Chronic Pyelonephritis Guidelines

Updated: Jun 19, 2023
  • Author: James W Lohr, MD; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Guidelines Summary

The 2010 American Urological Association (AUA) guidelines for management and screening of primary vesicoureteral reflux (VUR) in children were reconfirmed in 2017.  Key recommendations for initial management of children less than 12 months old include the following [4] :

  • Voiding cystourethrogram for neonates with high-grade (Society of Fetal Urology grade 3 and 4) hydronephrosis, hydroureter, or an abnormal bladder on ultrasound (late-term prenatal or postnatal), or who develop a urinary tract infection (UTI) on observation.
  • Continuous antibiotic prophylaxis (CAP) for VUR in patients with a history of a febrile UTI
  • CAP for VUR grades III–V in patients with no history of febrile UTI identified through screening
  • CAP may be offered for VUR grades I-II in patients with no history of UTI identified through screening

For children over one year old, several factors influence clinical outcome, including a greater likelihood of bowel and/or bladder dysfunction (BBD), lower probability of spontaneous resolution of VUR, lower risk of acute morbidity from febrile UTI, and a greater ability of the child to communicate complaint of symptoms of acute infection. Thus, the AUA notes that management decisions must take into account recognition of the clinical context (ie, age, VUR grade, presence of scarring, and parental preferences). The guidelines make the following treatment recommendations [4] :

  • In the absence of BBD, recurrent febrile UTI, or renal cortical abnormaties, CAP is optional. Observational management without continuous antibiotic prophylaxis, with prompt initiation of antibiotic therapy for UTIs, may be also be considered. 
  • CAP should be initiated in any child with VUR and BBD, recurrent febrile UTI, or renal cortical abnormaties.
  • Surgical intervention, including both open and endoscopic methods, may be considered. 
  • Following endoscopic injection of bulking agents, a postoperative voiding cystography should be performed
  • With the occurrence of a febrile UTI following resolution or surgical treatment of VUR, evaluation for BBD or recurrent VUR is required.