Acute pyelonephritis is one of the most common indications for antepartum hospitalization. When acute pyelonephritis is diagnosed, conventional treatment includes intravenous fluid and parenteral antibacterial administration. There are limited data by which to assess the superiority of one antibacterial regimen over the other in terms of efficacy, patient acceptance and safety for the developing fetus; however, it is important to consider antimicrobial resistance patterns in the local community when choosing an agent. Moreover, there are growing public health concerns regarding antimicrobial resistance to commonly prescribed medications for urinary tract infections in pregnancy. There is a small body of evidence to support the ambulatory treatment of pregnant women with pyelonephritis in the first and early second trimesters, but the majority of women will be managed as inpatients. This article provides a suggested algorithm for the treatment of pyelonephritis during pregnancy.