Pyelonephritis, Acute

• • High fever and chills

  • Dysuria

  • Pyuria

  • Bacturia

Epidemiology

• • 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

Symptoms and Signs

• • Flank, abdominal, or back pain

  • Fever and chills

  • Frequency of urination

  • Urgency of urination

  • Constitutional symptoms

Laboratory Findings

• • Leukocytosis

  • Pyuria

  • Bacturia

  • Microscopic hematuria

  • Bacteremia

Imaging Findings

• • 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

• • 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

Rule Out

• • Pancreatitis

  • Ruptured AAA

  • Obstruction in males

  • Vesicoureteral-reflux in children younger than 1 year

• • 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)

When to Admit

• • Constitutional symptoms

  • Nausea and vomiting

  • Failure to tolerate PO fluids and medications

  • Bacteremia

When to Refer

• • Presence of obstructive uropathy

  • Radiographic abnormality

  • Presence of vesicoureteral reflux

  • Recurrent episodes

• • 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

Surgery

Indications

• • Obstructive uropathy

  • Perinephric abscess

  • Vesicoureteral reflux

Medications

• • Outpatient: 1 week fluoroquinolone

  • Inpatient: IV penicillin and aminoglycoside

  • Narrow antibiotic therapy to culture results

Treatment Monitoring

• • Resolution of constitutional symptoms

  • Relieve of dysuria

Complications

• • Perinephric or psoas abscess

  • Chronic pyelonephritis

  • Acute renal failure

  • Chronic renal insufficiency

Prognosis

• • Typically excellent

Prevention

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

References