Oral antibiotic therapy for 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.

See Approach to managing acute pyelonephritis in children for a discussion of antibiotic choice.

For empirical oral therapy for acute pyelonephritis in children, useStein, Dogan, Hoebeke, Kocvara, Nijman, Radmayr, Tekgul, European Association of Urology, 2015 Strohmeier, 2014:

1amoxicillin+clavulanate orally, for 10 days amoxicillin + clavulanate

child 1 month to younger than 2 months: 15+3.75 mg/kg, 8-hourly

child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg, 8-hourly

2cefalexin 25 mg/kg up to 1 g orally, 6-hourly for 10 days cefalexin

OR (if adherence to a 6-hourly regimen is unlikely)

2cefalexin 45 mg/kg up to 1.5 g orally, 8-hourly for 10 days. cefalexin

For children with hypersensitivity to penicillins, useStein, Dogan, Hoebeke, Kocvara, Nijman, Radmayr, Tekgul, European Association of, , 2015:

1ciprofloxacin 12.5 mg/kg up to 500 mg orally, 12-hourly for 7 days¹ ² ciprofloxacin

OR if a liquid formulation is required

2trimethoprim+sulfamethoxazole (child 1 month or older) 4+20 mg/kg up to 160+800 mg orally, 12-hourly for 7 days³. trimethoprim + sulfamethoxazole

Modify empirical therapy based on the results of culture and susceptibility testing. If the pathogen is susceptible to one of the following regimens, stop the empirical regimen and use the narrowest spectrum antibiotic to which the pathogen is susceptibleNational Institute for Health and Care Excellence (NICE), October 2018:

1amoxicillin 30 mg/kg up to 1 g orally, 8-hourly for a total of 10 days amoxicillin

2trimethoprim+sulfamethoxazole (child 1 month or older) 4+20 mg/kg up to 160+800 mg orally, 12-hourly for a total of 7 days³ trimethoprim + sulfamethoxazole

3cefalexin 25 mg/kg up to 1 g orally, 6-hourly for a total of 10 days cefalexin

OR (if adherence to a 6-hourly regimen is unlikely)

3cefalexin 45 mg/kg up to 1.5 g orally, 8-hourly for 10 days. cefalexin

If resistance to all of the above drugs is confirmed, provided the pathogen is susceptible, useStein, Dogan, Hoebeke, Kocvara, Nijman, Radmayr, Tekgul, European Association of, 2015:

ciprofloxacin 12.5 mg/kg up to 500 mg orally, 12-hourly for 7 days¹ ². ciprofloxacin

Children with pyelonephritis caused by Pseudomonas aeruginosa often have co-existing urological abnormalities; treat with ciprofloxacin (as above) and seek expert adviceBitsori, 2012.

Fever may take 48 to 72 hours to resolve in pyelonephritis, but children may systemically improve before then. If the child is not improving clinically, consider if the child is at risk of a UTI caused by multidrug-resistant gram-negative bacteria, and reconsider the diagnosis of pyelonephritis.

For children with ongoing pyelonephritis symptoms following appropriate antibiotic therapy, seek expert advice.

Do not perform post-treatment urine culture to confirm resolution of infection for asymptomatic children.

¹ An oral liquid formulation of ciprofloxacin is not commercially available; for formulation options for children or people with swallowing difficulties, see Don’t Rush to Crush, which is available for purchase from the Advanced Pharmacy Australia website or through a subscription to eMIMSplus.Return

² Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, clinical trial data suggest that adverse musculoskeletal events are usually mild and short term, similar to those observed in adults. Ciprofloxacin can be used in children when it is the drug of choice.Return

³ If the child has been treated with trimethoprim or trimethoprim+sulfamethoxazole in the previous 6 months, or had a trimethoprim-resistant (or trimethoprim+sulfamethoxazole-resistant) Escherichia coli isolate during this time, use an alternative antibiotic for empirical therapyBryce, 2016.Return