eMedicine Specialties > Nephrology > Tubulointerstitial Diseases of the Kidney
Pyelonephritis, Chronic: Treatment & Medication
Updated: Sep 15, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Stages I and II VUR
- This is reflux of urine to the ureter or renal pelvis without ureteral dilatation.
- Medical therapy with antibiotics, such as amoxicillin, trimethoprim/sulfamethoxazole (Bactrim), trimethoprim alone, or nitrofurantoin, is usually sufficient.
- Continue antibiotic therapy until puberty or until reflux resolves.
- The rule in these cases is spontaneous resolution; surgery is not indicated.
- Stages III and IV VUR (severe reflux)
- Data from the Birmingham Reflux Study (international reflux study in children) show that medical and surgical therapies for reflux are equally effective.
- Surgery for severe reflux involves reimplantation of the ureters.
- The indications for surgery include the following: (1) medical noncompliance with formation of new scars, and (2) reflux persisting after puberty in women (should be surgically treated to prevent possible complications, eg, pyelonephritis, abortions in pregnancy).
Surgical Care
- The following are indications for surgical therapy:
- Failure to comply with medical regimen
- Breakthrough infections occurring in patients who are compliant
- Women of childbearing age who prefer surgical therapy
- Surgery entails the reimplantation of the ureters with the creation of an adequate submucosal tunnel and detrusor support.
Diet
- Progressive renal injury can be reduced by restricting dietary protein intake.
Medication
The penicillins (amoxicillin) and first-generation cephalosporins are the drugs of choice because of good activity against gram-negative rods and good oral bioavailability. In infants, the choice of antibiotics is either amoxicillin or a first-generation cephalosporin. In patients aged 3-6 months, therapy can be changed to sulfamethoxazole or nitrofurantoin. Older children and adults may be treated with trimethoprim-sulfamethoxazole (Bactrim). Once one antibiotic is chosen, frequent changes in the antibiotic regimen are discouraged to help prevent the development of resistance.
Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.
Amoxicillin (Amoxil)
Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.
Adult
500 mg PO q8h
Pediatric
125 mg PO q8h
Reduces efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; may enhance chance of candidiasis
Cephalexin (Keflex)
First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms.
Adult
500 mg PO qid
Pediatric
25-50 mg/kg/d PO divided qid; not to exceed 4 g/d
Coadministration with aminoglycosides increase nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Trimethoprim and sulfamethoxazole (Bactrim DS, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity includes common urinary tract pathogens, except Pseudomonas aeruginosa.
Adult
1 DS tab (TMP 160 mg/SMZ 800 mg) PO bid
Pediatric
8-12 mg/kg/d (TMP component) PO divided bid
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d of leucovorin)
Caution in folate deficiency (eg, chronic alcoholism, elderly, anticonvulsant therapy, malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP/SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
Nitrofurantoin (Furadantin, Macrodantin)
Synthetic nitrofuran that interferes with bacterial carbohydrate metabolism by inhibiting acetylcoenzyme A. Bacteriostatic at low concentrations (5-10 mcg/mL) and bactericidal at higher concentrations.
Adult
50-100 mg PO hs
Pediatric
Not established
Anticholinergics may delay gastric emptying and increase absorption, increasing nitrofurantoin bioavailability; antacids made of magnesium salts may decrease effects, decreasing absorption; high doses of concurrent probenecid decrease renal clearance and increase toxicity
Documented hypersensitivity; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause severe and irreversible peripheral neuropathy that can be fatal; renal impairment, diabetes, electrolyte imbalance, anemia, and vitamin B deficiency increase risk for adverse effects; prolonged use may result in fungal or bacterial overgrowth of resistant or nonsusceptible organisms
More on Pyelonephritis, Chronic |
| Overview: Pyelonephritis, Chronic |
| Differential Diagnoses & Workup: Pyelonephritis, Chronic |
 Treatment & Medication: Pyelonephritis, Chronic |
| Follow-up: Pyelonephritis, Chronic |
| References |
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References
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Further Reading
Keywords
chronic pyelonephritis, reflux nephropathy, kidney disease, renal injury, renal disease, kidney infection, renal infection, urinary tract obstruction, struvite calculi, renal dysplasia, vesicoureteral reflux, VUR, UTI, urinary tract infection, renal scar, renal scarring, flaccid bladder, end-stage renal disease, ESRD, end-stage kidney disease, intrarenal reflux, intra-renal reflux, progressive renal scarring, proteinuria, hypertension, focal glomerulosclerosis, FGS, xanthogranulomatous pyelonephritis, XPN, failure to thrive, Proteus, Escherichia coli, E coli, azotemia
