CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.
Pyelonephritis - acute - Management
View full scenario no prescriptions
When should I arrange admission for a person with acute pyelonephritis?
- Admit people who:
- Are significantly dehydrated or who are unable to take oral fluids and medications.
- Have signs of sepsis, including:
- A temperature greater than 38°C or less than 36°C, and
- Marked signs of illness (such as impaired level of consciousness, perfuse sweating, rigors, pallor, significantly reduced mobility), or
- Significant tachycardia, hypotension, or breathlessness.
- Are pregnant and pyrexial.
- Are frail, elderly residents in care homes who have recently been hospitalized or who have had recurrent urinary tract infection.
- Fail to improve significantly within 24 hours of starting antibiotics.
- Consider admitting people who are able to take oral fluids and medications if they are pyrexial and have a risk factor for developing a complication. In the absence of any widely accepted admission criteria, clinical judgement on when to admit is required. A low threshold is required for people with:
- Immunocompromise, due to immunosuppressant drug use, cancer, cancer therapies, or AIDS.
- A foreign body within the renal tract, including renal stones and ureteric or nephrostomy catheters.
- Abnormalities of renal tract anatomy or function, including vesico–ureteric reflux and polycystic kidney disease.
- Diabetes.
- Renal impairment.
- Advanced age.
- Manage in primary care those people with acute pyelonephritis who are:
- Pyrexial but have no risk factors for developing a complication from acute pyelonephritis.
- Apyrexial, with or without risk factors for developing a complication.
Basis for recommendation
These recommendations are largely based on expert opinion and limited evidence of the risk factors for developing complications from acute pyelonephritis.
Absolute indications for hospital admission
- There is expert consensus to arrange admission for people with acute pyelonephritis who:
- A number of experts recommend arranging admission for all pregnant women with acute pyelonephritis, for at least a short observation period, because of the risk of preterm labour and maternal renal complications [Ramakrishnan and Scheid, 2005].
- Experts from the Health Protection Agency recommend treatment with ertapenem, or other carbapenem, for frail elderly residents from care homes who have been recently hospitalized or who have recurrent urinary tract infection, because they are at increased risk of having a pathogen resistant to ciprofloxacin and cephalosporins [Livermore, Personal Communication, 2009]. Treatment requires hospital admission because this antibiotic is only available in an intravenous form and no other suitable oral alternative exists.
Relative indications for hospital admission
- Although experts recommend considering admission for people with a risk factor for developing a complication from acute pyelonephritis, CKS could find no specific criteria as to when to arrange admission for those with:
- Immunocompromise.
- A foreign body within the renal tract.
- Abnormalities of renal tract anatomy or function.
- Diabetes.
- Renal impairment.
- Advanced age.
- Serious complications from acute pyelonephritis can develop rapidly. It is therefore recommended that there should be a low threshold for arranging admission for people with risk factors.
Treatment in primary care
- People without signs of sepsis or risk factors for developing a complication of acute pyelonephritis have a good prognosis. Experts widely recommend treatment of these people in primary care [Ramakrishnan and Scheid, 2005].
- In the absence of any trial evidence, experts agree that people who are apyrexial and appear otherwise well can be considered to be at low risk for developing a serious complication from acute pyelonephritis, whether they have a risk factor or not [Solomon, Personal Communication, 2009; Wullt, Personal Communication, 2009].
How do I manage a person with suspected acute pyelonephritis in primary care?
- Arrange admission, if this is indicated. See Admission or treatment for further information.
- Obtain a midstream (or catheter specimen) of urine for culture and sensitivity testing before starting empirical antibiotics.
- Prescribe an antibiotic.
- For women who are not pregnant, men, and people with indwelling catheters:
- Treat with ciprofloxacin 500 mg twice daily for 7 days.
- Co-amoxiclav 500/125 mg three times a day for 14 days is an alternative.
- For pregnant women who do not require admission:
- Treat with cefalexin 500 mg twice daily for 10 to 14 days.
- Treat pain and fever with paracetamol.
- Maintain full hydration — advise sufficient fluid intake to ensure frequent passage of pale-coloured urine.
- Review 24 hours after starting treatment and arrange admission if there is any clinical deterioration or the person does not respond to treatment.
- Review culture and sensitivity results when they become available, and change the antibiotic if indicated.
- Consider referral for investigation of an underlying abnormality of the renal tract, for:
- Men, following their first episode of acute pyelonephritis.
- Women, following two or more episodes of acute pyelonephritis.
- All people with a urinary tract infection caused by Proteus species.
Basis for recommendation
Antibiotics
- These recommendations conform with Health Protection Agency (HPA) advice [HPA and Association of Medical Microbiologists, 2008].
- The HPA recommend ciprofloxacin and co-amoxiclav for the empirical treatment of acute pyelonephritis. This is based on the need to cover the broad spectrum of pathogens that cause acute pyelonephritis, and their excellent kidney penetration. Cefalexin has a reduced spectrum of activity, but is considered to have a better safety profile in pregnant women.
- Although ciprofloxacin, cefalexin, and co-amoxiclav are associated with an increased risk of Clostridium difficile, meticillin-resistant Staphylococcus aureus (MRSA), and other antibiotic-resistant infections, this has to be balanced against the risk of treatment failure and consequent serious complications with the use of narrower spectrum antibiotics.
Treatment of pain and fever
- Paracetamol is recommended by experts, based on the extrapolation of the effectiveness of paracetamol in the treatment of pain and fever in other conditions [COMPASS, 2007].
- Nonsteroidal anti-inflammatory drugs are generally not recommended by experts, because they are thought to increase the risk of renal impairment in people with acute pyelonephritis [COMPASS, 2007].
Maintenance of full hydration
- This is recommended by experts to maintain a high urine output [COMPASS, 2007], which is believed to help resolve acute pyelonephritis by mechanically flushing the bacteria from the kidney.
Referral for investigation of an underlying risk factor
- Experts recommend investigating people with acute pyelonephritis, especially men, because [Zandi-Nejad and Brown, 2001]:
- Men with acute pyelonephritis are more likely to have an underlying abnormality of renal function or anatomy.
- People with recurrent acute pyelonephritis are more likely to have an underlying abnormality of renal function or anatomy.
- Proteus species is much more common in people with renal calculi.
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
First-line antibiotics: ciprofloxacin or co-amoxiclav
Age from 16 years onwards
Co-amoxiclav tablets: 500/125mg three times a day
Co-amoxiclav 500mg/125mg tablets
Take one tablet three times a day for 14 days.
Supply 42 tablets.
Age from 18 years onwards
Ciprofloxacin tablets: 500mg twice a day for 7 days
Ciprofloxacin 500mg tablets
Take one tablet twice a day for 7 days.
Supply 14 tablets.
First-line antibiotic if pregnant: cefalexin
Age from 16 years onwards
Cefalexin tablets: 500mg twice a day for 10 days
Cefalexin 500mg tablets
Take one tablet twice a day for 10 days.
Supply 20 tablets.
Cefalexin tablets: 500mg twice a day for 14 days
Cefalexin 500mg tablets
Take one tablet twice a day for 14 days.
Supply 28 tablets.
Analgesia use when required
Age from 16 years onwards
Paracetamol tablets: 1g up to four times a day
Paracetamol 500mg tablets
Take two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.
Supply 50 tablets.
© NHS Institute for Innovation and Improvement