Pyelonephritis (quick hits)

8 Nov

submitted by Christina Brown, M.D.

Definition – Ascension of bacteria from lower urinary tract infection (UTI) into the upper pyelourinary tract. Primarily a clinical diagnosis.

 
Epidemiology of Male/female ratio:
• 1:10 in 1st years of life
• 1:5 in children
• 1:50 in reproductive years
• 1:1 in fifth decade and later

 
Bacteriology: Escherichia coli 80–95% predominates.

 
Risk Factors – Recent instrumentation, urinary obstruction, urinary retention, recent pyelonephritis (within 1 yr), anatomic variation, neurogenic bladder, DM, immunosuppression, pregnancy.

 
Signs & Symptoms
– Dysuria, urgency, frequency
– Back, flank, or abdominal pain
– Fever, chills, N/V, Malaise
– CVA Tenderness or suprapubic TTP

 

Pediatric Considerations
– Renal scarring: More common sequelae in young children than in adults.
– Group B streptococci

Geriatrics – AMS, nausea/vomiting, diarrhea, fever may predominate.

Urine Culture: >100,000 colony-forming units (CFU)/mL is (+).

CT Imaging:

Consistent or concerning findings:
• Stranding or inflammation and edema of parenchyma
• Perinephric fluid
• Calculi, obstruction
• Renal/perinephric abscess
• Intraparenchymal gas formation (consistent with emphysematous pyelonephritis)

ED Treatment – 14 days duration
– Oral Antibiotics – Ciprofloxacin, Cefdinir
– PEDS – Amoxicillin, Keflex
– IV Antibiotics – Ceftriaxone, Ciprofloxacin
– PEDS 0-3 months – Amp + Gent, Cefotaxime. 3+ months – Ceftriaxone may be used in place of Cefotaxime.

Additional Pediatric Considerations
All children with 1st episode of pyelonephritis should have urinary tract imaging performed later with pediatrician.

Renal US:
• Within 48 hr if no clinical improvement
• Within 3–6 wk if clinical improvement
Girls 4–10 yr old: Voiding cystogram for UVR w/ pediatrician
Boys 4–10 yr old: Voiding cystourethrogram after urine is sterile and bladder spasm has subsided

Disposition

– Admit septic, unable to tolerate PO intake, immunocompromised.

– If clinically stable, discharge home w/ pediatrician f/u within next 48 hrs with appropriate antibiotic regimen.

 

References:

1. Bitner M, Schaider, J., lfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Pyelonephritis. Rosen & Barkin’s Five Minute Emergency Medicine consult.

2. Piccoli B G, Cresto E, and Ragni F et al.: The clinical spectrum of acute uncomplicated pyelonephritis from an emergency medicine perspective. Int J Antimicrob Agents. 2008; 31(suppl S):S46-S53.

3.  Stunnell H, Buckley O, and Feeney J et al.: Imaging of acute pyelonephritis in the adult. Eur Radiol. 2007; 17:1820-1828.

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