Approach to managing acute pyelonephritis in children

For advice on management of urinary tract infection (UTI) in neonates and children younger than 3 months, see Urinary tract infection in neonates and children younger than 3 months.

For children with sepsis or septic shock, see Sepsis and septic shock from a urinary tract source in children.

Use intravenous antibiotic therapy for acute pyelonephritis in children 3 months or older who have any of the following features:

• risk factors for serious illness (eg immune compromise)
• systemic symptoms (eg persistent tachycardia in the absence of fever)
• inability to tolerate or absorb oral therapy.

Use oral antibiotic therapy for acute pyelonephritis in children 3 months or older who do not have any of the above features. It is the consensus of the Antibiotic Expert Group thatHeil, 2021Mponponsuo, 2023:

• oral amoxicillin+clavulanate can be used empirically to treat children with acute pyelonephritis, despite limited published clinical data
• oral cefalexin is an alternative empirical option for acute pyelonephritis in children because of its ease of administration and good palatability
• higher dosages of oral beta-lactam antibiotics should be used to ensure adequate antimicrobial exposure and activity against Enterobacterales (eg Escherichia coli).

For children 3 months or older, the considerations for the choice of empirical antibiotic therapy for acute pyelonephritis are the same as those for adults, but there is a lower threshold for starting treatment with intravenous antibiotics in the first 6 months of life. For additional information, see:

• Approach to empirical antibiotic choice for UTI in children
• Rationale for oral antibiotic therapy for acute pyelonephritis in nonpregnant adults
• Rationale for intravenous antibiotic therapy for acute pyelonephritis in in nonpregnant adults.