Pyelonephritis
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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.
- Renal/perirenal
- Ureteral
- Infected urolithiasis
- Bladder
- Acute cystitis ("UTI")
- Chronic cystitis
- Urethra/periurethra
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
Labs
- UA with clumps and/or high WBCs
- Nitrite
- Very high specificity (>90%) in confirming diagnosis of UTI
- Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected)
- Nitrite
- 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:
- History of Renal Stone
- Poor response to antibiotics
- Male
- Elderly
- Diabetic
- Severely ill
Differential Diagnosis
Major
- Acute cystitis
- Infected kidney stone
Flank Pain
- Vascular
- Abdominal aortic aneurysm
- Renal artery embolism
- Renal vein thrombosis
- Aortic dissection
- Mesenteric ischemia
- Renal
- Pyelonephritis
- Papillary necrosis
- Renal cell carcinoma
- Obstructive uropathy
- May or may not be due to nephrolithiasis
- Renal infarction
- Renal hemorrhage
- Ureter
- Nephrolithiasis
- Blood clot
- Stricture
- Tumor (primary or metastatic)
- Bladder
- Tumor
- Varicose vein
- Cystitis
- GI
- Biliary colic
- Pancreatitis
- Perforated peptic ulcer
- Appendicitis (appendix may be pushed to RUQ in pregnancy)
- Inguinal Hernia
- Diverticulitis
- Cancer
- Bowel obstruction
- Gynecologic
- GU
- Other
- Shingles
- Lower lobe pneumonia
- Retroperitoneal hematoma/abscess/tumor
- Epidural abscess
- Epidural hematoma
- Rib contusion/fracture
Dysuria
- Genitourinary infection
- Acute cystitis ("UTI")
- Pyelonephritis
- Urethritis
- Chronic cystitis
- Infected nephrolithiasis
- Prostatitis
- Epididymitis
- Renal abscess/perinephric abscess
- Emphysematous pyelonephritis
- Nephrolithiasis
- Urethral issue
- Urethritis
- Urolithiasis
- Urethral foreign body
- Urethral diverticulum
- Allergic reaction (contact dermatitis)
- Chemical irritation
- Urethral stricture or obstruction
- Trauma to vagina, urethra, or bladder
- Gynecologic
- Vaginitis/cervicitis
- PID
- Genital herpes
- Pelvic organ prolapse
- Fistula
- Cystocele
- Other
- Diverticulitis
- Interstitial cystitis
- Behavioral symptom without detectable pathology
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%
- Ciprofloxacin 500mg PO BID x7 days OR
- Trimethoprim-Sulfamethoxazole DS 160/800mg PO BID x14 days OR[1]
- Cephalexin 500mg QID PO x 10-14 days (OR consider 1000mg BID if difficulty with QID regimen) OR
- Cefdinir 300mg BID PO x 10-14 days OR
- Cefpodoxime 200mg PO BID x 10 days OR[2]
- Cefixime 400mg PO daily x 10 days OR[3]
- Levofloxacin 750mg PO QD x7 days[4]
Adult Inpatient Options
- Ciprofloxacin 400mg IV q12hr OR
- Ceftriaxone 1gm IV QD (Preferred in pregnancy) OR
- Cefotaxime 1-2gm IV q8hr OR
- Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr OR
- Piperacillin/Tazobactam 3.375 gm IV q6hr OR
- Cefepime 2gm IV q8hr OR
- Imipenem 500mg IV q8hr
Pediatric Inpatient Options
- Ceftriaxone 75mg/kg IV QD OR
- Cefotaxime 50mg/kg IV q8hrs OR
- Ampicillin 25mg/kg IV q6hrs + Gentamicin 2.5mg/kg IV q8hrs
Disposition
- Discharge
- Consider if young, otherwise healthy, tolerating PO
- Admission
- Consider if elderly, Renal Calculi, obstruction, recent hospitalization/instrumentation, DM
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 scaring
- Consider advanced imaging to rule out abscess of urolithiasis if patient has failed 3 days of therapy
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
See Also
References
- ↑ 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
- ↑ Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84(7):771-6.
- ↑ Acute Pyelonephritis in Adults. Johnson, JR and Russo, TA. New England Journal of Medicine 2018; 378:48-59.
- ↑ 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.