A retrospective review of oral cephalosporins versus fluoroquinolones for the treatment of pyelonephritis

PLoS One. 2022 Sep 9;17(9):e0274194. doi: 10.1371/journal.pone.0274194. eCollection 2022.


Background: The current Infectious Diseases Society of America guidelines for the treatment of acute uncomplicated pyelonephritis (AUP) advise caution when using oral beta-lactams due to concern for potentially inferior efficacy compared to fluoroquinolones (FQs) and trimethoprim-sulfamethoxazole; however, studies specifically evaluating the efficacy of oral cephalosporins (CPs) in AUP are limited.

Objective: To assess the safety and efficacy of oral CPs versus FQs for the treatment of AUP.

Design, setting and participants: This is a retrospective, chart review study conducted at a single-center, tertiary care hospital.

Measurements: The primary endpoint was treatment failure within 30 days, defined as a change in antibiotic or return to ED or clinic due to persistent symptoms. Secondary endpoints included adverse drug reactions (ADRs) and C. difficile infection (CDI) within 30 days.

Results: Of the 343 patients included in the study, treatment failure occurred in 54/338 (16.0%) patients and was similar between oral CPs and FQs (35/229 [15.3%] vs. 19/109 [17.4%]). A higher percentage of treatment failures were observed for third generation (3GC) and first generation (1GC) CPs compared to second generation CPs (2GC) (3GC: 15/65 [23.4%]; 1GC: 11/49 [22.4%]; 2GC: 9/115 [7.8%]). Documented ADRs were low (6/343 [1.7%]) and no cases of CDI were documented.

Conclusions: Oral CPs appear to be as safe and effective as FQs for the treatment of AUP. Fewer treatment failures were noted with 2GCs as compared to 3GCs and 1GCs.

MeSH terms

  • Anti-Bacterial Agents / adverse effects
  • Cephalosporins / adverse effects
  • Clostridioides difficile*
  • Fluoroquinolones / adverse effects
  • Humans
  • Pyelonephritis* / drug therapy
  • Retrospective Studies


  • Anti-Bacterial Agents
  • Cephalosporins
  • Fluoroquinolones

Grants and funding

The authors received no specific funding for this work.