- Design
- Multicentre retrospective cohort, 11 US EDs
- Population
- 1,147 adults discharged with pyelonephritis on an oral cephalosporin
- Primary outcome
- 14-day treatment failure (composite)
- Effect
- 19.6% vs 17.6% vs 18.0% (first, second, third generation); no significant difference
A retrospective cohort in Annals of Emergency Medicine (6 October) followed 1,147 adults, 85% women, discharged from 11 US emergency departments with pyelonephritis on an oral cephalosporin. Most received cephalexin, cefuroxime or cefdinir.
Fourteen-day treatment failure — recurrent symptoms, a return visit, a new antibiotic or admission — was 19.6% with first-generation, 17.6% with second-generation and 18.0% with third-generation agents. None of the differences was significant.
This challenges the habit of reaching for a third-generation agent for upper urinary infection. The choice should rest on local susceptibility and the patient's culture. Resistance patterns in India, where ESBL-producing organisms are common, differ from this US cohort, so the specific findings may not transfer.
- Failure rates were similar across first-, second- and third-generation oral cephalosporins
- Send urine culture before discharge and review the result
- Choose by local susceptibility rather than generation
- Arrange review for a patient not improving within 48–72 hours
Why it matters
Using broader agents than needed adds selection pressure without improving outcomes.
Don't overread it
Observational and from US centres — confounding by indication is possible, and local resistance will differ.
The statistics, in plain English
The confidence interval for first versus second generation (−7.1 to 11.1 points) is wide because only 91 patients received a second-generation agent; the first-versus-third comparison is more precise.
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