Pyelonephritis: Difference between revisions

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==Background==
==Background==
[[File:Blausen 0592 KidneyAnatomy 01.png|thumb|Renal anatomy.]]
===Definitions===
===Definitions===
*UTI = significant bacteriuria in presence of symptoms
*UTI = significant bacteriuria in presence of symptoms
**Described by location: urethritis, cystitis, or pyelonephritis
**Described by location: [[urethritis]], [[cystitis]], or pyelonephritis


{{UTI types}}
{{UTI types}}


==Diagnosis==
==Clinical Features==
===Clinical Features===
[[File:Pos-renal.png|thumb|Diagram showing the typical location of pain<ref>Urinary Tract Infection Common Clinical and Laboratory Features of Acute Pyelonephritis". netterimages.com. Retrieved 14 July 2019.</ref>]]
*Pyelo = Cystitis symptoms AND fever/chills/nausea/vomiting
*Pyelo = Cystitis symptoms AND [[fever]]/chills/[[nausea/vomiting]]
**CVAT alone may be referred pain from cystitis
**CVAT alone may be referred pain from cystitis
**CVAT is only physical examination finding that increases likelihood of a UTI
**CVAT is only physical examination finding that increases likelihood of a UTI


===Labs===
===Complications===
*UA with clumps and/or high WBCs
*Acute bacterial nephritis
**Nitrite
**CT shows ill-defined focal areas of decreased density
***Very high specificity (>90%) in confirming diagnosis of UTI
*Renal/[[Perinephric abscesses]]
***Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected)
**Sign/symptoms similar to [[pyelo]] ([[fever]], CVAT, dysuria)
*[[Urine culture]]
**Occurs in setting of ascending infection with obstructed pyelo
 
**Associated with [[DM]] and [[Renal Stones]]
;[[Blood cultures]] are NOT indicated (organisms in blood culture matched those in urine culture 97% of time)
**Also occurs due to [[bacteremia]] with hematogenous seeding (Staph)
 
*[[Emphysematous pyelonephritis]]  
===Imaging===
**Rare gas-forming infection nearly always occurring in patients with [[DM]] and obstruction
*Consider if any of the following:
***Patients appear toxic and [[septic]]; nephrectomy may be required
#History of [[Renal Stone]]
#Poor response to [[antibiotics]]
#Male
#Elderly
#[[Diabetic]]
#Severely ill


==Differential Diagnosis==
==Differential Diagnosis==
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{{Dysuria DDX}}
{{Dysuria DDX}}
==Evaluation==
[[File:Pyuria2011.jpg|thumb|Urine with pyuria.]]
[[File:Ultrasonography of acute pyelonephritis.jpg|thumb|[[Renal ultrasound]] showing acute pyelonephritis with increased cortical echogenicity and blurred delineation of the upper pole.<ref>Content initially copied from: Hansen, Kristoffer; Nielsen, Michael; Ewertsen, Caroline (2015). "Ultrasonography of the Kidney: A Pictorial Review". Diagnostics. 6 (1): 2. doi:10.3390/diagnostics6010002. ISSN 2075-4418. PMC 4808817. PMID 26838799. (CC-BY 4.0)</ref>]]
===Workup===
*[[Urinalysis]]
*[[Urine culture]]
*Consider imaging (CT or [[renal ultrasound|ultrasound]]) if any of the following:
**History of [[Renal Stone]]
**Poor response to [[antibiotics]]
**Male
**Elderly
**[[Diabetic]]
**Severely ill
;[[Blood cultures]] are NOT indicated (organisms in blood culture matched those in urine culture 97% of time)
===Diagnosis===
*[[Urinalysis]]
**Clumps and/or high WBCs
**Nitrite
***Very high specificity (>90%) in confirming diagnosis of UTI
***Low sensitivity ([[enterococcus]], [[pseudomonas]], [[acinetobacter]] are not detected)


==Management==
==Management==
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*Discharge
*Discharge
**Consider if young, otherwise healthy, tolerating PO
**Consider if young, otherwise healthy, tolerating PO
*Admission
*Consider admission if:<ref>Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.</ref>
**Consider if elderly, [[Renal Calculi]], obstruction, recent hospitalization/instrumentation, [[DM]]
**Elderly (>60)
**[[Renal Calculi]]
**Obstruction
**Recent hospitalization/instrumentation  
**[[DM]]
**Immunocompromised
**Unable to tolerate PO
**Pregnancy
**Solitary kidney or other anatomic abnormality


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


==Complications==
==Special Populations==
#Acute bacterial nephritis
===Elderly===
##CT shows ill-defined focal areas of decreased density
*Elderly patients with pyelonephritis: 20% present with primary respiratory or GI symptoms. Also 33% are afebrile.<ref>Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.</ref>
#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


==See Also==
==See Also==

Revision as of 10:42, 2 May 2020

Background

Renal anatomy.

Definitions

  • UTI = significant bacteriuria in presence of symptoms

Genitourinary infection

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.

"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

Diagram showing the typical location of pain[1]
  • 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

Urine with pyuria.
Renal ultrasound showing acute pyelonephritis with increased cortical echogenicity and blurred delineation of the upper pole.[2]

Workup

Blood cultures are NOT indicated (organisms in blood culture matched those in urine culture 97% of time)

Diagnosis

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:[7]
    • 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

Special Populations

Elderly

  • Elderly patients with pyelonephritis: 20% present with primary respiratory or GI symptoms. Also 33% are afebrile.[8]

See Also

References

  1. Urinary Tract Infection Common Clinical and Laboratory Features of Acute Pyelonephritis". netterimages.com. Retrieved 14 July 2019.
  2. Content initially copied from: Hansen, Kristoffer; Nielsen, Michael; Ewertsen, Caroline (2015). "Ultrasonography of the Kidney: A Pictorial Review". Diagnostics. 6 (1): 2. doi:10.3390/diagnostics6010002. ISSN 2075-4418. PMC 4808817. PMID 26838799. (CC-BY 4.0)
  3. 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
  4. Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84(7):771-6.
  5. Acute Pyelonephritis in Adults. Johnson, JR and Russo, TA. New England Journal of Medicine 2018; 378:48-59.
  6. 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.
  7. Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  8. Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.