How should I manage a patient with recurrent pyelonephritis, and what preventive measures are recommended?

Management of recurrent pyelonephritis:

• Ensure any acute infection is adequately treated with appropriate antibiotics based on culture and susceptibility results.
• Refer patients, especially children, with recurrent pyelonephritis for specialist assessment and investigations to identify underlying causes.
• Consider a trial of daily antibiotic prophylaxis if behavioural and hygiene measures are insufficient, tailoring antibiotic choice to local resistance patterns and previous sensitivities; preferred agents include trimethoprim and nitrofurantoin (if renal function allows), with cefalexin or amoxicillin as second-line options.
• Advise patients about the risks of long-term antibiotic use, including resistance and adverse effects, and arrange review within 6 months.
• For children, arrange urinary tract imaging such as ultrasound during or shortly after infection and a DMSA scan 4–6 months post-infection to detect renal scarring.
• Encourage behavioural and personal hygiene measures to reduce recurrence risk.
• In women, consider methenamine hippurate as an alternative to daily antibiotic prophylaxis if appropriate and after specialist advice.

Preventive measures:

• Promote adequate hydration and timely voiding to reduce infection risk.
• Manage any underlying conditions such as dysfunctional elimination syndromes or constipation in children.
• Provide education on symptom recognition and prompt treatment seeking for acute UTI symptoms.
• Review and adjust prophylaxis regularly, considering antibiotic rotation and patient preferences.