Chronic pyelonephritis

Mainstays of preventive therapy include treatment of acute infections and possibly surgical correction of anatomic abnormalities. See Urinary tract infections in children, Urinary tract infections in men, and Urinary tract infections in women.

Xanthogranulomatous pyelonephritis (XGP) is an uncommon disease with no clear primary prevention strategies; treatment of renal stones, obstruction, and infection is recommended. Emphysematous pyelonephritis is extremely rare and, as with XGP, no clear primary prevention strategies exist; treatment of renal stones, obstruction, and infection is recommended.

For patients with recurrent infections, a high index of suspicion for infection and rapid treatment is important.[65]Montini G, Rigon L, Zucchetta P, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics. 2008 Nov;122(5):1064-71. http://www.ncbi.nlm.nih.gov/pubmed/18977988?tool=bestpractice.com

The American Urological Association (AUA) recommends dimercaptosuccinic acid (DMSA) imaging for children with primary vesicoureteral reflux and any of the following:[66]American Urological Association. Management and screening of primary vesicoureteral reflux in children (2010, amended 2017). 2021 [internet publication]. https://www.auanet.org/guidelines/guidelines/vesicoureteral-reflux-guideline#x3333 ​

• An abnormal renal ultrasound

• Concern for scarring (e.g., breakthrough urinary tract infection (UTI)

• Grade III-V vesicoureteral reflux (VUR)

• Elevated serum creatinine

UK guidance recommends that, in children with pyelonephritis, DMSA scans should be performed at least 4 months after acute infection to assess for renal parenchymal defects.[67]National Institute for Health and Care Excellence. Urinary tract infection in under 16s: diagnosis and management. Jul 2022 [internet publication]. https://www.nice.org.uk/guidance/ng224 [68]Kanaan N, Cooper S, Landau D, et al. Patterns of damage observed on dimercaptosuccinic acid kidney scans and future risk of urinary tract infections or reduced kidney function. Pediatr Nephrol. 2025 Apr 28. https://link.springer.com/article/10.1007/s00467-025-06779-1 http://www.ncbi.nlm.nih.gov/pubmed/40289209?tool=bestpractice.com ​​​

The AUA recommends continuous antibiotic treatment for children:[66]American Urological Association. Management and screening of primary vesicoureteral reflux in children (2010, amended 2017). 2021 [internet publication]. https://www.auanet.org/guidelines/guidelines/vesicoureteral-reflux-guideline#x3333 ​

• <1 year old with VUR and febrile UTIs

• <1 year old with VUR stages III-V without a history of febrile UTIs

• With bladder and bowel dysfunction and VUR before and while therapies are being initiated.

Patients who are not on continuous prophylactic antibiotic therapy who have breakthrough febrile UTIs should be considered for initiation of continuous therapy. If these children have anatomically abnormal urinary tracts and have not undergone surgical treatment, surgical treatment should be considered. Medical and surgical treatments for VUR may be combined, depending on the degree of anatomic abnormalities found. In patients already on continuous prophylactic antibiotic therapy who develop febrile UTIs, a change in prophylactic antibiotic is recommended after treatment of the acute infection.[66]American Urological Association. Management and screening of primary vesicoureteral reflux in children (2010, amended 2017). 2021 [internet publication]. https://www.auanet.org/guidelines/guidelines/vesicoureteral-reflux-guideline#x3333

Diet and glucose control is recommended in patients with diabetes mellitus.