pyelonephritis
Table of Contents
acute pyelonephritis
see also:
introduction
- acute pyelonephritis is a bacterial infection of the renal parenchyma
- it usually arises from ascending bacteria in the urinary tract associated with urinary tract infections (UTIs) / cystitis
- it is 5x more likely in females as males aged under 65 years
- females have peak incidences at ages 0-4yrs, 15-35 years, then a gradual rise from age 50, peaking at 80yrs age.
- males have a peak at age 0-4 years, then gradual rise from age 35yrs to a peak at 85yrs age
- paediatric cases are often associated with underlying urologic tract abnormalities including vesicoureteral reflux
- it develops in 20-30% of pregnant women with untreated asymptomatic bacteriuria, most often during the late second and early third trimesters
- timely Rx is important to reduce renal damage, complications and also potentially lethal urosepsis
clinical features
- most adult patients present with:
- flank pain and tenderness, often with suprapubic discomfort of cystitis, developing over hours to days
- high fever
- anorexia, nausea +/- vomiting
- some will be afebrile
- some will have dysuria and frequency
- some will have frank haematuria associated with haemorrhagic cystitis
- elderly patients are more likely to present with delirium
- pain radiating to the groin or testis suggests renal colic
- children aged under 2yrs usually present with failure to thrive, feeding difficulty, fever, and vomiting
- neonates may develop worsening of neonatal jaundice and may develop concurrent meningitis
Mx in ED of adult patients
- most require initial parenteral antibiotics for 12-48hrs, although some will be able to be managed as an outpatient with a single dose of parenteral antibiotic then a course of oral antibiotics
- iv access
- bloods for FBE, U&E
- MSU m/c/s and urinalysis
- look for and Rx evidence of sepsis / septicaemia as septic shock from urosepsis has a high mortality
- consider admission into ED observation ward if uncomplicated
- iv ceftriaxone 1g daily is a reasonable choice for most patients
- many doctors are now steering away from the use of single dose of iv gentamicin 4-5mg/kg given recent reports of permanent ototoxicity may occur with only 1 dose (although this is a rare complication)
- if highly likely to have resistant organisms (eg. ESBL) such as, PH ESBL, recent hospital admission or travel overseas (especial SE Asia where ESBL carriage is > 50%) and in septic shock:
- IV meropenem (preferred over Tazocin in ESBL severe sepsis)1) + IV amikacin (to cover carbapenem resistance), consider adding IV vancomycin if Gram +ve sepsis possible
- patients are often discharged on oral trimethoprim or cephalexin - but this depends upon your regional antibiotic resistance profiles
- patients who have returned from India are highly likely to have a multi-resistant organism which may require consultation with infectious diseases on selection of antibiotic until sensitivities are back.
- pregnant patients require inpatient care and prolonged course of antibiotics as they have ureteric stasis secondary to progesterone, etc, and have a higher risk of Rx failure
- urgent urology consult if either:
- obstructed kidney (eg. ureteric calculus) with UTI
- patients with renal colic and infection should be referred to urology ASAP for possible intervention to drain the urine proximal to ureteric calculus causing the obstruction
- renal abscess
- post-urologic procedure
complications
- renal abscesses and perinephric abscesses which may require early surgical drainage by urology
- renal papillary necrosis
- xanthogranulomatous pyelonephritis
- a rare (1% of all renal infections), serious, chronic inflammatory disorder of the kidney characterised by a destructive mass that invades the renal parenchyma
- often associated with urinary tract obstruction, infection, urolithiasis, diabetes mellitus, and/or immunocompromise
- 4 x more common in women than in men
- usually occurs in the fifth and sixth decades of life but may also occur in children under 8yrs when it is more common in boys 2)
- chronic pyelonephritis - usually children aged under 2yrs, associated with vesicoureteral reflux
- recurrent pyelonephritis
pyelonephritis.txt · Last modified: 2021/12/15 01:37 by gary1