Question: How to diagnose and treat pyelonephritis

Renal USS - spot the bad oneIn children suspected of having a UTI, what clinical and radiological features diagnoses pylonephritis, and what mode of antibiotic treatment is necessary to produce clinical improvement and avoid chronic renal impairment?

With the publication of the NICE guidance in the UK on the management of UTI in childhood, many paediatricians have been spurred to review their understanding of the evidence underpinning certain aspects of the clinical pathway.Questions about pyelonephritis are being asked in the City Hospital, Birmingham, UK – how should it be diagnosed, and treated with what sorts of antibiotics, given by which route, and for how long? The questions are certainly open for debate — as is this blog entry.

Can we reliably differentiate between a bladder and a kidney infection in children? Does the diagnosis make any difference anyway? Do you really need 48h of IV antibiotics just because you’re <12m old with white cells in your urine?


Image: mariaboismain from Flickr under the creativecommons2.0 licence.

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  • Kay Tyerman

    Pyelonephritis is a diagnosis usually made on the basis of a positive urine culture in conjunction with clinical signs and symptoms ie fever, malaise, vomiting, abdominal pain/tenderness +/ – haematuria.
    Children under 3 months of age should be treated with a minimum of 48 hours iv antibiotics followed by oral for a total of 10 days. Older children may warrant initial iv antibiotics if they are systemically unwell based on clinical judgement. A lower threshold for IV antibiotics should be used in young children and those with significant risk factors (eg renal impairment, hypertension,poor urine, family history of VUR).
    Children requiring IV antibiotics should ideally have an acute renal USS. This may reveal an increase in size/ abnormal echotexture consistent with an acute infection. A DMSA scan would also show abnormal uptake in an acute pyelonephritis. This investigation would only be indicated in the acute illness if the diagnosis was unclear in a child with ongoing fever and no other focus of infection. A DMSA scan is indicated for all children under 3 years who receive IV antibiotics and for older children if they have recurrent UTIs or abnormalities on USS.
    Children with pyelonephritis may go on to develop renal scarring however this may also occur in children with predominantly lower tract infections who would normally proceed to DMSA scans after recurrent UTIs.
    I would recommend reading the NICE clinical guideline 54. Quick reference guide available at

  • Pyelonephritis course of more than six months, accompanied by one of the following conditions may be diagnosed as chronic pyelonephritis: ① intravenous pyelography in the film, made visible pelvis renal calyceal deformation and narrow; ② renal rugged appearance, and two kidney size ranging ③ tubular function of the damage sustained.

    Common following five types:

    (1) often repeated recurrence of acute onset they have symptoms of systemic infection, urinary tract partial performance and changes in urine, similar to acute pyelonephritis.

    (2) a low heat-low heat as the main long-term performance, with fatigue, lumbar acid, loss of appetite, weight loss, etc..

    (3) type of hematuria can be hematuria as the main performance, a microscope or gross hematuria, flank pain onset, with the waist stimulate acid and urinary tract symptoms.

    (4) the absence of any occult or partial systemic symptoms, the only changes in the urine, urine culture can be positive bacteria, also known as asymptomatic bacteriuria in.

    (5) in the pathogenesis of hypertension in hypertension, even radical can be developed for hypertension, accompanied anemia, but no significant proteinuria and edema.

  • some symptoms that differentiate bladder infection from kidney infection are that bladder inflammation leads to mild fever which becomes strong, if you suffer from kidney infection..Moreover, you can also notice pus or blood in urine during Pyelonephritis.