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  • • High fever and chills

    • Dysuria

    • Pyuria

    • Bacturia

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Epidemiology

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  • • Common in women

    • Usually ascending infection

    • Often incompetent ureterovesical junction

    • In men, frequently due to obstructive uropathy

    • Associated with vesicoureteral reflux in children younger than 1 year

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Symptoms and Signs

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  • • Flank, abdominal, or back pain

    • Fever and chills

    • Frequency of urination

    • Urgency of urination

    • Constitutional symptoms

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Laboratory Findings

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  • • Leukocytosis

    • Pyuria

    • Bacturia

    • Microscopic hematuria

    • Bacteremia

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Imaging Findings

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  • Abdominal x-ray: Loss of psoas stripe

    Intravenous pyelography (IVP): Delayed visualization and poor concentrating ability

    CT scan: Zones of decreased renal contrast enhancement and perinephric fat stranding

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  • • Acute cystitis

    • Ureteral colic

    • Renal colic

    • Renal infarct

    • Pancreatitis

    • Ruptured abdominal aortic aneurysm (AAA)

    • Psoas abscess

    • Pelvic abscess

    • Acute salpingitis

    • Pneumonia

    • Acute cholecystitis

    • Diverticulitis

    • Intestinal angina

    • Acute appendicitis

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Rule Out

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  • • Pancreatitis

    • Ruptured AAA

    • Obstruction in males

    • Vesicoureteral-reflux in children younger than 1 year

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  • • CBC

    • Basic chemistries

    • UA

    • Urine culture and sensitivity

    • Amylase and lipase

    • Abdominal x-ray

    • Evaluate males for obstruction with US

    • Children younger than 1 year should have a voiding cysto-urethrogram (VCU)

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When to Admit

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  • • Constitutional symptoms

    • Nausea and vomiting

    • Failure to tolerate PO fluids and medications

    • Bacteremia

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When to Refer

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  • • Presence of obstructive uropathy

    • Radiographic abnormality

    • Presence of vesicoureteral reflux

    • Recurrent episodes

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  • • IV hydration to ensure good urine production

    • Symptomatic therapy for flank pain and irritative voiding symptoms

    • Specific IV antibiotic therapy

    • Evaluate for obstructive uropathy if no clinical improvement in 48 hours

    • Empiric antibiotic therapy until culture results available

    • Substitute PO antibiotics after fever and other constitutional symptoms have resolved

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Surgery

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Indications

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  • • Obstructive uropathy

    • Perinephric abscess

    • Vesicoureteral reflux

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Medications

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  • • Outpatient: 1 week fluoroquinolone

    • Inpatient: IV penicillin and aminoglycoside

    • Narrow antibiotic therapy to culture results

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Treatment Monitoring

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  • • Resolution of constitutional symptoms

    • Relieve of dysuria

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Complications

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  • • Perinephric or psoas abscess

    • Chronic pyelonephritis

    • Acute renal failure

    • Chronic renal insufficiency

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Prognosis

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  • • Typically excellent

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Prevention

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  • • Empiric antibiotics for some patients with mild forms of vesicoureteral reflux

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References

Hodson EM, Willis NS, Craig JC: Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev 2007;4:CD003772.
Smaill F, ...

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