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Pyelonephritis

Definition

Pyelonephritis is an infection of the kidney and the ureters, the ducts that carry urine
away from the kidney.

Alternative Names

Urinary tract infection - complicated; Infection - kidney; Complicated urinary tract
infection; Kidney infection

Causes

Pyelonephritis most often occurs as a result of urinary tract infection , particularly when
there is occasional or persistent backflow of urine from the bladder into the ureters or an
area called the kidney pelvis. See: Vesicoureteric reflux

Pyelonephritis can be sudden (acute) or long-term (chronic).

• Acute uncomplicated pyelonephritis is the sudden development of kidney
inflammation.
• Chronic pyelonephritis is a long-standing infection that does not go away.

Pyelonephritis occurs much less often than a bladder infection, although a history of such
an infection increases your risk. You're also at increased risk for a kidney infection if you
have any of the following conditions:

• Backflow of urine into the ureters or kidney pelvis
• Kidney stones
• Ostructive uropathy
• Renal papillary necrosis

You are also more likely to get a kidney infection if you have a history of chronic or
recurrent urinary tract infection , especially if the infection is caused by a particularly
aggressive type of bacteria.

Acute pyelonephritis can be severe in the elderly and in people who are
immunosuppressed (for example, those with cancer or AIDS ).

Symptoms

• Back pain orflank pain
• Chills with shaking
• Severe abdominal pain (occurs occasionally)

• Other urine tests may show bacteria in the urine. These tests can also help rule out underlying disorders. Additional tests and procedures that may be done include: • Kidney biopsy • Kidney scan • Kidney ultrasound • Voiding cystourethrogram Treatment The goals of treatment are to: . • Urinalysis commonly reveals white or red blood cells in the urine. • Fatigue • Fever o Higher than 102 degrees Fahrenheit o Persists for more than 2 days • General ill feeling • Chills with shaking • Mental changes or confusion* • Skin changes o Flushed or reddened skin o Moist skin (diaphoresis ) o Warm skin • Urination problems o Blood in the urine o Cloudy or abnormal urine color o Foul or strong urine odor o Increased urinary frequency or urgency o Need to urinate at night (nocturia) o Painful urination • Vomiting. • Blood culture may show an infection. An intravenous pyelogram (IVP) or CT scan of the abdomen may show swollen kidneys. Exams and Tests A physical exam may show tenderness when the health care provider presses (palpates ) the area of the kidney. nausea * Mental changes or confusion may be the only signs of a urinary tract infection in the elderly.

However. Severe episodes of acute kidney injury may result in permanent kidney damage and lead to chronic kidney disease. and persons with a weakened immune system have an increased risk for developing shock and a severe blood infection called sepsis . In rare cases. Commonly used antibiotics include the following: • Amoxicillin • Cephalosporin • Levofloxacin and ciprofloxacin • Sulfa drugs such as sulfisoxazole/trimethoprim Outlook (Prognosis) With treatment. It is very important that you finish all the medicine. Sudden (acute) symptoms usually go away within 48 to 72 hours after appropriate treatment. Pregnant women and persons with diabetes or spinal paralysis should have a urine culture after finishing antibiotic therapy to make sure that the bacteria are no longer present in the urine. the treatment may need to be aggressive or prolonged. prompt treatment is recommended. you may receive a 10. . Often. The elderly.to 14-day course of antibiotics. Chronic pyelonephritis may require long-term antibiotic therapy. most kidney infections get better without complications. you may be given antibiotics through a vein (intravenously) at first. such patients will be admitted to the hospital for frequent monitoring and IV antibiotics. IV fluids. In acute cases. permanent kidney damage can result when: • Chronic kidney infections occur in a transplanted kidney • Many kidney infections occur during infancy or childhood Acute kidney injury (acute renal failure) may occur if a severe infection leads to significantly low blood pressure (shock). and other medications as necessary. infants. If you have a severe infection or cannot take antibiotics by mouth. Your doctor will select the appropriate antibiotics after a urine culture identifies the bacteria that is causing the infection. • Control the infection • Relieve symptoms Due to the high death rate in the elderly population and the risk of complications.

Call your health care provider if you have been diagnosed with this condition and new symptoms develop. • Urinating immediately after sexual intercourse. . You can help preventing kidney infections by taking the following steps: • Keep the genital area clean. Wiping from front to back helps reduce the chance of introducing bacteria from the rectal area to the urethra.Possible Complications • Acute kidney failure • Kidney infection returns • Infection around the kidney (perinephric abscess) • Severe blood infection (sepsis) When to Contact a Medical Professional Call your health care provider if you have symptoms of pyelonephritis. • Drink more fluids (64 to 128 ounces per day). Doing so prevents certain types of bacteria from attaching to the wall of the bladder and may lessen your chance of infection. Chronic or recurrent urinary tract infection should be treated thoroughly. • Drink cranberry juice. This encourages frequent urination and flushes bacteria from the bladder. especially: • Decreased urine output • Persistent high fever • Severe flank pain or back pain Prevention Prompt and complete treatment of bladder infections may prevent development of many cases of pyelonephritis. This may help eliminate any bacteria that may have been introduced during sexual activity.

(See "Xanthogranulomatous pyelonephritis" and "Presentation. a pelvic examination should be performed to distinguish pelvic inflammatory disease from acute uncomplicated pyelonephritis.8ºC). Pregnancy testing is also appropriate. (See 'Acute complicated pyelonephritis' below. multiple organ system dysfunction. vomiting. physical examination. (See "Clinical features and diagnosis of pelvic inflammatory disease". Affected patients can present with weeks to months of insidious symptoms. and laboratory evaluation. fever (≥37. young women and must be distinguished from acute complicated pyelonephritis and from chronic pyelonephritis: * Acute complicated pyelonephritis is progression of upper urinary tract infection to emphysematous pyelonephritis.) A urinalysis should be performed to evaluate for pyuria. shock. The microbiology and pathogenesis of acute pyelonephritis are discussed separately. Fever has been strongly correlated with the diagnosis of acute pyelonephritis. patients with clinical manifestations of acute pyelonephritis in the absence of fever should be evaluated for alternative diagnoses [2]. Symptoms of cystitis may or may not be present [3]. The absence of pyuria strongly suggests an alternative diagnosis or the presence of an obstructing lesion [4].) ACUTE UNCOMPLICATED PYELONEPHRITIS Clinical manifestations — The clinical manifestations of acute uncomplicated pyelonephritis include flank pain. the presentation may mimic pelvic inflammatory disease. which is present in virtually all patients with acute pyelonephritis. In some cases. Acute uncomplicated pyelonephritis typically occurs in healthy. diagnosis. such as infection in association with a chronically obstructing kidney stone (possibly producing xanthogranulomatous pyelonephritis) or vesicoureteral reflux. patients with acute pyelonephritis present with sepsis. and clinical course of vesicoureteral reflux". Other urinalysis parameters lack adequate sensitivity for evaluation . Most episodes of acute pyelonephritis are uncomplicated but hospitalization may be required [1]. The physical examination should focus on vital signs and evaluation of the abdomen. pelvis. and/or acute renal failure. and the costovertebral angles.) * Chronic pyelonephritis is an uncommon cause of chronic tubulointerstitial disease due to recurrent infection. perinephric abscess. diagnosis. (See "Microbiology and pathogenesis of acute pyelonephritis".) The clinical features. and treatment of acute uncomplicated and complicated pyelonephritis will be reviewed here. thus. Rarely. or papillary necrosis. Diagnosis — The diagnosis of acute uncomplicated pyelonephritis can usually be made from the history. nausea. and/or costovertebral angle tenderness. White cell casts indicate a renal origin for the pyuria. abdominal or pelvic pain.RODUCTION — Acute pyelonephritis is a urinary tract infection that has progressed from the lower urinary tract to the upper urinary tract. In the setting of vaginal symptoms or poorly localized tenderness. renal corticomedullary abscess.

