Clinical Notes : Urology

158. Acute Pyelonephritis prescribing

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Acute Pyelonephritis prescribing

 

Managing acute pyelonephritis

  • 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

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Antibiotics for non-pregnant women and men aged 16 years and over

 Antibiotics for pregnant women aged 12 years and over

 
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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

  • 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 in line with the NICE guideline on urinary tract infection in under 16s

 

 

  • Offer an antibiotic (see the recommendations on choice of antibiotic) to people with acute pyelonephritis. Take account of:

    • the severity of symptoms

    • the risk of developing complications, which is higher in people with known or suspected structural or functional abnormality of the genitourinary tract or immunosuppression

    • previous urine culture and susceptibility results

    • previous antibiotic use, which may have led to resistant bacteria

 

  • results of urine cultures are available:

    • review the choice of antibiotic and

    • change the antibiotic according to susceptibility results if the bacteria are resistant, using a narrow spectrum antibiotic wherever possible

 

 

Advice when an antibiotic prescription is given

 

  • When an antibiotic is given, as well as the general advice on self-care, give advice about:

    • possible adverse effects of the antibiotic, particularly diarrhoea and nausea

    • nausea with vomiting also being a possible indication of worsening pyelonephritis seeking medical help if:

    • symptoms worsen at any time or

    • symptoms do not start to improve within 48 hours of taking the antibiotic or

    • the person becomes systemically very unwell

 

 

Reassessment

  • Reassess if symptoms worsen at any time, or do not start to improve within 48 hours of taking the antibiotic, taking account of:

    • other possible diagnoses

    • any symptoms or signs suggesting a more serious illness or condition, such as sepsis previous antibiotic use, which may have led to resistant bacteria

 

 

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)

 

  • 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])

 

 

 

Self-care

 

  • 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

 

  • Advise people with acute pyelonephritis about drinking enough fluids to avoid dehydration

 

 

Choice of antibiotic

 

  • When prescribing an antibiotic for acute pyelonephritis, take account of local antimicrobial resistance data and follow:

    • table 1 for non-pregnant women and men aged 16 years and over table 2 for pregnant women aged 12 years and over

    • table 3 for children and young people under 16 years

 

  • Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics

 

  • intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible

 
 
 
 
 
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Beware of increased risk of tendon rupture with Ciprofloxacin use (fluoroquinolones)

46 fold increase with concurrent corticosteroid exposure

Achilles tendon most commonly affected

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Diagnosis of urinary tract infections

Public Health England. 

November 2018

Access

 

Urological Infections

​EAU Urological Infections Guidelines Panel

2018

Access

Pyelonephritis (acute): antimicrobial prescribing

National Institute for Health and Care Excellence

November 2018

Access

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).

Access

Michaels T, Sands J.

Dysuria: Evaluation and Differential Diagnosis in Adults.

American Family Physician. 2015;92(9)

Access

Management of suspected bacterial urinary tract infection in adults.

Scottish Intercollegiate Guidelines Network (SIGN).

July 2012

Access

Urinary tract infections in women

BMJ Best Practice

Last updated: January  2019

Last reviewed: March 2019

Access

Urinary tract infections in men

BMJ Best Practice

Last updated: September 2018

Last reviewed: March 2019

Access

Acute pyelonephritis

BMJ Best Practice

Last updated: October 2018

Last reviewed: March 2019

Access

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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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