What are the treatment guidelines for post-streptococcal pyelonephritis in pediatrics?

Treatment Guidelines for Post-Streptococcal Pyelonephritis in Pediatrics

For post-streptococcal pyelonephritis in pediatrics, treatment should include appropriate antibiotics based on age and severity, with third-generation cephalosporins being the first-line therapy for children over 6 months of age.

Initial Antibiotic Selection

Based on Age

• For newborns and infants under 6 months:

  • Parenteral ampicillin combined with an aminoglycoside OR
  • A third-generation cephalosporin 1

• For children over 6 months with uncomplicated pyelonephritis:

  • Third-generation cephalosporin (e.g., ceftriaxone, cefotaxime) 1

• For children over 6 months with complicated pyelonephritis:

  • Ceftazidime and ampicillin, OR
  • An aminoglycoside and ampicillin 1

Treatment Duration and Administration

• For uncomplicated cases, evidence supports:

  • Initial intravenous therapy (3 days) followed by oral therapy (7-10 days), OR
  • Complete oral antibiotic course (10 days) in clinically stable patients 2

• Total treatment duration should be 10-14 days 1

• For oral step-down therapy, options include:

  • Co-amoxiclav (amoxicillin-clavulanate) at 50 mg/kg/day in three divided doses 2
  • Other appropriate oral antibiotics based on culture sensitivity

Special Considerations for Post-Streptococcal Etiology

• Even if active infection is no longer present, antibiotic treatment is recommended to decrease antigenic load 3

• For penicillin-susceptible streptococci:

  • Penicillin G or ampicillin is recommended for 4 weeks 1
  • Ceftriaxone is an alternative that allows once-daily dosing 1

• For penicillin-allergic patients:

  • Vancomycin is an effective substitute 1
  • Erythromycin can be considered for mild cases 3

Monitoring During Treatment

• Monitor for clinical response:

  • Defervescence (resolution of fever)
  • Improvement in inflammatory markers
  • Sterile urine culture after 72 hours of treatment 1, 2

• For patients with post-streptococcal glomerulonephritis component:

  • Regular assessment of kidney function, blood pressure, proteinuria, and hematuria 3
  • Monitor complement levels (C3) which are typically low in post-streptococcal glomerulonephritis 4

Management of Complications

• For hypertension and edema:

  • Loop or thiazide diuretics are most effective 4
  • Restrict dietary sodium intake 3

• For severe cases with acute kidney injury:

  • Consider dialysis if necessary 3

• For severe crescentic glomerulonephritis:

  • Corticosteroids may be considered in select cases, though evidence is limited 3

Prevention of Recurrence

• Ensure complete eradication of streptococcal infection 5
• During outbreaks, systemic antimicrobials should be used to eliminate nephritogenic strains of Streptococcus pyogenes from the community 3

Prognosis

• The prognosis for post-streptococcal glomerulonephritis is generally excellent 6, 7
• Long-term follow-up may be needed to monitor for persistent microscopic hematuria and proteinuria, which can occur in less than 10% of patients 4

Common Pitfalls to Avoid

• Failing to treat with appropriate antibiotics even when active infection is not detected 3
• Overlooking the need to monitor complement levels (C3) which are typically low in post-streptococcal glomerulonephritis 4
• Using angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for hypertension control without considering the risk of hyperkalemia and temporarily impairing recovery of renal function 4