management

Last edited 03/2021 and last reviewed 06/2021

If suspected pyelonephritis then (1):

  • in people aged 16 years and over with acute pyelonephritis, obtain a midstream urine sample before antibiotics are taken and send for culture and susceptibility testing.
  • in children and young people under 16 years with acute pyelonephritis, obtain a urine sample before antibiotics are taken and send for culture and susceptibility testing
  • assess and manage children under 5 with acute pyelonephritis who present with fever as outlined in the NICE guideline on fever in under 5s
  • offer an antibiotic

If ESBL risk in an people aged 16 years and over and with microbiology advice consider IV antibiotic via outpatients (2)

Referral and seeking specialist advice

  • refer people aged 16 years and over with acute pyelonephritis to hospital if they have any symptoms or signs suggesting a more serious illness or condition (for example, sepsis)
    • signs of sepsis, include (3):
      • a temperature greater than 38°C or less than 36°C, and
      • marked signs of illness (such as impaired level of consciousness, perfuse sweating, rigors, pallor, significantly reduced mobility), or
      • significant tachycardia, hypotension, or breathlessness

  • consider referring or seeking specialist advice for people aged 16 years and over with acute pyelonephritis if they:
    • are significantly dehydrated or unable to take oral fluids and medicines or
    • are pregnant or
    • have a higher risk of developing complications (for example, people with known or suspected structural or functional abnormality of the genitourinary tract or underlying
    • disease [such as diabetes or immunosuppression])

  • refer children and young people with acute pyelonephritis to hospital in line with the NICE guideline on urinary tract infection in under 16 years
    • infants and children with a high risk of serious illness should be referred urgently to the care of a paediatric specialist
    • infants younger than 3 months with a possible UTI should be referred immediately to the care of a paediatric specialist
    • consider referral to a paediatric specialist for infants and children 3 months or older with acute pyelonephritis/upper urinary tract infection

  • other suggested indicators for admission (3):

    • patients who:
      • are frail, elderly residents in care homes who have recently been hospitalized or who have had recurrent urinary tract infection
      • fail to improve significantly within 24 hours of starting antibiotics

When managing acute pyelonephritis in the community advise:

  • possible adverse effects of antibiotics include diarrhoea and nausea
  • nausea with vomiting is also a possible indication of worsening pyelonephritis
  • seeking medical help if symptoms worsen at any time or do not start to improve within 48 hours of taking the antibiotic, or the person becomes systemically very unwell

Notes:

  • suggested also should consider hospital admission in people who are able to take oral fluids and medications if they are pyrexial and have a risk factor for developing a complication (3)
    • in the absence of any widely accepted admission criteria, apply clinical judgement on when to admit is required. A low threshold is required for people with:
      • immunosuppression e.g. due to immunosuppressant drug use, cancer, cancer therapies, or AIDS
      • if there is a foreign body within the renal tract e.g. renal tract stones, ureteric or nephrostomy catheters
      • abnormalities of renal tract anatomy or function e.g. vesico-ureteric reflux, polycystic kidney disease
      • diabetes mellitus
      • chronic kidney disease
      • advanced age
  • Nitrofurantoin should not be used if there are symptoms of pyelonephritis (such as fever), because it will not achieve adequate levels in renal tissue (1)

Reference: