Pyelonephritis

Pyelonephritis: Infection in the bladder that ascends to the kidneys

Acute pyelonephritis is an ascending urinary tract infection that has progressed from the lower urinary tract. Pyelonephritis is an acute infection and inflammatory disease of the upper urinary tract of one or both kidneys. Upper urinary tract infections are less common and more serious than lower tract infections.

Diagnostics Voiding Cystourethrogram IVP Renal Cystoscopy if structural problems suspected Renal Abscess: Pelvic CT

Diagnostic tests used in pyelonephritis include urinalysis, urine culture and sensitivity, CBC with differential. urine culture and sensitivity should always be performed before initial empiric treatment with antibiotics. Voiding cystourethrogram, IVP, renal scan, and cystoscopy may be indicated if structural abnormality is suspected. If renal abscess suspected order abdominal and pelvic CT. Blood cultures should be considered if their fever is high. These women are most likely going to be admitted and refer to medical management

Management Fluroquinolones: first line if not pregnant Alternative: Septra DS

Fluroquinolones Cipro 500 mg PO b.i.d. times seven days, Levaquin 750 mg PO daily for 5 to 7 days, or Septra DS one PO b.i.d. 7 to 10 days. Fluoroquinolones are not used in pregnancy due to the risk of auditory and vestibular toxicity in the fetus.

Follow UP 24-48 hours to check for improvement if OP If no improvement admit pregnant: IV and discharge when afebrile for 48 hours

Follow-up the patient and 24 to 48 hours depending on the evaluation of the initial severity of symptoms. If the patient feels that she is not progressing well or is getting worse, evaluate the patient emergently and consider hospital admission and IV antibiotics. Based on the higher risk of complications and pregnancy, pyelonephritis has traditionally been treated with hospitalization and intravenous antibiotics until the woman is afebrile for 48 hours and symptoms improve.

Physical Exam Appear more toxic than regular UTI

On physical exam, please assess your patient's general appearance. Make sure that you are aware of their vital signs. Tachycardia may or may not be present depending on associated fever, dehydration, and sepsis. Auscultate heart and lungs. Check for costovertebral angle tenderness. Check the abdomen for suprapubic tenderness. A pelvic exam may or may not be indicated based on the history and the results of the lab tests.

Predisposing factors: Previous UTI, sickle cell, urinary cath, Trauma

Predisposing factors for pyelonephritis include: previous UTI, cystitis, and pyelonephritis, sickle cell disease, diabetes, urinary catheterization, neurogenic bladder, trauma, incomplete bladder emptying, sexual activity, pregnancy, and atrophic vaginal mucosa.

Causative organism for Pyelonephritis E. Coli

Pyelonephritis is an ascending infection from the bladder usually caused by E. coli and other gram-negative bacteria. Gram-positive are less common.

Symptoms: Fever, chills, back pain costovertebral angle tenderness and flank pain

Symptoms of pyelonephritis include: fever that is often greater than 102°F, shaking chills, flank pain, or tenderness, urinary frequency, or urgency, CVA tenderness, hematuria, suprapubic, tenderness, dysuria nausea, and vomiting.

Diagnostics UA dipstick: Leukocyte esterase=Pyuria Nitrite positive Hematuria or Protein Urine Culture: If suspected Pyelonephritis or Fever Microscopy: Will show WBC casts Pyuria: Greater than 2-5 Leukocytes on HPF

Urinalysis Dipstick: Leukocyte esterase or nitrite positive Leukocyte esterase detects pyuria or WBC Significant Pyuria: >2-5 Leukocyte per HPF Microscopic Hematuria may be present (contrast with Gross Hematuria in Acute Cystitis) Microscopic examination may show WBC casts Consider urine Gram Stain where available Gram Positive Cocci suggests Enterococcus or Staphylococcus saprophyticus Urine Culture (positive in 90% of Pyelonephritis) Manditory in all suspected cases of Pyelonephritis Diagnosis requires at least 10,000 CFU/mm3 Consider lower threshold in men and in pregnancy Blood Culture indications (positive in up to 30% cases, obtain in severe infection or hospitalized patients) Immunocompromised patient Unclear diagnosis Hematogenous source suspected