Systematic Reviews
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Infect Dis. Sep 18, 2020; 10(3): 33-41
Published online Sep 18, 2020. doi: 10.5495/wjcid.v10.i3.33
Antibiotics for complicated urinary tract infection and acute pyelonephritis: A systematic review
Leong Tung Ong
Leong Tung Ong, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
Author contributions: Ong LT designed the literature search, performed the search, analysed the data, wrote the paper, and approved the final manuscript.
Conflict-of-interest statement: The author declares that he has no competing interests.
PRISMA 2009 Checklist statement: The guidelines of the PRISMA 2009 statement have been adopted.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Leong Tung Ong, MBBS, Faculty of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Kuala Lumpur 50603, Malaysia.
Received: April 19, 2020
Peer-review started: April 19, 2020
First decision: July 8, 2020
Revised: July 8, 2020
Accepted: August 1, 2020
Article in press: August 1, 2020
Published online: September 18, 2020

The increasing rates of antibiotic-resistance in recent years have supported emergence of multiple drug-resistant bacteria. Therefore, antibiotics that are recommended by the current clinical guidelines may not be effective for the treatment of complicated urinary tract infection (UTI) and acute pyelonephritis.


To determine the clinical efficacy and safety of antibiotics for the treatment of complicated UTI and acute pyelonephritis.


A search of PubMed, EMBASE, and Google Scholar was conducted for eligible articles describing the use of antibiotics in managing complicated UTI and acute pyelonephritis. The following keywords were used to perform the literature search: “urinary tract infection”, “complicated UTI”, “pyelonephritis”, “treatment”, and “antibiotics”. Additional articles of interest were retrieved from the reference lists of selected papers. Eligibility criteria for this systematic review were diagnosis of either complicated UTI or acute pyelonephritis and use of antibiotics in management. Clinical trials and observational studies were included, while case reports and reviews were excluded. The methodological quality of clinical trials and observational studies was assessed. A descriptive approach was adopted to analyze the data, due to the variation of methodology and interventions.


A total of 183 studies were screened, and 8 matched all the eligibility criteria and were included in this review. The antibiotics used included ceftazidime-avibactam, doripenem, levofloxacin, meropenem-vaborbactam, piperacillin-tazobactam, plazomicin, tazobactam-ceftolozane, and gentamicin. Two clinical trials reported that shorter-duration levofloxacin or non-fluoroquinolone antibiotic treatment was as effective as the duration of antibiotic therapy recommended by the current guidelines in treating complicated UTI and pyelonephritis. Besides that, ceftazidime-avibactam, piperacillin-tazobactam and tazobactam-ceftolozane can be used as alternatives to carbapenem in treating extended-spectrum -lactamase-producing Escherichia coli. The cure rates of complicated UTI and pyelonephritis by meropenem-vaborbactam, piperacillin-tazobactam and tazobactam-ceftolozane was comparable (95.6%-98.4%). Furthermore, levofloxacin had a relatively high rate of adverse events (33.1% and 47.7% in two clinical trials respectively), while tazobactam-ceftolozane had a relatively low rate of adverse events (17.5%). All studies have limitations and a potential for bias.

Keywords: Antibiotics, Urinary tract infections, Pyelonephritis, Therapeutics, Drug resistance

Core Tip: There is an increasing resistance rate to the antibiotics recommended by current guidelines for the treatment of complicated urinary tract infection (UTI) and acute pyelonephritis. Therefore, alternative antibiotics need to be explored to increase the cure rate and improve the outcomes of patients. The aim of this systematic review is to investigate the efficacy and safety of different antibiotic therapy in treating complicated UTI and acute pyelonephritis. The use of novel antibiotics and combination antibiotic therapy can be considered in treating complicated UTI and acute pyelonephritis when resistance to recommended antibiotics occurs.