Pyelonephritis

Background

Definitions
  • UTI = significant bacteriuria in presence of symptoms
    • Described by location: urethritis, cystitis, or pyelonephritis

Genitourinary infection

"UTI" frequently refers specifically to acute cystitis, but may also be used as a general term for all urinary infections; use location-specific diagnosis.

Clinical Features
  • Pyelo = Cystitis symptoms AND fever/chills/nausea/vomiting
    • CVAT alone may be referred pain from cystitis
    • CVAT is only physical examination finding that increases likelihood of a UTI

Complications
  • Acute bacterial nephritis
    • CT shows ill-defined focal areas of decreased density
  • Renal/Perinephric abscesses
    • Sign/symptoms similar to pyelo (fever, CVAT, dysuria)
    • Occurs in setting of ascending infection with obstructed pyelo
    • Associated with DM and Renal Stones
    • Also occurs due to bacteremia with hematogenous seeding (Staph)
  • Emphysematous pyelonephritis
    • Rare gas-forming infection nearly always occurring in patients with DM and obstruction
      • Patients appear toxic and septic; nephrectomy may be required

Differential Diagnosis

Major

Flank Pain

Dysuria

Evaluation
  • Urinalysis with clumps and/or high WBCs
    • Nitrite
      • Very high specificity (>90%) in confirming diagnosis of UTI
      • Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected)
  • Urine culture
Blood cultures are NOT indicated (organisms in blood culture matched those in urine culture 97% of time)

Imaging
  • Consider if any of the following:
  1. History of Renal Stone
  2. Poor response to antibiotics
  3. Male
  4. Elderly
  5. Diabetic
  6. Severely ill

Management

Antibiotics

Treatment is targeted at E. coli, Enterococcus, Klebsiella, Proteus mirabilis, S. saprophyticus

Outpatient

Consider one dose of Ceftriaxone 1g IV or Gentamycin 7mg/kg IV if the regional susceptibility of TMP/SMX or Fluoroquinolones is <80%

Adult Inpatient Options

Pediatric Inpatient Options

Disposition
  • Discharge
    • Consider if young, otherwise healthy, tolerating PO
  • Consider admission if:[5]
    • Elderly (>60)
    • Renal Calculi
    • Obstruction
    • Recent hospitalization/instrumentation
    • DM
    • Immunocompromised
    • Unable to tolerate PO
    • Pregnancy
    • Solitary kidney or other anatomic abnormality

Disposition
  • Admit all second trimester pregnant patients with OBGYN consult
  • Urology consult during the inpatient admission for pediatric patients due to the risk for urologic scarring
  • Consider advanced imaging to rule out abscess of urolithiasis if patient has failed 3 days of therapy

See Also

References
  1. Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women. Clinical Infectious Diseases. 2011;52(5):e103-e120. doi:10.1093/cid/ciq257
  2. Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84(7):771-6.
  3. Acute Pyelonephritis in Adults. Johnson, JR and Russo, TA. New England Journal of Medicine 2018; 378:48-59.
  4. 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 Aug 4;380(9840):484-90.
  5. Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
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