Management of PSGN with Previous Co-Amoxiclav Intake
Continue supportive care as the primary management strategy, as the prior co-amoxiclav intake has already addressed the streptococcal antigenic load, and PSGN treatment is fundamentally supportive rather than antimicrobial. 1
Antibiotic Considerations
The previous co-amoxiclav (amoxicillin/clavulanate) intake is actually appropriate and sufficient for PSGN management, as this combination provides excellent coverage against streptococcal organisms. 2
No additional antibiotics are needed if the patient has already completed an adequate course of co-amoxiclav, as the goal of antibiotic therapy in PSGN is to reduce antigenic load, not to treat active infection. 1
Co-amoxiclav has been specifically studied and validated for streptococcal infections and achieves adequate tissue concentrations. 2
The key principle is that antibiotics in PSGN serve to decrease the antigenic burden even when active infection has resolved—the prior co-amoxiclav has accomplished this goal. 1
Primary Management Focus: Supportive Care
Since antibiotic therapy has been addressed, focus entirely on managing the nephritic syndrome manifestations:
Hypertension and Fluid Management
Restrict dietary sodium to <2.0 g/day (<90 mmol/day) as the first-line intervention for both edema control and blood pressure management. 2, 1
Use diuretics as the preferred first-line agents for managing both fluid overload and hypertension in PSGN. 1, 3
Loop or thiazide diuretics are most effective and may also address hyperkalemia if present. 3
Monitor closely for diuretic-related adverse effects including hyponatremia, hypokalemia, GFR reduction, and volume depletion—these require particular attention. 2, 1
Blood Pressure Targets
Target systolic blood pressure <120 mm Hg using standardized office measurement in adults. 2
In children, target 24-hour mean arterial pressure at ≤50th percentile for age, sex, and height by ambulatory blood pressure monitoring. 2
Additional Supportive Measures
Treat metabolic acidosis if serum bicarbonate is <22 mmol/L. 2, 1
Provide dialysis if necessary for severe acute kidney injury with uremia, refractory fluid overload, or life-threatening hyperkalemia. 1
Restrict dietary protein to 0.8-1 g/kg/day if nephrotic-range proteinuria is present. 2
Immunosuppression: When to Consider
Avoid corticosteroids in typical PSGN as the disease is self-limited with excellent prognosis. 1
Reserve corticosteroids ONLY for severe crescentic PSGN with rapidly progressive glomerulonephritis, and even then, the evidence is anecdotal at best. 1, 4
For most patients with idiopathic immune complex glomerulonephritis presenting with eGFR <30 ml/min per 1.73 m², supportive care alone is recommended. 1
Monitoring Protocol
Establish a structured monitoring schedule to track disease resolution:
Monitor C3 complement levels at 8-12 weeks to confirm normalization—this is the hallmark of PSGN resolution. 1, 5
If C3 remains persistently low beyond 12 weeks, perform kidney biopsy to exclude C3 glomerulonephritis (C3GN) rather than PSGN. 1, 5
Regular assessment of kidney function (serum creatinine, eGFR), blood pressure, proteinuria (urine protein-to-creatinine ratio), and hematuria. 1, 5
The most critical period is the first 7-10 days when hypertension, edema, gross hematuria, and impaired renal function are greatest. 3
Critical Pitfalls to Avoid
Do not withhold antibiotics thinking they are unnecessary—even though the infection may have resolved, reducing antigenic load is beneficial, and the prior co-amoxiclav was appropriate. 1
Do not routinely use immunosuppression—most cases resolve spontaneously and immunosuppression carries significant risks without proven benefit in typical PSGN. 1
Do not use ACE inhibitors or ARBs as first-line agents in acute PSGN—while effective for chronic proteinuric kidney disease, they carry risks of hyperkalemia and may temporarily impair recovery of renal function in the acute setting. 3
Do not delay kidney biopsy if C3 fails to normalize by 12 weeks—this suggests an alternative diagnosis like C3GN rather than PSGN. 1, 5
Prognosis
The prognosis for PSGN is excellent, particularly in children, with complete recovery expected in the vast majority of cases. 5, 3
Even long-term prognosis is good, with PSGN rarely causing chronic kidney disease. 3
Persistent microscopic hematuria and proteinuria may be seen in less than 10% of patients but does not necessarily indicate poor outcomes. 3
Histological resolution may take up to 9 years, but clinical resolution typically occurs much earlier. 6