7 percent of isolates in women and 6. has a sensitivity of 35 to 80 percent.2 percent in men. although some patients with pyelonephritis have colony counts of 10(3) to 10(4) CFU per mL [5].) Treatment — Initial treatment includes supportive care and initiation of empiric antibiotic therapy. (See "Radiologic evaluation in acute pyelonephritis". Empiric antibiotics — Empiric antibiotic selection should be guided by knowledge of the epidemiology of antimicrobial susceptibility when available.) Urine gram stain may be helpful for rapid preliminary diagnostic purposes and for guiding the choice of empiric therapy pending culture results. Nitrite testing. some clinicians consider a colony count of ≥10(2) CFU per mL sufficient for diagnosis of pyelonephritis. such as enterococci and staphylococci. Inpatient management is appropriate in the following circumstances: * Severe illness with high fevers. pain. In a report of over 2700 uropathogens isolated from patients with acute pyelonephritis. for example. Escherichia coli accounted for about 82 percent of isolates in women and about 73 percent in men [6]. Klebsiella pneumoniae was next in frequency.of pyelonephritis. The lower colony counts are extrapolated from studies of cystitis but have not been systematically evaluated in the setting of pyelonephritis. and marked debility * Inability to maintain oral hydration or take oral medications * Pregnancy * Concerns about patient compliance Outpatient management is safe and effective for patients with mild to moderate illness who can be stabilized with rehydration and antibiotics in an outpatient facility and discharged on oral antibiotics under close supervision. Staphylococcus saprophyticus accounted for less than 3 percent of isolates. Up to 95 percent of episodes of pyelonephritis are associated with >10(5) CFU per mL of organisms.) Microbiology — Escherichia coli is the most common cause of acute pyelonephritis. it is not useful for detecting presence of organisms unable to reduce nitrate to nitrite. If the urine sample for culture is obtained through a newly-inserted catheter. a 12 hour observation period with parenteral antibiotic therapy. In an emergency department report of 44 patients with pyelonephritis. (See "Urine sampling and culture in the diagnosis of urinary tract infection in adults". (See "Microbiology and pathogenesis of acute pyelonephritis". Urine culture and antimicrobial susceptibility testing of uropathogens should be performed in the setting of acute pyelonephritis. followed by completion of outpatient oral antibiotics was effective management for 97 percent of patients [7]. since rates of antibiotic . for example. accounting for 2. Imaging studies are not routinely required for diagnosis of acute uncomplicated pyelonephritis but can be helpful in certain circumstances.

