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Curse of stone

First pbl of last module.


Treatment and management.

★ Analgesic-to relieve loin pain


★ Hydration -with IV fluifds
★ Antiobiotics to treat Acute
pyelonephritis
★ Ureteric stenting to relieve obstruction
★ Nephrolithotripsy
Treatment and management.

AIM of antibiotic treatment.

❏ Treatment regimen chosen should have a very high likelihood of eradicating the causative
organism (commonly E.coli) and should reach therapeutic blood levels quickly since since
Pyelonephritis is tissue invasive disease.
❏ Outpatient treatment is appropriate for most patients. Inpatient therapy is recommended for
patients who have severe illness or in whom a complication is suspected.
Basically ….

❏ Practice guidelines recommend oral fluoroquinolones as initial outpatient therapy if the rate of
fluoroquinolone resistance in the community is 10 percent or less.
❏ If the resistance rate exceeds 10 percent, an initial intravenous dose of ceftriaxone or gentamicin
should be given, followed by an oral fluoroquinolone regimen.
❏ Oral beta-lactam antibiotics and trimethoprim/sulfamethoxazole are generally inappropriate for
outpatient therapy because of high resistance rates.
❏ Several antibiotic regimens can be used for inpatient treatment, including fluoroquinolones,
aminoglycosides, and cephalosporins.
Empiric Outpatient
● Empiric, initial, oral, outpatient treatment: if local rates of E. coli fluoroquinolone resistance are low
(< 10%):
○ Ciprofloxacin 500 mg PO twice daily x 7 d
○ Ciprofloxacin extended release 1000 mg PO x 7 d
○ Levofloxacin 750 mg orally x 5-7 d
● Consider an initial dose of a parenteral agent, particularly if fluoroquinolone resistance is >10%.
Then complete treatment as guided by antimicrobial sensitivity results.
○ Ceftriaxone 1 gm IM or IV x 1
○ Gentamicin 5 mg/kg IM or IV x 1
○ Ciprofloxacin 400 mg IV x 1
Empiric Inpatient
● Use local antibiotic susceptibility data to guide initial empiric therapy.
○ Ciprofloxacin 400 mg IV q12h (if local fluoroquinolone resistance rates < 10%)
○ Levofloxacin 500 mg IV once daily (if local fluoroquinolone resistance rates < 10%)
○ Ceftriaxone 1 g IV once daily (with or without an aminoglycoside, e.g., gentamicin 5 mg/kg IV daily)
○ Gentamicin 5 mg/kg IV once daily (with or without ampicillin 2 grams IV q4h)
○ Tobramycin 5 mg/kg IV once daily (with or without ampicillin 2 grams IV q4h)
○ Piperacillin/tazobactam 3.375 g IV q6h (with or without an aminoglycoside, e.g., gentamicin 5
mg/kg IV daily)
○ Meropenem 2 grams IV q8h
● Duration: typically 48h parenteral therapy or until afebrile, then switch to oral therapy based upon
susceptibility data to complete 7d (fluoroquinolone) or 14d (TMP-SMX) course.
Pathogen 1st Line Agent 2nd Line Agent
Enterobacteriaceae including Outpatient Regimens: Outpatient
Escherichia coli Ciprofloxacin Regimens:
Levofloxacin TMP/SMX
Cephalexin
Cefpodoxime
Cefixime
Ceftriaxone
Gentamicin
Enterobacteriaceae including Inpatient regimen (until afebrile x 48h, then outpatient
Escherichia coli regimen)
Ciprofloxacin
Levofloxacin
Gentamicin ± ampicillin
Tobramycin ± ampicillin
Ceftriaxone ± gentamicin
Staphylococcus saprophyticus Outpatient regimens: Outpatient
Ciprofloxacin regimens:
Levofloxacin Amoxicillin/clavulan
Inpatient regimens (Give IV until afebrile X 48h, then PO for ate
total 14d):
Ciprofloxacin
Levofloxacin
Ceftriaxone ± gentamicin
FLUOROQUINOLONES
FLUOROQUINOLONE-CIPROFLOXACIN
CEPHALOSPORINS
SERUM SICKNESS
AMINOGLYCOSIDES
URETERIC STENT.
Treatment: Nephrolithiasis.
● Medical therapy can enhance passage of ureteral stones. Oral 1-adrenergic blockers relax ureteral muscle
and have been shown to reduce time to stone passage and the need for surgical removal of small stones.

● There are now three alternatives for stone removal.

● Extracorporeal lithotripsy causes the in situ fragmentation of stones in the kidney, renal pelvis, or ureter
by exposing them to shock waves. After multiple shock waves, most stones are reduced to powder that
moves through the ureter into the bladder.

