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Acute PyelonephritisAka: Pyelonephritis

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  1. See Also
    1. Urinary Tract Infection
  2. Definition
    1. Upper Urinary Tract Infection involving kidney
  3. Causes
    1. Ascending infection via bladder and ureter (most cases)
    2. Hematogenous spread
      1. Prostatitis or Benign Prostatic Hyperplasia
      2. Serious comorbid chronic illness
      3. Immunocompromised patients
      4. Hematogenous spread of staph. or fungal infection
  4. Etiologies
    1. Normal host
      1. Escherichia coli (80%)
      2. Gram Negative Bacteria
      3. Staphylococcus saprophyticus
      4. Enterococcus
    2. Elderly
      1. Escherichia coli (60%)
      2. Proteus
      3. Klebsiella
      4. Serratia
      5. Pseudomonas
    3. Urinary Catheter associated infection
      1. Bacteriuria in 50% at 5 days, and 100% at 30 days
      2. Mixed bacterial infection
    4. Diabetes Mellitus
      1. Klebsiella
      2. Enterobacter
      3. Clostridium
      4. Candida
    5. Immunosuppression
      1. Aerobic, Gram Negative Rods (non-enteric)
      2. Candida
  5. Risk Factors for complicated Pyelonephritis
    1. Age under 1 or over 60 years
    2. Abnormality (Polycystic kidney, Vesicoureteral reflux)
    3. Obstruction (Nephrolithiasis, BPH, tumor)
    4. Immunocompromised (Diabetes, HIV, Corticosteroids)
    5. Indwelling Urinary Catheter
    6. Pregnancy
  6. Symptoms
    1. Fever and chills
    2. Flank pain
    3. Nausea and Vomiting
    4. Acute Cystitis symptoms (Dysuria, frequency, urgency)
  7. Signs
    1. Costovertebral angle tenderness
  8. Diagnostic criteria for Pyelonephritis
    1. Fever
      1. Not uniformly present in elderly (only in 80%)
      2. Not uniformly present in catheter-associated UTI
    2. Flank pain
    3. Urinalysis with bacteriuria and pyuria
  9. Labs
    1. Urinalysis
      1. Leukocyte esterase or nitrite positive
      2. Hematuria may be present
      3. Microscopic examination may show WBC casts
    2. Urine Culture (positive in 90% of Pyelonephritis)
      1. Diagnosis requires at least 10,000 CFU/mm3
      2. Consider lower threshold in men and in pregnancy
    3. Blood Culture indications (not indicated in most cases)
      1. Immunocompromised patient
      2. Unclear diagnosis
      3. Hematogenous source suspected
  10. Differential Diagnosis
    1. Pelvic Inflammatory Disease
    2. Acute Cholecystitis
    3. Appendicitis
    4. Pneumonia
  11. Indications for hospitalization
    1. Inability to stay hydrated and take medications orally
    2. Noncompliance
    3. Uncertain diagnosis
    4. Severe illness with high fever
    5. Severe pain
    6. Debilitated condition
    7. Pregnancy (some cases may be treated outpatient)
  12. Management: Oral agents for acute uncomplicated cases
    1. Preferred agents: Fluoroquinolones
      1. Ciprofloxacin 500 mg PO bid for 10 days
      2. Gatifloxacin 400 mg PO daily for 10 days
      3. Moxifloxacin 400 mg PO daily for 10 days
      4. Levofloxacin 250 mg PO daily for 10 days
      5. Enoxacin 400 mg PO bid for 10 days
    2. Alternative agents
      1. Amoxicillin-Clavulanate (Augmentin) bid for 14 days
      2. Trimethoprim-Sulfamethoxazole (Bactrim) bid 14 days
        1. Higher resistance rates
  13. Management: IV agents for acute uncomplicated cases
    1. Duration of treatment
      1. Convert from IV to oral in first 48-72 hours
      2. Total Course: 14 days
    2. Preferred agents
      1. Ceftriaxone (Rocephin) 1-2 grams IV q24 hours
      2. Cefotaxime (Claforan) 1 gram IV q12 hours
      3. Ampicillin with Gentamicin
      4. Piperacillin
    3. Alternative agents
      1. Ticarcillin-Clavulanate (Timentin)
      2. Ampicillin-Sulbactam (Unasyn)
      3. Piperacillin-Tazobactam (Zosyn)
      4. Ertapenem
  14. Complications
    1. Emphysematous Pyelonephritis
      1. Occurs in Diabetes Mellitus
      2. Associated with papillary necrosis and Renal Failure
    2. Urinary Tract Infection due to obstruction
      1. Associated with Nephrolithiasis, BPH, or tumor
      2. May result in renal abscess and severe infection
  15. References
    1. Escobar in Marx (2002) Rosen's Emergency Med, p. 1401
    2. Gilbert (2002) Sanford Guide, p. 23
    3. Hooton (2003) Infect Dis Clin North Am 17(2):303
    4. Ramakrishnan (2005) Am Fam Physician 71(5):933
    5. Roberts (1999) Urol Clin North Am 26:753

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