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Acute complicated cystitis and pyelonephritis

Thomas M Hooton, MD
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Allyson Bloom, MD


Urinary tract infections (UTIs) include cystitis (infection of the bladder) and pyelonephritis (infection of the kidney). Most episodes of cystitis and pyelonephritis are generally considered to be uncomplicated in otherwise healthy nonpregnant adults. A complicated urinary tract infection, whether localized to the lower or upper tract, is associated with an underlying condition that increases the risk of failing therapy.

Issues related to acute complicated cystitis and pyelonephritis will be reviewed here. Issues related to acute uncomplicated cystitis and pyelonephritis in women are discussed separately, as are issues related to UTIs in pregnant women, in men, and in the setting of indwelling urethral catheters. (See "Urinary tract infections and asymptomatic bacteriuria in pregnancy" and "Acute uncomplicated cystitis and pyelonephritis in men" and "Catheter-associated urinary tract infection in adults" and "Acute uncomplicated cystitis and pyelonephritis in women".)

Urinary tract infections in renal transplant patients are also discussed in detail elsewhere. (See "Urinary tract infection in renal transplant recipients".)


A complicated urinary tract infection, whether localized to the lower or upper tract, is associated with an underlying condition that increases the risk of failing therapy, including the following:

Poorly controlled diabetes mellitus

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Literature review current through: Oct 2017. | This topic last updated: Feb 09, 2016.
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  1. Echols RM, Tosiello RL, Haverstock DC, Tice AD. Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis. Clin Infect Dis 1999; 29:113.
  2. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis 2007; 45:273.
  3. Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am 1987; 1:823.
  4. Nicolle LE. Catheter-related urinary tract infection. Drugs Aging 2005; 22:627.
  5. Nicolle LE. A practical guide to the management of complicated urinary tract infection. Drugs 1997; 53:583.
  6. Zilberberg MD, Shorr AF. Secular trends in gram-negative resistance among urinary tract infection hospitalizations in the United States, 2000-2009. Infect Control Hosp Epidemiol 2013; 34:940.
  7. Lautenbach E. Editorial commentary: flying under the radar: the stealth pandemic of Escherichia coli sequence type 131. Clin Infect Dis 2013; 57:1266.
  8. Colpan A, Johnston B, Porter S, et al. Escherichia coli sequence type 131 (ST131) subclone H30 as an emergent multidrug-resistant pathogen among US veterans. Clin Infect Dis 2013; 57:1256.
  9. Bent S, Nallamothu BK, Simel DL, et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA 2002; 287:2701.
  10. Fairley KF, Carson NE, Gutch RC, et al. Site of infection in acute urinary-tract infection in general practice. Lancet 1971; 2:615.
  11. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52:e103.
  12. Sandberg T, Stokland E, Brolin I, et al. Selective use of excretory urography in women with acute pyelonephritis. J Urol 1989; 141:1290.
  13. Kanel KT, Kroboth FJ, Schwentker FN, Lecky JW. The intravenous pyelogram in acute pyelonephritis. Arch Intern Med 1988; 148:2144.
  14. http://www.guideline.gov/summary/summary.aspx?doc_id=13683&nbr=007017&string=pyelonephritis (Accessed on September 14, 2009).
  15. Johnson JR, Vincent LM, Wang K, et al. Renal ultrasonographic correlates of acute pyelonephritis. Clin Infect Dis 1992; 14:15.
  16. Meyrier A, Condamin MC, Fernet M, et al. Frequency of development of early cortical scarring in acute primary pyelonephritis. Kidney Int 1989; 35:696.
  17. Kawashima A, LeRoy AJ. Radiologic evaluation of patients with renal infections. Infect Dis Clin North Am 2003; 17:433.
  18. Tsugaya M, Hirao N, Sakagami H, et al. Computerized tomography in acute pyelonephritis: the clinical correlations. J Urol 1990; 144:611.
  19. Demertzis J, Menias CO. State of the art: imaging of renal infections. Emerg Radiol 2007; 14:13.
  20. Soulen MC, Fishman EK, Goldman SM. Sequelae of acute renal infections: CT evaluation. Radiology 1989; 173:423.
  21. Hooper DC, Wolfson JS. Fluoroquinolone antimicrobial agents. N Engl J Med 1991; 324:384.
  22. MacFadden DR, Ridgway JP, Robicsek A, et al. Predictive utility of prior positive urine cultures. Clin Infect Dis 2014; 59:1265.
  23. Stamm WE, Hooton TM. Management of urinary tract infections in adults. N Engl J Med 1993; 329:1328.
  24. Rodríguez-Baño J, Alcalá JC, Cisneros JM, et al. Community infections caused by extended-spectrum beta-lactamase-producing Escherichia coli. Arch Intern Med 2008; 168:1897.
  25. Tasbakan MI, Pullukcu H, Sipahi OR, et al. Nitrofurantoin in the treatment of extended-spectrum β-lactamase-producing Escherichia coli-related lower urinary tract infection. Int J Antimicrob Agents 2012; 40:554.
  26. Pullukcu H, Tasbakan M, Sipahi OR, et al. Fosfomycin in the treatment of extended spectrum beta-lactamase-producing Escherichia coli-related lower urinary tract infections. Int J Antimicrob Agents 2007; 29:62.
  27. Senol S, Tasbakan M, Pullukcu H, et al. Carbapenem versus fosfomycin tromethanol in the treatment of extended-spectrum beta-lactamase-producing Escherichia coli-related complicated lower urinary tract infection. J Chemother 2010; 22:355.
  28. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010; 50:625.
  29. The prevention and management of urinary tract infections among people with spinal cord injuries. National Institute on Disability and Rehabilitation Research Consensus Statement. January 27-29, 1992. J Am Paraplegia Soc 1992; 15:194.
  30. Peterson J, Kaul S, Khashab M, et al. A double-blind, randomized comparison of levofloxacin 750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for the treatment of complicated urinary tract infections and acute pyelonephritis. Urology 2008; 71:17.
  31. Parasuraman R, Julian K, AST Infectious Diseases Community of Practice. Urinary tract infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:327.