10]. Cefpodoxime (200 mg orally twice daily) or cefixime (400 mg orally once daily) may also be effective for the treatment of acute uncomplicated pyelonephritis. Oral antibiotics — We favor an oral fluoroquinolone such as levofloxacin (500 to 750 mg orally once daily) or ciprofloxacin (500 mg orally twice daily) for initial empiric treatment of acute pyelonephritis (table 1) [11. or trimethoprim (200 mg orally once daily) can be used if the infecting strain is known to be susceptible. the prevalence of resistance to trimethoprim-sulfamethoxazole rose from 9 to 18 percent over a five year period [8]. there was a decrease in trimethoprim-sulfamethoxazole resistance together with an increase in the rate of ciprofloxacin resistance (24 to 13 percent and 1. coli isolates from over 3200 patients in the late 1990s. Among E.7 to 3. and risk stratification cannot reliably predict patients at for infection with resistant organisms [9. In comparison. resistance to ciprofloxacin and aminoglycosides was very low. Ampicillin and sulfonamides should not be used for empiric therapy because of the high rate of resistance among causative pathogens. The newer fluoroquinolone moxifloxacin should be avoided because of uncertainty regarding effective concentrations in urine. respectively) [6]. Patients with penicillin allergy may be treated with a fluoroquinolone.resistance fluctuate with patterns of antibiotic use in the community. Trimethoprim-sulfamethoxazole (1 double strength tablet orally twice daily). respectively). Parenteral antibiotics — We favor ceftriaxone or fluoroquinolones (in areas where fluoroquinolone resistance is relatively low) for initial empiric treatment of hospitalized patients with acute uncomplicated pyelonephritis (table 2). Recent antibiotic use should be considered in the selection of an empiric regimen pending culture and susceptibility data. In a report of 4342 urine isolates from patients with cystitis in the mid 1990s. Patients with fluoroquinolone resistance may be treated with ceftriaxone. Paitents unable to take beta- lactam or fluoroquinolone agents (due to hypersensitivity and/or resistance) may be treated with aztreonam (1 g IV every 8 to 12 hours). However. Cefixime likely has limited activity against S. Risk for pyelonephritis due to an organism resistance to trimethoprim-sulfamethoxazole or fluoroquinolones appears to vary substantially by region.12]. . although published data are limited. Some clinicians favor fluoroquinolones over ceftriaxone given their excellent genitourinary penetration. saprophyticus.4 percent. a subsequent study in this region demonstrated that antibiotic resistance trends had reversed [6]. saprophyticus should be suspected and amoxicillin (500 mg orally three times daily or 875 mg orally twice daily) should be added to the treatment regimen until the causative organism is identified. enterococcus or S. These changes paralleled a reduction in the use of trimethoprim-sulfamethoxazole and an increase in the use of a fluoroquinolone for management of outpatient urinary tract infections (53 to 32 percent and 35 to 61 percent. If gram-positive cocci are observed on Gram stain.

radiographic studies should be performed to evaluate for complicated pyelonephritis. We favor a 7-day course of antibiotics for mild to moderately ill patients with a prompt response to treatment and with infecting strains that are susceptible to the chosen antibiotic [11]: * In a study of 255 women with uncomplicated pyelonephritis comparing a 7-day course of ciprofloxacin to a 14-day course of trimethoprim-sulfamethoxazole. In addition. * A five-day course of oral levofloxacin 750 mg once daily was as effective as a ten- day course of ciprofloxacin [15]. (See 'Acute complicated pyelonephritis' below. Persistent symptoms — Patients with persistent clinical symptoms on antibiotic therapy should be evaluated for complicated pyelonephritis with radiographic imaging and additional laboratory investigation. patients treated with ciprofloxacin had a more favorable clinical cure rate than those treated with trimethoprim-sulfamethoxazole (96 versus 83 percent ) [14]. although follow-up urine cultures are not needed in patients with acute pyelonephritis whose symptoms resolve on antibiotics. Imaging — Patients with persistent fever or clinical symptoms after 48 to 72 hours of appropriate antimicrobial therapy for uncomplicated pyelonephritis should undergo radiologic evaluation of the upper urinary tract with ultrasound or computed tomography (CT) scan. beta lactam regimens should be administered for a full 14-day course given failure rates with a shorter duration of therapy [16]. If the pathogen isolated is the same isolate as in the initial episode with the same susceptibility profile. a repeat course of treatment with another antibiotic agent should be instituted. Resolution of radiographic hypodensities may . These modalities are useful for evaluating obstruction.Routine follow-up management — Patients initially treated with parenteral therapy who improve clinically and can tolerate oral fluids may transition to oral antibiotic therapy. The duration of antibiotic therapy need not be extended in the setting of bacteremia in the absence of other complicating factors. Surveillance blood cultures to demonstrate clearance of bacteremia are appropriate. there is no evidence that bacteremia portends a worse prognosis [13]. and the modes of delivery are equally effective clinically [13]. abscess. even in the absence of evidence for complicated disease. Patients with recurrent symptoms within a few weeks of treatment for pyelonephritis should have repeat urine culture and antimicrobial susceptibility testing. This levofloxacin regimen has FDA approval for uncomplicated pyelonephritis only and is not appropriate for complicated pyelonephritis. Fluoroquinolone serum levels achieved with oral and intravenous dosing are equivalent. However.) Patients with delayed response to therapy should receive a longer course of antibiotics (14 to 21 days). or other complications of pyelonephritis [17-19].

