pyelonephritis
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Introduction
Inflammation/infection of the upper urinary tract. In adults, chronic pyelonephritis usually does not develop in the absence of a major underlying functional or structural anomaly.
Etiology
- etiologic agents
- Escherichia coli (most common etiologic agent)
- Proteus (staghorn calculi)
- Klebsiella (staghorn calculi)
- Staphylococcus saprophyticus
- Enterococcus
- risk factors
Epidemiology
- short length & positioning of urethra makes females more susceptible to UTIs & pyelonephritis than men
Pathology
- colonic bacteria ascend through the urinary tract & invade the renal parenchyma
- virulence factors make some strains of bacteria more prone than others to cause pyelonephritis
Clinical manifestations
- abrupt onset
- fever/chills
- nausea/vomiting
- back or flank pain (costovertebral angle tenderness)
- symptoms of cystitis:
- dysuria, urinary frequency, urinary urgency
- 1/3 of patients with pyelonephritis have symptoms of cystitis only
- tachypnea
- tachycardia
- altered mental status (elderly)
Laboratory
- urinalysis: clean-catch or in & out catheterization
- spun urine specimen with > 5 WBC/high-power field
- gram stain: bacteria
- RBC (non-specific)
- WBC: pyruria
- WBC casts suggests pyelonephritis
- urine culture
- culture & antibiotic sensitivities on all suspected case of pyelonephritis
- > 10E6 colonies/mL indicates significant infection
- Candida generally represents colonization, but failure to respond to antibacterial agents in a patient with diabetes mellitus suggests candidiasis
- follow-up urine culture only in pregnant women[3]
- blood culture
- indicated if patient appears ill-enough for hospitalization
- more likely to be positive in elderly individuals
Diagnostic procedures
- cystoscopy: if indicated after ultrasound
Radiology
- renal ultrasound
- persistence or worsening of symptoms after 48-72 hours of IV antibiotics
- recurrent glomerulonephritis in women
- single episode of pyelonephritis in men
- may show blunting of cortical-medullary junction
- may show perinephric abscess or renal abscess
- CT or MRI preferable to intravenous pyelogram if ultrasound not adequate[3]
- CT has greater sensitivity than ultrasound but exposes patient to contrast & radiation
Complications
- intrarenal abscess
- frequently associated with nephrolithiasis
- perinephric abscess
- diabetes mellitus & urinary calculus are risk factors[3]
- emphysematous pyelonephritis (parenchymal gas, renal emphysema)
- hypotension & septic shock[3]
Differential diagnosis
- pelvic inflammatory disease (PID)
- acute appendicitis
- acute cholecystitis
- nephrolithiasis
- diverticulitis
- pneumonia
- intestinal obstruction
Management
- factors favoring hospitalization
- elderly patient
- underlying medical condition
- male gender (likely underlying anatomic anomaly)
- known genitourinary tract abnormality
- uncontrolled nausea/vomiting
- signs/symptoms of sepsis
- hypotension
- altered mental status
- 15-30% of patients with pyelonephritis may become septic
- obstructing urinary calculi with pyelonephritis is a surgical emergency
- percutaneous drainage for emphysematous pyelonephritis[12]
- emergency department observation
- hydration with IV fluids for 8-12 hours
- administration of antiemetics
- administration of 1-2 doses of parenteral antibiotics
- reassessment for hospital admission
- outpatient oral treatment for young, otherwise healthy females, reliable & tolerating oral intake
- empiric antibiotics after urine culture
- empiric oral antibiotic coverage
- fluoroquinolone for uncomplicated pyelonephritis[3]
- avoid fluoroquinolone in pregnant woman
- ciprofloxacin (Cipro) 250 mg every 12 hours for 7 days[3]
- for women with acute pyelonephritis, a 7 day course of ciprofloxacin as effective as 14 day course[4]
- community resistance to fluoroquinolone of 4% acceptable[7]
- levofloxacin for 5 days[3]
- amoxicillin clavulanate (Augmentin) 250-500 mg every 8 hours
- Bactrim DS BID (controversial, conflicting recommendations[3])
- do not use oral cephalosporin, fosfomycin, or nitrofurantoin[3]
- nitrofurantoin & fosfomycin do not achieve adequate renal tissue levels
- fluoroquinolone for uncomplicated pyelonephritis[3]
- empiric intravenous antibiotic coverage
- avoid fluoroquinolone in seriously ill patients with complicated pyelonephritis
- includes men, pregnant women, indwelling catheters, nephrolithiasis
- due to increasing antibiotic resistance of E coli & other gram-negative bacilli[3]
- 3rd generation cephalosporin - ceftriaxone (Rocephin) 1-2 g QD
- Cefipime
- beta lactam/beta-lactamase inhibitor
- aztreonam in pregnant woman with beta-lactam allergy
