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:

• NICE (October 2018). Pyelonephritis (acute): antimicrobial prescribing
• Public Health England (October 2014). Management of infection guidance for primary care for consultation and local adaptation
• CKS (Accessed 7/3/201). Pyelonephritis