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ACUTE PYELONEPHRITIS

Acute pyelonephritis is a potentially organ- and/or lifethreatening infection that characteristically causes scarring of the kidney. An episode of acute pyelonephritis may lead to:

kidney failure;

• abscess
• sepsis • septic •

formation (eg, nephric, perinephric);

shock,

multiorgan system failure.

Pathophysiology
Acute pyelonephritis results from bacterial invasion of the renal parenchyma.
• Bacteria

usually reach the kidney by ascending from the lower urinary tract. all age groups, episodes of bacteriuria occur commonly, but most are asymptomatic and do not lead to infection.

• In

• The

development of infection is influenced by bacterial factors and host factors. • Bacteria may also reach the kidney via the bloodstream Most bacterial data are derived from research with Escherichia coli, which accounts for 70-90% of uncomplicated UTIs and 21-54% of complicated UTIs

Pathogen s • Staphylococcus saprophyticus • • Klebsiella pneumoniae Proteus mirabilis • • • • Enterococci S aureus Pseudomonas aeruginosa Enterobacter species .

Complicated infection Complicated UTI is an infection of the urinary tract in which the efficacy of antibiotics is reduced because of the presence of one or more of the following: • Structural abnormalities of the urinary tract abnormalities of the urinary tract • Functional • Metabolic • Unusual • Recent • Recent abnormalities predisposing to UTIs pathogens antibiotic use urinary tract instrumentation .

obstruction : chronic constipation . cancer). and retroperitoneal mass. • • • Extrinsic . It negates the flushing effect of urine flow. infection. hypertrophy. allows urine to pool (urinary stasis)=>providing bacteria a medium in which to multiply. prostatic swelling/mass (eg. =>changes intrarenal blood flow.• Obstruction • is the most important factor. Obstruction may be extrinsic or intrinsic. affecting neutrophil delivery.

. fungus ball. papillary necrosis. cystocele.5 vs 3. stricture. Atrophic vaginal mucosa in postmenopausal women predisposes to the colonization of urinary tract pathogens and UTIs because of the higher pH (5. Bacterial prostatitis (acute or chronic) produces bacteriuria. and urinary stones.8) and the absence of lactobacilli.Intrinsic obstruction occurs with bladder outlet obstruction.

Pregnancy produces hormonal and mechanical changes that predispose the woman to upper urinary traction infections. with the ureters containing up to 200 mL of urine. Progesterone decreases ureteral peristalsis and increases bladder capacity. • . secondary to both hormonal and mechanical factors. manifests as dilatation of the renal pelvis and ureters (greater on the left than on the right). • Hydroureter of pregnancy.

glucosuria. and nephrosclerosis.Diabetes mellitus produces autonomic bladder neuropathy. microangiopathy. Complicated UTIs in patients who have diabetes mellitus include the following: • Renal and perirenal abscess pyelonephritis cystitis • Emphysematous • Emphysematous • Fungal infections pyelonephritis • Xanthogranulomatous • Papillary necrosis . leukocyte dysfunction.

Enterobacter spp <1 Pseudomonas aeruginosa < 1 Other < 1 6-20 Gram positive Coagulase-negative staphylococci 5-10 Enterococci 1-2 Group B streptococci <1 Staphylococcus aureus < 1 Other <1 % Complicated 21-54 1-10 2-17 5 2-10 2-19 1-4 1-23 1-4 1-23 2 .Bacteria % Uncomplicated Gram negative Escherichia coli 70-95 Proteus mirabilis 1-2 Klebsiella spp 1-2 Citrobacter spp < 1.

of cystitis : urinary frequency. • Symptoms • • Symptoms .History • The classic presentation =triad : fever. symptoms develop over several days and may even be present for a few weeks before the patient seeks medical care. hesitancy. lower abdominal pain. may be minimal to severe and usually develop over hours or over the course of a day. and urgency. costovertebral angle pain. and nausea and/or vomiting.

heaviness. Pain may be : • mild. and radiation of pain to the groin is suggestive of a ureteral stone. or severe unilateral /bilateral. or pressure.Gross hematuria (hemorrhagic cystitis) is present in 30-40% of pyelonephritis cases in females. • in • Upper . most often young women. pain. Gross hematuria is unusual in males and should prompt consideration of a more serious cause. abdominal pain is unusual. Patients may describe suprapubic symptoms as discomfort. • moderate. the back (lower or middle) and/or the suprapubic area.