Risk factors for progression to complicated pyelonephritis include urinary tract obstruction. Antibiotics alone may not be successful unless such underlying conditions are corrected. (See "Radiologic evaluation in acute pyelonephritis". Transitioning to . (See "Xanthogranulomatous pyelonephritis". and fungi account for a higher proportion in complicated than uncomplicated pyelonephritis [21]. Underlying urinary tract anatomic or functional abnormalities (such as obstruction or neurogenic bladder) should be addressed in consultation with an urologist [21]. emphysematous pyelonephritis. Patients with complicated pyelonephritis due to urolithiasis may present with renal colic and gross or microscopic hematuria. or abdominal pain. urologic dysfunction. Pseudomonas aeruginosa.) Clinical manifestations — In addition to the clinical manifestations of uncomplicated pyelonephritis discussed above. complicated pyelonephritis may be associated with weeks to months of insidious. or papillary necrosis. coli is the most common cause of complicated pyelonephritis. Enterobacter sp.) Diagnosis — Acute complicated pyelonephritis is associated with pyuria and bacteriuria. These findings should prompt consideration of xanthogranulomatous pyelonephritis. (See "Renal and perinephric abscess" and "Emphysematous urinary tract infections". Microbiology — E. Parameters for interpretation of urine colony counts are as outlined above for acute uncomplicated pyelonephritis (see 'Diagnosis' above. Other pathogens including Citrobacter sp. nonspecific signs and symptoms such as malaise. enterococci. Broad-spectrum parenteral antibiotics should be used for empiric treatment of complicated pyelonephritis as outlined in the Table (table 2). although these findings may be absent if the infection does not communicate with the collecting system or if the collecting system is obstructed. a variant of chronic pyelonephritis that may be confused with renal cell carcinoma. perinephric abscess. Staphylococcus aureus. fatigue.lag behind clinical improvement by up to three months [20]. (See "Microbiology and pathogenesis of acute pyelonephritis". antibiotic resistant pathogen(s). saprophyticus is an uncommon cause of complicated UTI. nausea. Antimicrobial therapy subsequently must be tailored to individual patient circumstances with consideration of the results of susceptibility testing and prior recent antibiotic therapy. S.) ACUTE COMPLICATED PYELONEPHRITIS — Complicated pyelonephritis is progression of upper urinary tract infection to renal corticomedullary abscess.) Treatment — Patients with complicated pyelonephritis should be managed initially as inpatients. Urine culture with antimicrobial susceptibility testing should be performed. and diabetes (particularly for emphysematous pyelonephritis and papillary necrosis) (table 3).

