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; formation (eg, nephric, perinephric);

abscess sepsis

septic

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

is the most important factor.

It negates the flushing effect of urine flow; allows urine to pool (urinary stasis)=>providing bacteria a medium in which to multiply; =>changes intrarenal blood flow, affecting neutrophil delivery. Obstruction may be extrinsic or intrinsic.

Extrinsic

obstruction : chronic constipation , prostatic swelling/mass (eg, hypertrophy, infection, cancer), and retroperitoneal mass.

Intrinsic obstruction occurs with bladder outlet obstruction, cystocele, fungus ball, papillary necrosis, stricture, and urinary stones. Atrophic vaginal mucosa in postmenopausal women predisposes to the colonization of urinary tract pathogens and UTIs because of the higher pH (5.5 vs 3.8) and the absence of lactobacilli. Bacterial prostatitis (acute or chronic) produces bacteriuria,

Pregnancy produces hormonal and mechanical changes that predispose the woman to upper urinary traction infections.

Hydroureter of pregnancy, secondary to both hormonal and mechanical factors, manifests as dilatation of the renal pelvis and ureters (greater on the left than on the right), with the ureters containing up to 200 mL of urine.
Progesterone decreases ureteral peristalsis and increases bladder capacity.

Diabetes mellitus produces autonomic bladder neuropathy, glucosuria, leukocyte dysfunction, microangiopathy, and nephrosclerosis. 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

Bacteria % Uncomplicated Gram negative Escherichia coli 70-95 Proteus mirabilis 1-2 Klebsiella spp 1-2 Citrobacter spp < 1. 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

History

The

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

Symptoms

Symptoms

Gross hematuria (hemorrhagic cystitis) is present in 30-40% of pyelonephritis cases in females, most often young women. Gross hematuria is unusual in males and should prompt consideration of a more serious cause.
Pain may be :
mild,

moderate, or severe

unilateral /bilateral. the back (lower or middle) and/or the suprapubic area. Patients may describe suprapubic symptoms as discomfort, heaviness, pain, or pressure. abdominal pain is unusual, and radiation of pain to the groin is suggestive of a ureteral stone.

in

Upper

Fever

is not always present. is not unusual for the temperature to exceed 103F (39.4C).

it

Gastrointestinal symptoms.
Anorexia

is common.

Nausea and vomiting vary in frequency and intensity from absent to severe. occurs infrequently.

Diarrhea

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

Complicated pyelonephritis A history of the following indicates an increased risk of complicated pyelonephritis:

Structural

abnormalities of the urinary tract abnormalities of the urinary tract

Functional Metabolic

abnormalities predisposing to UTIs

Recent
Recent

antibiotic use
urinary tract instrumentation

abdominal examination:

suprapubic tenderness usually ranges from mild to moderate without rebound. Abdominal tenderness other than in the suprapubic area suggests another diagnosis. Patients usually do not have rigidity or guarding, and bowel sounds are often normally active.

Flank or costovertebral angle (CVA) tenderness is most commonly unilateral over the involved kidney, although bilateral discomfort may be present.

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

Complications Complications occur more often in patients with diabetes mellitus, chronic renal disease, sickle cell disease, renal transplant (particularly during the first 3 months), AIDS, and other immunocompromised states. Complications may involve any of the following:

Acute

renal failure
renal damage leading to hypertension and renal

Chronic

failure
Sepsis Renal

syndromes

papillary

Differential Diagnoses

Acute Abdomen and Pregnancy

Acute Bacterial Prostatitis Appendicitis Cervicitis Chronic Bacterial Prostatitis Chronic Pyelonephritis Cystitis in Females Endometritis Pelvic Inflammatory Disease

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

catheterization,

suprapubic needle aspiration.

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. Almost all patients with pyelonephritis have significant pyuria (>20 WBCs/hpf). The dipstick leukocyte esterase test (LET) helps screen for pyuria. LET results have a sensitivity of 75-96% and a specificity of 94-98% for detecting more than 10 WBC/hpf. The nitrite production test (NPT) for bacteriuria has 92-100% sensitivity and 35-85% specificity. Combined, the LET-NPT has a sensitivity of 79.2% and a specificity of 81%, which is too low for it to be used as the only screening study for bacteriuria.

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

Urine and Blood Cultures Urine culture is indicated in any patient with pyelonephritis, whether treated in an inpatient or an outpatient setting, 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

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 patients condition

persisting for longer than 72 hours

Complicated

UTI

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

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

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

Admission is usually appropriate for :

patients

who are severely ill,

pregnant, elderly who

have comorbid disorders that increase the complexity of management or the complication rate (eg, diabetes mellitus, chronic lung disease, congenital or acquired immunodeficiency). Admission may also be advisable for patients whose social situation is unstable, because of the possibility of poor compliance or poor follow-up.

Antibiotic Selection Antibiotic selection is typically empirical, because the results of blood or urine cultures are rarely available by the time a decision must be made. Initial selection should be guided by local antibiotic resistance patterns. 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, cephalosporins, penicillins, extended-spectrum penicillins, carbapenems, and aminoglycosides. enterococci => ampicillin or vancomycin can replace the fluoroquinolone. If any doubt exists as to the diagnosis, coverage of both Enterobacteriaceae and enterococci is acceptable.

Regimens for complicated cases With complicated acute pyelonephritis, treat patients parenterally until defervescence and improvement in the clinic condition warrants changing to oral antibiotics. 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

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

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)

Alternative therapy Oral beta-lactams are not as effective for treating pyelonephritis; however, 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