Diarrhea occurs infrequently. Gastrointestinal symptoms.Fever • is not always present. • . • it is not unusual for the temperature to exceed 103°F (39. • Nausea and vomiting vary in frequency and intensity from absent to severe. • Anorexia is common.4°C).

or they may experience fever. decompensation in another organ system.Elderly patients may present with typical manifestations of pyelonephritis. or generalized deterioration. . mental status change.

Complicated pyelonephritis A history of the following indicates an increased risk of complicated pyelonephritis: • Structural abnormalities of the urinary tract • Functional • Metabolic • Recent • Recent abnormalities of the urinary tract abnormalities predisposing to UTIs antibiotic use urinary tract instrumentation .

Abdominal tenderness other than in the suprapubic area suggests another diagnosis. Flank or costovertebral angle (CVA) tenderness is most commonly unilateral over the involved kidney. although bilateral discomfort may be present. • • • . and bowel sounds are often normally active. Patients usually do not have rigidity or guarding.abdominal examination: • suprapubic tenderness usually ranges from mild to moderate without rebound.

In women: a pelvic examination should be performed. and adnexa should be absent. Tenderness of the cervix. Any positive finding suggests an additional or alternative diagnosis . uterus.

Complications Complications occur more often in patients with diabetes mellitus. chronic renal disease. sickle cell disease. Complications may involve any of the following: • Acute renal failure renal damage leading to hypertension and renal • Chronic failure • Sepsis • Renal syndromes papillary . and other immunocompromised states. AIDS. renal transplant (particularly during the first 3 months).

Differential Diagnoses • Acute Abdomen and Pregnancy Acute Bacterial Prostatitis Appendicitis Cervicitis • • • • • Chronic Bacterial Prostatitis Chronic Pyelonephritis • • • Cystitis in Females Endometritis Pelvic Inflammatory Disease .

Other laboratory studies are used to identify complicating conditions and to assist in determining whether the patient should be admitted. pyelonephritis is usually suggested by the history and physical examination and supported by urinalysis results.Approach Considerations In the outpatient setting. . which should include microscopic analysis. Easily diagnosed cases typically occur in women. both pregnant and nonpregnant.

Collection of Urine Specimens Urine specimens obtained for urinalysis and culture should approximate the urine contained in the bladder as closely as possible. The 3 procedures for collecting such a urine specimen are: • clean catch. • urethral • suprapubic needle aspiration. . catheterization.

The dipstick leukocyte esterase test (LET) helps screen for pyuria. The nitrite production test (NPT) for bacteriuria has 92-100% sensitivity and 35-85% specificity.2% and a specificity of 81%. LET results have a sensitivity of 75-96% and a specificity of 94-98% for detecting more than 10 WBC/hpf. . Combined. Almost all patients with pyelonephritis have significant pyuria (>20 WBCs/hpf).Urinalysis Pyuria is defined as more than 5-10 WBCs per high-power field (hpf) on a specimen spun at 2000 rpm for 5 minutes. which is too low for it to be used as the only screening study for bacteriuria. the LET-NPT has a sensitivity of 79.

Microscopic hematuria may be present in patients with uncomplicated acute pyelonephritis. When it exceeds 3 g/day. When gross hematuria is present. trauma. the differential should include calculi. glomerulonephritis should be considered. tuberculosis. White cell casts are suggestive of pyelonephritis Proteinuria is expected (up to 2 g/day). particularly calculi Microscopic hematuria may be present in patients with uncomplicated acute pyelonephritis.Gross hematuria occurs infrequently with pyelonephritis and is more common with cystitis (hemorrhagic cystitis). . particularly calculi. cancer. but other causes should be considered. glomerulonephritis. but other causes should be considered. and vasculitis.

Urine and Blood Cultures Urine culture is indicated in any patient with pyelonephritis. because of the possibility of antibiotic resistance. Blood cultures are indicated in any patient who is being admitted or who has already been admitted. Approximately 12-20% of patients have cultures that are positive for infection . whether treated in an inpatient or an outpatient setting.

Indications for Imaging Studies Imaging may be required to make the diagnosis in infants and children in whom pyelonephritis presents insidiously. Imaging is warranted at the time of admission in patients with the following conditions: AIDS Poorly controlled diabetes Organ transplant (particularly renal) Other immunocompromised state Sepsis syndrome Septic shock .