● Percutaneous nephrolithotomy requires the passage of a nephroscope into the renal pelvis through a
small incision in the flank. Stones are then disrupted by a small ultrasound transducer or holmium laser.

● The third method is ureteroscopy with stone disruption using a holmium laser. Ureteroscopy generally is
used for stones in the ureter, but some surgeons are now using ureteroscopy for stones in the renal pelvis
as well.
Loin refers to the side of the human body below the rib
Definition of loin, cage to just above the pelvis.

surface anatomy It is frequently used as reference to the general area

and organ involved


below the ribs.

The lumbar region of the spinal column is located in


the loin area of the body
Right lumbar region; Gallbladder, Liver, Right colon (Ascending), Right kidney
Left lumbar region; Left colon (Descending), Left kidney

Region of the loin


9. Causes of renal calculi
Kidney stones form when there is a decrease in
urine volume and/or an excess of stone-forming
substances in the urine.

● Genetic Heritability
● Disease-Related Contributors
● Environmental Contributors
● Anatomical Abnormalities
● Medication Contributors
● Genetic heritability ● Anatomic
Approximately 40 percent of people who form
kidney stones have a positive family history for
stones.
abnormalities
- Hypercalciuria (the presence of excessive
● Benign prostatic hypertrophy
amounts of calcium in the urine)
● Calyceal diverticulum
● Horseshoe kidney: With a horseshoe kidney, the two
- Hypocitraturia (too little citrate in the
kidneys are actually fused together, giving it a
urine)
horseshoe-like appearance.
● Hydronephrotic renal pelvis or calices
- Primary hyperoxaluria (type I and type
● Medullary sponge kidney (tubular ectasia): This is
II) is caused by a defect in liver enzyme
the most common anatomic abnormality seen in
originating from a gene mutation passed on
patients with calcium-containing stones.
genetically.
● Ureterocele
● Ureteropelvic junction (UPJ) obstruction
- Cystinuria is a rare inherited disease that
● Uretheral stricture
results in the formation of stones made of an
● Urinary tract obstruction: Obstruction of the urinary
amino acid called cystine.
tract leads to urinary stasis, urine supersaturation and
stone formation
● Vesicoureteral reflux
● Medications
● Environmental ● Decongestants

● Diuretics: Diuretics that increase urination are associated


with increased risk for calcium stones in a small number of
- Physical activity
individuals who take them because they can increase the
● Very active
calcium concentration of urine.
● Very inactive
● Protease inhibitors: Indinavir sulfate, a protease inhibitor
- Work environment used to increase CD4+ cell counts and to decrease HIV-RNA
titers in patients with HIV and AIDS, significantly increases
- Nutrition the risk for stones made of indinavir.

● Lack of fluids ● Anticonvulsants: Felbamate, topiramate and zonisamide


● Too much sodium increase stone risk.
● Too much meat from beef, pork,
poultry, fish, and seafood ● Steroids: Long-term corticosteroid use can increase enteric
absorption of calcium, leading to hypercalciuria and an
● Too little or too much calcium
increased risk for calcium-containing stones.
● Too much oxalate absorbed
● Too few fruits and vegetables ● Chemotherapeutic agents: Certain cancer chemotherapies
● Too much sugar lead to cell breakdown and can cause uric acid stones.

- Body mass ● Uricosuric agents: Cause hyperuricosuria and thus increase


the risk for uric acid as well as calcium stones.
● Disease-related
Risk factors of renal Sign & Symptoms
calculi
Risk factors that can be controlled: ● severe pain is called renal colic - radiates to the lower
abdomen and groin
● dehydration. ● blood in the urine (red, pink, or brown urine)
● obesity ● vomiting
● high-protein, salt, or glucose diet ● nausea
● taking medications such as diuretics, anti-seizure drugs, ● discolored or foul-smelling urine
and calcium-based antacids ● chills
● fever
Risk factors that can’t be controlled :
● frequent need to urinate
● Age and gender.
● urinating small amounts of urine
-Men between the ages of 30 and 50 are most likely to
● dysuria (pain when you urinate)
get kidney stones.
-Postmenopausal women with low estrogen levels have
an increased risk for kidney stones. Women who have
Symptoms usually occur if the kidney stone:
had their ovaries removed are also at increased risk.
● A family history of kidney stones.
● A personal history of frequent urinary tract infections. ● gets stuck in your kidney
● Genetic diseases ● starts to travel down the ureter (the tube that attaches each
● Ethnicity. Among Americans, Caucasians have the kidney to the bladder) – the ureter is narrow and kidney stones
highest incidence of kidney stones, followed by can cause pain as they try to pass through
Mexican-Americans. African-Americans have the lowest ● causes an infection
risk.