Approach Considerations
Routine supportive care in pyelonephritis includes adequate hydration, analgesia, and the use of antipyretics. IV fluid replacement and parenteral antibiotics are indicated for children unable to take medication and fluids orally. IV therapy may be continued until the child can receive oral medication and fluids. Septic or toxic patients require hospitalization for treatment.
Treatment with fluids and oral antibiotics may be given on an outpatient basis if children are not vomiting and not markedly ill. [24]
The optimal duration of therapy is not well studied, although recommended treatment is in the range of 7-14 days. Some studies have shown that recurrent infection rates increase with short courses of treatment.
Deterrence and prevention
A study noted that in children with or without primary nonsevere reflux, prophylaxis does not reduce the rate of recurrent febrile UTIs after the first episode and thus is no longer recommended. [25, 26]
A study by Lee et al compared the effectiveness of probiotic and antibiotic prophylaxis or no-prophylaxis in infants with pyelonephritis and normal urinary tract. The study found that the incidence of recurrent UTI in the probiotic group was 8.2%, 20.6% in the no-prophylaxis group and 10.0% of the antibiotic group. [27]
Consultations
Consultations are typically not required at the time of presentation. A urologist should be consulted for an infant or child with obstruction or a clinically significant anomaly of the urinary tract. Consultation with an infectious diseases specialist is necessary only if an unusual or resistant organism is identified. Consult a nephrologist when patients have impaired renal function.
Antibiotic Therapy
The results of urine cultures ultimately dictate the choice of antibiotics. [28] Because E coli causes more than 95% of all cases of acute pyelonephritis in children, initial treatment should be based on regional susceptibility to this pathogen. Because of high resistance rates to amoxicillin, initial treatment should include a cephalosporin, amoxicillin-clavulanic acid, trimethoprim-sulfamethoxazole (TMP-SMZ), or aminoglycoside. [29, 30, 31]
Initial therapy with IV antibiotics for 3-4 days followed by oral therapy to complete a 10-14 day course is equivalent to 10-14 days of IV therapy.
Initial oral therapy with cefixime or amoxicillin-clavulanate is equivalent to IV ceftriaxone for 3 days followed by oral therapy. Rates of renal scarring are equal in children treated orally or intravenously, although further study is needed to determine whether a subgroup of children with dilating VUR may have high rates of renal scarring if treated with oral antibiotics. Further studies are needed to ensure that currently available antibiotics have the same efficacy. The results of one study noted that children with a high risk of renal scar formation realized a reduced occurrence and/or severity of renal scarring with antibiotic therapy combined with oral methylprednisolone sodium phosphate (1.6 mg/kg/d for 3 d). [32]
A single dose of ceftriaxone given intramuscularly (IM) followed by oral therapy offers no advantage over 10 days of oral therapy alone. Hospitalization is required in similar numbers because of vomiting.
IV gentamicin may be dosed daily, rather than 3 times a day, for children who require IV treatment or who are infected with multiresistant organisms.
Inpatient Care
Hospitalization is necessary for pyelonephritis in any of the following situations:
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Toxicity or sepsis
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Signs of urinary obstruction or significant underlying disease
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Inability to tolerate adequate oral fluids or medications
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Infants and children younger than age 2 years with febrile UTI, presumed pyelonephritis
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All infants younger than age 3 months
Outpatient Care
Patients treated exclusively in the outpatient setting should be reevaluated in 48 hours to ensure adequate hydration and an appropriate response to therapy. For a first infection, perform renal ultrasonography. Manage constipation and voiding dysfunction. Recommendations for imaging following febrile UTI are in flux. [33, 34]
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Application of low-risk criteria and approach for the febrile infant: A reasonable approach for treating febrile infants younger than 3 months who have a temperature of greater than 38°C.