It is frequently associated with an underlying condition such as obstruction. (See 'Clinical manifestations' above.) * Clinical manifestations of pyelonephritis include flank pain. or to refer patients to our public web site. urologic dysfunction. The five- day regimen of levofloxacin 750 mg once daily has FDA approval for uncomplicated pyelonephritis only and is not appropriate for complicated pyelonephritis. although some patients with pyelonephritis have colony counts of 10(3) to 10(4) CFU per mL. (See 'Acute uncomplicated pyelonephritis' above.) We encourage you to print or e-mail this topic review. fever (≥37. although a longer duration of therapy may be warranted for patients with underlying complicating factors. (See 'Diagnosis' above.oral antibiotic therapy is as outlined above for acute uncomplicated pyelonephritis (table 1) and (see "Renal and perinephric abscess") and "(see 'Routine follow-up management' above.) * For patients unable to tolerate oral antibiotics. SUMMARY AND RECOMMENDATIONS * Acute uncomplicated pyelonephritis is a urinary tract infection that has progressed from the lower urinary tract to the upper urinary tract.uptodate. (See 'Parenteral antibiotics' above. we suggest intravenous ceftriaxone or a fluoroquinolone for initial empiric parenteral treatment of acute uncomplicated pyelonephritis (table 2) (Grade 2B). which includes this and other topics. urine culture and antimicrobial susceptibility testing.) . nausea. Most episodes of pyelonephritis are associated with >10(5) CFU per mL of organisms. or infection with an antibiotic-resistant pathogen. we suggest an oral fluoroquinolone for initial empiric treatment of acute uncomplicated pyelonephritis (table 1) (Grade 2B). perinephric abscess. (See "Urinary tract infections and asymptomatic bacteriuria in pregnancy".com/patients.) * Acute complicated pyelonephritis is progression of acute pyelonephritis to emphysematous pyelonephritis.8ºC) and/or costovertebral angle tenderness. diabetes.) * Laboratory evaluation should include urinalysis (to evaluate for pyuria). (See 'Acute complicated pyelonephritis' above. PREGNANCY — Acute pyelonephritis in pregnant women is discussed separately. (See 'Oral antibiotics' above.) INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients.) * For patients able to tolerate oral antibiotics. www. Antibiotics should be administered for at least 10 to 14 days. renal corticomedullary abscess. or papillary necrosis. (See "Patient information: Kidney infection (pyelonephritis)". vomiting.

or other complications of pyelonephritis.) * Imaging (ultrasonography or computed tomography) is warranted in the setting of persistent fever or clinical symptoms after 48 to 72 hours of appropriate antimicrobial therapy to evaluate for obstruction. * For patients with complicated pyelonephritis. (See 'Imaging' above. we suggest broad-spectrum parenteral antibiotics as outlined in the Table (table 2) (Grade 2B).) . (See 'Routine follow-up management' above. * Subsequent choice and duration of antibiotic therapy must be tailored to antimicrobial susceptibility findings and clinical circumstances. abscess.

which is an upper tract infection. one may encounter few specific symptoms. After the neonatal period.Background Urinary tract infections (UTIs) are relatively common infections in children. usually bowel flora. Pathophysiology UTIs are generally ascending in origin and caused by perineal contaminants. Older children are most likely to have symptoms attributable to the urinary tract. . such as renal scarring. Host genetic factors that promote inflammation contribute to renal scarring. Vesicoureteral reflux (VUR) has been reported in as many as 33% of children with acute pyelonephritis. and renal failure. Interleukin (IL)-8 and CXCR1 polymorphisms. in neonates. hypertension. scarring. Some causes of these conditions include infrequent voiding. incomplete voiding. bacteremia is generally not the source of infection. obstruction or other urinary tract abnormalities. Differentiating cystitis from pyelonephritis in the pediatric patient may be difficult and sometimes impossible. infection is assumed to be hematogenous in origin rather than ascending. if severe. Findings on nuclear renal scans suggest that the vast majority of infants and young children with febrile UTIs have acute pyelonephritis (APN). ACE insertion/deletion (ACE I/D) gene polymorphism. Even in the absence of urinary tract abnormalities. Early recognition and prompt treatment of UTIs is important to prevent late sequelae. cystitis may result in VUR or worsen preexisting VUR and lead to pyelonephritis. Cystitis (lower-tract infection) is characterized by voiding-related symptoms with or without fever and often without other systemic signs. This feature may explain the nonspecific symptoms associated with UTI in these patients. and tumor necrosis factor-[alpha] polymorphism have been identified as potential mediators to tissue fibrosis and subsequent renal scarring following acute pyelonephritis. Febrile UTI should be assumed to be pyelonephritis and treated accordingly. Bacterial colonization of the bladder is most likely to develop into infection if urinary stasis or low-flow conditions are present. However. and. rather. chronic renal failure. Chronic or recurrent pyelonephritis results in renal damage. UTI or pyelonephritis is the cause of the bacteremia. When assessing the pediatric patient with UTI.