If suspected pyelonephritis then (1):
- 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
- assess and manage children under 5 with acute pyelonephritis who present with fever as outlined in the NICE guideline on fever in under 5s
- offer an antibiotic
If ESBL risk in an people aged 16 years and over and with microbiology advice consider IV antibiotic via outpatients (2)
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)
- signs of sepsis, include (3):
- 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
- 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])
- refer children and young people with acute pyelonephritis to hospital in line with the NICE guideline on urinary tract infection in under 16 years
- infants and children with a high risk of serious illness should be referred urgently to the care of a paediatric specialist
- infants younger than 3 months with a possible UTI should be referred immediately to the care of a paediatric specialist
- consider referral to a paediatric specialist for infants and children 3 months or older with acute pyelonephritis/upper urinary tract infection
- other suggested indicators for admission (3):
- patients who:
- 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
When managing acute pyelonephritis in the community advise:
- possible adverse effects of antibiotics include diarrhoea and nausea
- nausea with vomiting is also a possible indication of worsening pyelonephritis
- seeking medical help if symptoms worsen at any time or do not start to improve within 48 hours of taking the antibiotic, or the person becomes systemically very unwell
Notes:
- suggested also should consider hospital admission in people who are able to take oral fluids and medications if they are pyrexial and have a risk factor for developing a complication (3)
- in the absence of any widely accepted admission criteria, apply clinical judgement on when to admit is required. A low threshold is required for people with:
- immunosuppression e.g. due to immunosuppressant drug use, cancer, cancer therapies, or AIDS
- if there is a foreign body within the renal tract e.g. renal tract stones, ureteric or nephrostomy catheters
- abnormalities of renal tract anatomy or function e.g. vesico-ureteric reflux, polycystic kidney disease
- diabetes mellitus
- chronic kidney disease
- advanced age
- Nitrofurantoin should not be used if there are symptoms of pyelonephritis (such as fever), because it will not achieve adequate levels in renal tissue (1)
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