Pyelonephritis Disease

DESCRIPTION
  • Acute pyelonephritis is a syndrome caused by an infection of the pyelocaliceal system, producing localized flank or back pain combined with systemic symptoms such as fever, chills and prostration. It is accompanied by bacteriuria, and often by bacteremia, which can progress to "septic shock" and death.
  • Chronic pyelonephritis is the pathological result of progressive inflammation on the renal interstitium and tubules, and the radiologic diagnosis of the renal scarring and destructive changes in the caliceal system that are presumed to be caused by bacterial infection, vesicoureteral reflux, or both.
  • System(s) affected: Renal/Urologic
  • Genetics: N/A
  • Incidence/Prevalence in USA:
    • Community acquired acute pyelonephritis - 15.7 per 100,000/per year
    • Hospital acquired acute pyelonephritis - 7.3 per 10,000 hospital persons
  • Predominant age: All ages, especially > 50
  • Predominant sex: Female > Male
SIGNS AND SYMPTOMS
  • In adults
    • Fever; above 38.5°C
    • Chills
    • Unilateral vs. bilateral pain in the lumbar flank area
    • Malaise
    • Myalgia
    • Anorexia
    • Nausea
    • Vomiting
    • Diarrhea
    • Headache
    • Dysuria
    • Frequency
    • Urgency
    • Suprapubic discomfort
    • Flank pain on palpation
    • From no physical findings to septic shock
  • In infants and children
    • Sepsis
    • Fever
    • Irritability
    • Poor skin perfusion
    • Inadequate weight gain or weight loss
    • Gastrointestinal symptoms
    • Jaundice to gray skin color
    • Flank mass
    • Enuresis
    • Vaginal discharge, vulval soreness or pruritus in girls
CAUSES
  • E. coli (75%)
  • Other gram-negative rods, Proteus mirabilis, Klebsiella and Enterobacter account for 10-15%
  • Enterococcus
  • Staphylococcus - epidermis, saprophyticus (number two cause in young women) and aureus
  • Leptospira
  • Salmonella typhi
  • Mycoplasma
  • Anaerobes
RISK FACTORS
  • Underlying urinary tract abnormalities
  • Indwelling catheter
  • Nephrolithiasis
  • Diabetes mellitus
  • Immunocompromised conditions
  • Elderly, institutionalized women
  • Acute pyelonephritis within the prior year
  • Prostatic enlargement
  • Recent urinary tract instrumentation
  • Childhood UTI
  • Symptoms longer than 7 days at presentation
LABORATORY
  • Urine culture (> 100,000 colony-forming units [CFU/mL]) and sensitivities
  • Urine gram stain
  • Pyuria
  • The leukocyte esterase test in the urine
  • Leukocyte casts
  • Hematuria and mild proteinuria
  • Leukocytosis
  • Blood culture(s)

Drugs that may alter lab results: Antibiotics
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS
  • Acute:
    • Abscess formation with neutrophils
    • Glomeruli spared
    • The area of the infection is wedge-shaped toward the medulla
  • Chronic:
    • Fibrosis
    • Reduction in renal tissue
    • Scarring
    • Calyceal clubbing, dilatation and distortion
SPECIAL TESTS
  • Bladder washout
  • Antibody coated bacteria or ACB test
IMAGING
67gallium or 131I-Hippuran scanning
DIAGNOSTIC PROCEDURES
  • If febrile for longer than 72 hours or if obstruction/anatomic abnormality suspected
    • Cystoscopy with ureteral catheterization
    • Contrast-enhanced computed tomography (CT) - spiral more sensitive than conventional
    • Ultrasound
    • Intravenous pyelogram (IVP)
APPROPRIATE HEALTH CARE
  • Outpatient therapy if mild to moderate illness (not pregnant, no nausea or vomiting; fever and pain not severe)
  • Inpatient therapy for severe illness (pregnant, high fevers, severe pain, marked debility, intractable vomiting, possible urosepsis)
GENERAL MEASURES
  • Intravenous fluids when needed
  • Broad-spectrum antibiotics initially, tailoring therapy to culture and sensitivity results
  • Analgesics and antipyretics
  • Urinary analgesics (e.g., phenazopyridine 200 mg tid) for severe dysuria
SURGICAL MEASURES

Percutaneous drainage of abscess if necessary

ACTIVITY

As tolerated

DIET

Encourage fluid

PATIENT EDUCATION

Griffith, H. W.: Instructions for Patients; Philadelphia, W.B. Saunders Co. 1998

PREVENTION/AVOIDANCE

N/A

POSSIBLE COMPLICATIONS
  • Kidney abscess
  • Metastatic infection: skeletal system, endocardium, eye, meningitis with subsequent seizures
  • Septic shock and death
  • Chronic renal insufficiency
  • Complications of antibiotics
EXPECTED COURSE AND PROGNOSIS

95% respond in 48 hours

ASSOCIATED CONDITIONS

N/A

AGE-RELATED FACTORS

Pediatric: Nonspecific systems, jaundice, enuresis, sepsis
Geriatric:

  • May present as confusion
  • Characteristics may change

Others: N/A

PREGNANCY
  • The most common medical complications requiring hospitalization
  • May complicate the pregnancy course and produce low weight babies
OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations
  • Cardiology
  • Dermatology
  • General Destistry
  • Cardiology
  • Dermatology

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