Grabe M, Bishop MC, Bjerkland-Johansen TE, Botto H, Cek M, Lobel B, Naber KG, Palou, J, Tenke, P, Wagenlehner F. Guidelines on Urological Infections. European Association of Urology 2009: 1-110. RATIONALE: Expert consensus is that admission should be arranged for more severe cases of acute uncomplicated pyelonephritis (e.g. dehydrated, cannot take oral medication, signs of sepsis).

Public Health England and the British Infection Association recommends that people with acute pyelonephritis are admitted if there is no response to antibiotics within 24 hours. Lack of response to treatment is likely to be due to antibiotic resistance. The complications of acute pyelonephritis can be life-threatening.

Talan DA, Stamm WE, Hooton TM, Moran GJ, Burke T, Iravani A, Reuning-Scherer J and Church DA. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis in women. A randomized trial. JAMA 2000;283:1583-90. RATIONALE:This randomized double-blind controlled trial found that 7 days of ciprofloxacin 500 mg bd was as effective as 14 days co-trimoxazole. (E coli isolates were 100% susceptible to ciprofloxacin in this study.)

Public Health England and the British Infection Association recommend ciprofloxacin and co-amoxiclav for the empirical treatment of acute pyelonephritis. This is based on the need to cover the broad spectrum of pathogens that cause acute pyelonephritis, and their excellent kidney penetration. Although they are associated with an increased risk of Clostridium difficile, MRSA, and other antibiotic-resistant infections, this has to be balanced against the risk of treatment failure and consequent serious complications in acute pyelonephritis. Trimethoprim may be used if the the causative organism is known to be susceptible to this antibiotic.

Eliakim-Raz N, Yahav D, Paul M, Leibovici L. Duration of antibiotic treatment for acute pyelonephritis and septic urinary tract infection- 7 days or less versus longer treatment: systematic review and meta-analysis of randomized controlled trails. J Antimicrob Chemother 2013 doi:10.1093/jac/dkt177. RATIONALE: This systematic review found that a shorter 7 day course of quinolones or beta lactam antibiotics was as effective as a 14 day course. However there was no direct comparison of 7 versus 14 days of trimethoprim or co-trimoxazole, and therefore we recommend 14 days of this antibiotic.

Chapman ALN, Seaton RA, Cooper MA et al. Good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults in the UK: a consensus statement. J Antimicrob Chemother 2012;67:1053-62. RATIONALE: If intravenous treatment is needed for an antibiotic resistant organism, outpatient based treatment can reduce hospitalisation and spread of antibiotic resistant pathogens. This document covers best practice when providing such a service.

The POCAST project is funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London and by the Imperial College Healthcare Charity (Grant Ref No:7006/P36U).