- aminoglycoside
- monobactam
- carbapenam (meropenem, imipenem, ertapenem)
- linezolid or Synercid + 3rd generation cephlosporin or beta lactam/beta-lactamase inhibitor
- antibiotic coverage for patients admitted from long-term care facilities should include coverage for vancomycin-resistant enterococci & fluoroquinolone-resistant gram-negative bacteria
- meropenem vaborbactam vs piperacillin-tazobactam
- ampicillin 1 g every 6 hours & gentamicin 1.5 mg/kg every 8 hours
- suspected Enterococcus (Gm+ cocci on Gm stain)
- not recommended[3]
- trimethoprim-sulfamethoxazole (TMP/SMX, Bactrim, Septra) 160/800 mg every 12 hours - not recommended[3]
- switch to oral therapy when patient is improving (provided GI tract is functional)
- 14 days in the elderly & complicated pyelonephritis[3]
- avoid fluoroquinolone in seriously ill patients with complicated pyelonephritis
- duration of therapy:
- 5 days if fluoroquinolone is used[11] (incomplicated pyelonephritis)
- 14 days if Bactrim used[11] (Bactrim use controversial)
- 14 days in the elderly & complicated pyelonephritis[3]
- 42 days for recurrent pyelonephritis (failure of 14 days of therapy)
- if patients do not improve after 72 hours of appropriate antibiotic therapy, renal ultrasound or MRI indicated
- Candida pyelonephritis
- empiric oral antibiotic coverage
- patient education
- patients should improve after 2-3 days of therapy
- patients should complete full course of antibiotics
- voiding after sexual intercourse can decrease frequency of UTIs in some women
- adequate hydration is important
More general terms
More specific terms
- acute pyelonephritis
- chronic pyelonephritis (xanthogranulomatous pyelonephritis)
- emphysematous pyelonephritis
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 542-43
- ↑ The Sanford Guide to Antimicrobial Therapy, 29th ed., Gilbert, DN et al (editors), Antimicrobial Therapy, Inc., Hyde Park VT, 1999
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 4.0 4.1 Sandberg T et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: A randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet 2012 Jun 21 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22726802 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60608-4/fulltext
Nicolle LE. Minimum antimicrobial treatment for acute pyelonephritis. Lancet 2012 Jun 21 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22726803 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60770-3/fulltext - ↑ Gupta K, Hooton TM, Naber KG, Wullt B et al International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21292654 (corresponding NGC guideline withdrawn Jan 2017)
- ↑ Johnson JR, Russo TA. Acute Pyelonephritis in Adults. N Engl J Med 2018; 378:48-59. January 4, 2018 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29298155 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMcp1702758
Rothaus C Acute Pyelonephritis. NEJM Resident 360. Jan 3, 2018 https://resident360.nejm.org/content_items/acute-pyelonephritis-in-adults - ↑ 7.0 7.1 Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med 2012 Mar 16; 366:1028 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22417256
- ↑ Talan DA, Stamm WE, Hooton TM et al. Comparison of ciprofloxacin (7 days) and trimethoprim- sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis in women: a randomized trial. JAMA 2000 Mar 29; 283:1583-90. PMID: https://www.ncbi.nlm.nih.gov/pubmed/10735395
- ↑ NEJM Knowledge+ Question of the Week. Jan 30, 2018 https://knowledgeplus.nejm.org/question-of-week/1569/
- ↑ NEJM Knowledge+ Question of the Week. June 25, 2019 https://knowledgeplus.nejm.org/question-of-week/610/
Eloubeidi MA, Fowler VG. Images in clinical medicine. Emphysematous pyelonephritis. N Engl J Med 1999 Sep 2; 341:737 PMID: https://www.ncbi.nlm.nih.gov/pubmed/10471460 Free full text https://www.nejm.org/doi/full/10.1056/NEJM199909023411005
Kawashima A, LeRoy AJ. Radiologic evaluation of patients with renal infections. Infect Dis Clin North Am 2003 Jun; 17:433. PMID: https://www.ncbi.nlm.nih.gov/pubmed/12848478
Nikolaidis P et al. American College of Radiology. ACR Appropriateness Criteria. acute pyelonephritis. https://acsearch.acr.org/docs/69489/Narrative/ - ↑ 11.0 11.1 11.2 Lee RA, Centor RM, Humphrey LL et al. Appropriate use of short-course antibiotics in common infections: Best practice advice from the American College of Physicians. Ann Intern Med 2021 Apr 6; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33819054 https://www.acpjournals.org/doi/10.7326/M20-7355
- ↑ 12.0 12.1 NEJM Knowledge+ Nephrology/Urology
- ↑ Pyelonephritis (Kidney Infection) in Adults http://kidney.niddk.nih.gov/kudiseases/pubs/pyelonephritis/index.htm