Indications for imaging studies are as follows: • Fever or positive blood culture results that persist for longer than 48 hours • Sudden • Toxicity worsening of the patient’s condition persisting for longer than 72 hours UTI • Complicated .

Ultrasonography Ultrasonography (US) can sometimes detect acute pyelonephritis. but a negative study does not exclude the possibility. both in adults and in children with acute pyelonephritis.Computed Tomography Contrast-enhanced helical/spiral computed tomography (CECT) is the imaging study of choice. perinephric fluid. and it can more readily identify alterations in renal parenchymal perfusion. and nonrenal disease. . alterations in contrast excretion. CECT is more sensitive than ultrasonography and intravenous pyelography (which has only 25% sensitivity).

. which was the prior mainstay of urinary tract imaging.CT and MR Urography CT urography and MR urography are evolving modalities that surpass intravenous urography.

antipyretic pain medication.) In addition. . (They must be otherwise healthy and must not be pregnant. they must be treated initially in the emergency department (ED) with vigorous oral or IV fluids.Approach Considerations Ambulatory younger women who present with signs and symptoms of uncomplicated acute pyelonephritis may be candidates for outpatient therapy. and a dose of parenteral antibiotics.

• elderly • who have comorbid disorders that increase the complexity of management or the complication rate (eg. . • pregnant. because of the possibility of poor compliance or poor follow-up. congenital or acquired immunodeficiency). Admission may also be advisable for patients whose social situation is unstable. chronic lung disease.Admission is usually appropriate for : • patients who are severely ill. diabetes mellitus.

. carbapenems.Antibiotic Selection Antibiotic selection is typically empirical. extended-spectrum penicillins. Initial selection should be guided by local antibiotic resistance patterns. cephalosporins. Culture results from specimens collected before the initiation of therapy should be checked in 48 hours to determine antibiotic efficacy. E coli or other Enterobacteriaceae => Acceptable regimens may include fluoroquinolones. and aminoglycosides. coverage of both Enterobacteriaceae and enterococci is acceptable. because the results of blood or urine cultures are rarely available by the time a decision must be made. penicillins. If any doubt exists as to the diagnosis. enterococci => ampicillin or vancomycin can replace the fluoroquinolone.

Complete the course of therapy with an oral agent selected on the basis of culture results Acceptable regimens include the following: Ampicillin and an aminoglycoside Cefepime Imipenem Meropenem Piperacillin-tazobactam Ticarcillin-clavulanate .Regimens for complicated cases With complicated acute pyelonephritis. treat patients parenterally until defervescence and improvement in the clinic condition warrants changing to oral antibiotics.

provided they are monitored within the first 48 hours. .Outpatient Treatment Antibiotic therapy Patients presenting with acute pyelonephritis can be treated with a single dose of a parenteral antibiotic followed by oral therapy.

First-line therapy ciprofloxacin (Cipro) 500 mg PO BID for 7d or ciprofloxacin extended-release (Cipro XR) 1000 mg PO dai for 7d or levofloxacin (Levaquin) 750 mg PO daily for 5d If fluoroquinolone resistance is thought to be >10%. administe a single dose of ceftriaxone (Rocephin) 1g IV or a consolidate 24-hour dose of an aminoglycoside (gentamicin 7 mg/kg IV or tobramycin 7 mg/kg IV or amikacin 20 mg/kg IV) cefaclor 500 mg PO TID for 7d .

Second-line therapy trimethoprim/sulfamethoxazole* 160 mg/800 mg (Bactrim DS. Septra DS) 1 tablet PO BID for 14d If trimethoprim/sulfamethoxazole is used when the susceptibility is not known. an initial single IV dose of the following may also be given: ceftriaxone (Rocephin) 1 g IV or a consolidated 24-h dose of an aminoglycoside (gentamicin 7 mg/kg IV or tobramycin 7 mg/kg IV or amikacin 20 mg/kg IV) .

however.Alternative therapy Oral beta-lactams are not as effective for treating pyelonephritis. if they are used. administer with a single dose of ceftriaxone (Rocephin) 1 g IV or a consolidated 24-h dose of an aminoglycoside (gentamicin 7 mg/kg IV or tobramycin 7 mg/kg IV or amikacin 20 mg/kg IV) amoxicillin-clavulanate (Augmentin) 500 mg/125 mg PO BID for 14d or amoxicillin-clavulanate (Augmentin) 250 mg/125 mg PO TID for 3-7d or cefaclor 500 mg PO TID for 7d .