Clinical Notes : Urology
158. Acute Pyelonephritis prescribing
Acute Pyelonephritis prescribing
Managing acute pyelonephritis
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Be aware that acute pyelonephritis is an infection of one or both kidneys usually caused by bacteria travelling up from the bladder
Pyelonephritis (acute): antimicrobial prescribing
Antibiotics for non-pregnant women and men aged 16 years and over
Antibiotics for pregnant women aged 12 years and over
Because oral Cefalexine is not available in the ROI, consider substitute Cefuroxime (Zinnat, Ceftal) 500mg BD for 7-10 days as first choice antibiotic for pregnant women aged 12 and over who are not vomiting or severely unwell.
Antibiotics for children and young people under 16 years
Treatment
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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
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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 in line with the NICE guideline on urinary tract infection in under 16s
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Assess and manage children under 5 with acute pyelonephritis who present with fever as outlined in the NICE guideline on fever in under 5s
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Offer an antibiotic (see the recommendations on choice of antibiotic) to people with acute pyelonephritis. Take account of:
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the severity of symptoms
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the risk of developing complications, which is higher in people with known or suspected structural or functional abnormality of the genitourinary tract or immunosuppression
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previous urine culture and susceptibility results
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previous antibiotic use, which may have led to resistant bacteria
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results of urine cultures are available:
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review the choice of antibiotic and
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change the antibiotic according to susceptibility results if the bacteria are resistant, using a narrow spectrum antibiotic wherever possible
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Advice when an antibiotic prescription is given
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When an antibiotic is given, as well as the general advice on self-care, give advice about:
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possible adverse effects of the antibiotic, particularly diarrhoea and nausea
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nausea with vomiting also being a possible indication of worsening pyelonephritis seeking medical help if:
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symptoms worsen at any time or
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symptoms do not start to improve within 48 hours of taking the antibiotic or
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the person becomes systemically very unwell
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Reassessment
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Reassess if symptoms worsen at any time, or do not start to improve within 48 hours of taking the antibiotic, taking account of:
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other possible diagnoses
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any symptoms or signs suggesting a more serious illness or condition, such as sepsis previous antibiotic use, which may have led to resistant bacteria
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Referral and seeking specialist advice
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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)
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Consider referring or seeking specialist advice for people aged 16 years and over with acute pyelonephritis if they:
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are significantly dehydrated or unable to take oral fluids and medicines or are pregnant or
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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])
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Refer children and young people with acute pyelonephritis to hospital in line with the NICE guideline on urinary tract infection in under 16s
Self-care
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Advise people with acute pyelonephritis about using paracetamol for pain, with the possible addition of a low-dose weak opioid such as codeine for people over 12 years
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Advise people with acute pyelonephritis about drinking enough fluids to avoid dehydration
Choice of antibiotic
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When prescribing an antibiotic for acute pyelonephritis, take account of local antimicrobial resistance data and follow:
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table 1 for non-pregnant women and men aged 16 years and over table 2 for pregnant women aged 12 years and over
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table 3 for children and young people under 16 years
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Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics
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intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible
Beware of increased risk of tendon rupture with Ciprofloxacin use (fluoroquinolones)
46 fold increase with concurrent corticosteroid exposure
Achilles tendon most commonly affected
Diagnosis of urinary tract infections
Public Health England.
November 2018
Urological Infections
EAU Urological Infections Guidelines Panel
2018
Pyelonephritis (acute): antimicrobial prescribing
National Institute for Health and Care Excellence
November 2018
Giesen, L. G. et al.
Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs.
BMC Family Practice. 2010;11(78).
Michaels T, Sands J.
Dysuria: Evaluation and Differential Diagnosis in Adults.
American Family Physician. 2015;92(9)
Management of suspected bacterial urinary tract infection in adults.
Scottish Intercollegiate Guidelines Network (SIGN).
July 2012
Urinary tract infections in women
BMJ Best Practice
Last updated: January 2019
Last reviewed: March 2019
Urinary tract infections in men
BMJ Best Practice
Last updated: September 2018
Last reviewed: March 2019
Acute pyelonephritis
BMJ Best Practice
Last updated: October 2018
Last reviewed: March 2019
The following oral antibiotics are available in Ireland :
- Nitrofuradantoin as Macrobid (100mg BD) and as Macrodantin (100mg QID)
- Trimethoprim as Monoprim, Trimoptin
- Fosfomycin as Monuril
- Co-amoxiclav as Augmentin, Amoclav, Clavamel, Gementin
- Ciprofloxacin as Cifloxager, Cifox, Ciplox, Ciprofloxacin Teva, Ciproxin, Profloxin, Truoxin
- Cefuroxime as Zinnat, Ceftal
The following oral antibiotics are not available in Ireland :
- Pivmecillinam
- Cefalexin
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