID × 7 d PO BID — Outpatient pyelo, local FQ R <10%, no FQ contraindication, PO tolerant (IDSA 2010 outpatient first-line (Gupta PMID 21292654))
4. levofloxacin 750 mg PO daily × 5 d PO once daily — Compliance preference; FQ-eligible (IDSA 2010 outpatient alternative — 5-day high-dose)
5. IV ceftriaxone bridge 1 g IV × 1 dose IV single dose — Local FQ R >10% OR FQ contraindicated; outpatient-eligible otherwise (IDSA 2010 — IV loading dose ensures empiric coverage, then oral step-down)
6. TMP-SMX (susceptible-only) 160/800 mg PO BID × 14 d PO BID — Culture-confirmed susceptibility; FQ contraindicated (IDSA 2010 alternative — 14-day course only if susceptible)

Non-pharmacologic actions:
- Patient education — symptom trajectory + return precautions (worsening fever, vomiting, hypotension, no improvement at 48–72 h)
- 48–72 h follow-up call to assess clinical response (IDSA 2010)
- Hydration counsel
- Avoid steroid use with FQ (tendinopathy amplification; FDA)

AVOID / contraindication checks:
- Nitrofurantoin_CONTRAINDICATED_in_pyelonephritis_no_renal_tissue_penetration (IDSA 2010 Gupta PMID 21292654)
- Fluoroquinolones_avoid_throughout_pregnancy_cartilage (FDA / IDSA)
- Fluoroquinolones_FDA_black_box_tendinopathy_aortic_CNS_dysglycemia (FDA 2016 PMID 31357640)
- Fluoroquinolones_avoid_if_local_resistance_gt_10pct_for_outpatient_pyelo (IDSA 2010)
- Fluoroquinolones_steroid_combination_tendinopathy_amplified (FDA)
- TMP_SMX_avoid_near_term_pregnancy_kernicterus (USPSTF)
- TMP_SMX_interaction_with_warfarin_INR_rise (IDSA 2010)
- TMP_SMX_interaction_with_methotrexate_toxicity (IDSA 2010)
- Aminoglycoside_nephrotoxicity_ototoxicity_monitor_levels (KDIGO)
- Aminoglycoside_avoid_in_pregnancy_ototoxicity_fetus (FDA)
- Carbapenem_CNS_lowered_seizure_threshold_renal_dose_adjust (FDA)
- Cefepime_neurotoxicity_in_renal_impairment_dose_adjust (FDA)
- ESBL_use_ertapenem_first_meropenem_sparing (IDSA 2019 Tamma PMID 33106864)
- Asymptomatic_bacteriuria_DO_NOT_TREAT_except_pregnancy_or_pre_procedure (IDSA / USPSTF 2019)
- Source_control_mandatory_for_obstruction_abscess_emphysematous (EAU 2020)

Monitoring

Regimen monitoring:
- fever curve q4h to q8h until afebrile (IDSA 2010)
- lactate q4 to 6h if sepsis until cleared (SCC 2026)
- urine output q1h if admitted or septic (SCC 2026)
- creatinine q24h KDIGO AKI staging (KDIGO AKI 2026)
- blood cultures q24 48h until negative if initial positive (IDSA 2010)
- PO step down when afebrile 24h and tolerating PO (IDSA 2010)
- repeat imaging if fever gt 72h on appropriate abx (IDSA 2010)
- aminoglycoside levels per pharmacy (KDIGO)
- pregnancy repeat culture at 1 to 2 wk to confirm clearance (USPSTF 2019)

Setting (outpatient) monitoring:
- Symptom resolution at 48–72 h (IDSA 2010)
- Culture results back at 24–48 h → narrow / broaden per susceptibility (IDSA 2010)
- Treatment failure → admit + IV ceftriaxone

Follow-up plan: Outpatient urology if obstruction / recurrent; pregnancy → repeat culture at 1–2 wk; counsel recurrent pyelo prevention; recurrent breakthrough → urology workup (IDSA 2010; AUA 2022)
- Close-out criterion: follow-up scheduled

Monitoring phase: Fever curve, lactate, urine output, creatinine, culture results; PO step-down when afebrile + tolerating PO; imaging if non-resolving at 72 h (IDSA 2010; KDIGO AKI 2026)

Disposition

Current setting: outpatient — Stable, FQ-eligible, PO-tolerant, reliable follow-up → oral ciprofloxacin × 7 d OR levofloxacin × 5 d if local FQ R <10%; OR initial IV ceftriaxone 1 g + oral step-down; 48–72 h re-check (IDSA 2010)

Disposition criteria:
- Discharge with oral abx + 48–72 h follow-up + return precautions (IDSA 2010)
- Admit if any complicated criterion (IDSA 2010)

Escalation triggers (move to higher acuity):
- Treatment failure at 48–72 h → admit (IDSA 2010)
- Worsening symptoms / new red flags → ED (SCC 2026)
- Recurrent pyelo → urology referral for anatomic workup (AUA 2016)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Pyelo + sepsis (qSOFA ≥2 or hypotension) + obstruction on imaging — STAT decompression emergency (SCC 2026; AUA 2016; EAU 2020)
- [LIFE_THREATENING] Diabetic patient with gas in renal parenchyma on CT — emphysematous pyelo; high mortality without source control (EAU 2020)
- [SEVERE] Severe symptoms, vomiting, ill-appearing, cannot tolerate PO, age >60 + comorbidities — admit (IDSA 2010)

Citations

- IDSA 2011 Acute Uncomplicated Cystitis/Pyelonephritis (Gupta) + Hooton NEJM 2012 uncomplicated-UTI review + IDSA 2020 ESBL/CRE (Tamma — ertapenem for ESBL pyelo) + fluoroquinolone disabling-ADR evidence (FDA safety review) + SCC 2026 sepsis bundle (urosepsis pathway) [PMID:21292654](https://pubmed.ncbi.nlm.nih.gov/21292654/)
- Cited evidence (PMID 22417256) [PMID:22417256](https://pubmed.ncbi.nlm.nih.gov/22417256/)
- Cited evidence (PMID 33106864) [PMID:33106864](https://pubmed.ncbi.nlm.nih.gov/33106864/)
- Cited evidence (PMID 31357640) [PMID:31357640](https://pubmed.ncbi.nlm.nih.gov/31357640/)

Last reconciled with current guidelines: 2026-05-22.
References
  • IDSA 2011 Acute Uncomplicated Cystitis/Pyelonephritis (Gupta) + Hooton NEJM 2012 uncomplicated-UTI review + IDSA 2020 ESBL/CRE (Tamma — ertapenem for ESBL pyelo) + fluoroquinolone disabling-ADR evidence (FDA safety review) + SCC 2026 sepsis bundle (urosepsis pathway) — PMID:21292654
  • Cited evidence (PMID 22417256) — PMID:22417256
  • Cited evidence (PMID 33106864) — PMID:33106864
  • Cited evidence (PMID 31357640) — PMID:31357640