Pyelonephritis

Nephrology

Clinicals - History

Fact Explanation
Dysuria Pyelonephritis is an infection of the upper urinary tract, specifically the renal parenchyma and renal pelvis. Dysuria occurs due to inflammation Dysuria
Pyelonephritis is an infection of the upper urinary tract, specifically the renal parenchyma and renal pelvis. Dysuria occurs due to inflammation
Urinary bladder frequency and urgency Occurs due to the irritation caused by the inflammatory process Urinary bladder frequency and urgency
Occurs due to the irritation caused by the inflammatory process
Backache Kidneys are retroperitoneal organs. The left kidney is approximately at the vertebral level T12 to L3 and the right slightly lower.Inflammation of these organs give rise to backache Backache
Kidneys are retroperitoneal organs. The left kidney is approximately at the vertebral level T12 to L3 and the right slightly lower.Inflammation of these organs give rise to backache
Fever with chills Pyelonephritis is an infection of the upper urinary tract, specifically the renal parenchyma and renal pelvis.Inflammatory process give rise to fever with chills Fever with chills
Pyelonephritis is an infection of the upper urinary tract, specifically the renal parenchyma and renal pelvis.Inflammatory process give rise to fever with chills
Hematuria During the inflammatory process, the cells in the urinary tract can get damage and bleed Hematuria
During the inflammatory process, the cells in the urinary tract can get damage and bleed
Severely ill with altered consciousness Pyelonephritis can give rise to septicemia and shock Severely ill with altered consciousness
Pyelonephritis can give rise to septicemia and shock
Nausea and Vomiting Occurs due to the inflammatory mediators which are released due to ongoing inflammatory process Nausea and Vomiting
Occurs due to the inflammatory mediators which are released due to ongoing inflammatory process
Anatomic/functional abnormality: Polycystic kidney disease Horseshoe kidney Double ureter Ureterocele Vesicoureteric reflux More prone to get infections as these abnormalities interrupts the urinary flow.Stagnation of urine causes more infection Anatomic/functional abnormality: Polycystic kidney disease Horseshoe kidney Double ureter Ureterocele Vesicoureteric reflux
More prone to get infections as these abnormalities interrupts the urinary flow.Stagnation of urine causes more infection
Foreign body: Urinary, ureteric, or nephrostomy catheters Calculus More prone to get infections Foreign body: Urinary, ureteric, or nephrostomy catheters Calculus
More prone to get infections
Immunosuppressed state Reduced level of immunity has more chances of getting an infection.
eg: Diabetes mellitus
Sickle cell disease
Transplantation
Malignancy
Chemoradiation
HIV infections
Corticosteroid use
Immunosuppressed state
Reduced level of immunity has more chances of getting an infection.
eg: Diabetes mellitus
Sickle cell disease
Transplantation
Malignancy
Chemoradiation
HIV infections
Corticosteroid use
Gender : male Males have more anatomic abnormalities in urinary tract, prostatic obstruction which has more chances of getting infections Gender : male
Males have more anatomic abnormalities in urinary tract, prostatic obstruction which has more chances of getting infections
Obstruction Foreign body Calculi Bladder neck obstruction Posterior urethral valve Benign prostatic hypertrophy Neurogenic bladder More prone for infections as stagnated urine is a good medium for bacterial growth Obstruction Foreign body Calculi Bladder neck obstruction Posterior urethral valve Benign prostatic hypertrophy Neurogenic bladder
More prone for infections as stagnated urine is a good medium for bacterial growth
Age Infants,elderly (> 60 years of age) have poor immunity, thus more prone to get severe infections Age
Infants,elderly (> 60 years of age) have poor immunity, thus more prone to get severe infections

Clinicals - Examination

Fact Explanation
Renal angle tenderness Kidneys are retroperitoneal organs. The left kidney is approximately at the vertebral level T12 to L3 and the right slightly lower.Inflammation of these oragans give rise to renal angle tenderness Renal angle tenderness
Kidneys are retroperitoneal organs. The left kidney is approximately at the vertebral level T12 to L3 and the right slightly lower.Inflammation of these oragans give rise to renal angle tenderness
Supra pubic pain Pyelonephritis is an infection of the upper urinary tract, specifically the renal parenchyma and renal pelvis.Inflammatory process may cause irritation of the bladder Supra pubic pain
Pyelonephritis is an infection of the upper urinary tract, specifically the renal parenchyma and renal pelvis.Inflammatory process may cause irritation of the bladder
Signs of shock : ill looking patient, hypotension, tachycardia, cold peripheries Pyelonephritis can give rise to septicemia and shock Signs of shock : ill looking patient, hypotension, tachycardia, cold peripheries
Pyelonephritis can give rise to septicemia and shock
Febrile patient Inflammatory process give rise to fever due to inflammatory mediators Febrile patient
Inflammatory process give rise to fever due to inflammatory mediators

Investigations - Diagnosis

Fact Explanation
Urine full report Pus cells will be present in urine due to the infection.
> 5 WBCs/HPF
Sensitivity (%) : 72 to 95
Specificity (%) : 48 to 82
Red blood cells may also be present as the cells in the urinary tract can get damage and bleed due to the inflammatory process.
Protein may also be positive in urine as proteins may be excreted during an infection of the urinary tract
Urine full report
Pus cells will be present in urine due to the infection.
> 5 WBCs/HPF
Sensitivity (%) : 72 to 95
Specificity (%) : 48 to 82
Red blood cells may also be present as the cells in the urinary tract can get damage and bleed due to the inflammatory process.
Protein may also be positive in urine as proteins may be excreted during an infection of the urinary tract
Leukocyte esterase test Leukocyte esterase is a screening test used to detect a substance that suggests there are white blood cells in the urine.This will be positive in pyelonephritis as pus cells are present in urine due to the infection.
Sensitivity (%) : 74 to 96
Specificity (%) : 94 to 98
Leukocyte esterase test
Leukocyte esterase is a screening test used to detect a substance that suggests there are white blood cells in the urine.This will be positive in pyelonephritis as pus cells are present in urine due to the infection.
Sensitivity (%) : 74 to 96
Specificity (%) : 94 to 98
Nitrite test A nitrite test is a chemical test used to determine the presence of nitrite ion in solution. A positive nitrite test indicates that the cause of the urinary tract infection ( UTI ) is a gram negative organism, most commonly Escherichia coli. The reason for nitrites' existence in the presence of a UTI is due to a bacterial conversion of endogenous nitrates to nitrites.
Sensitivity (%) : 35 to 85
Specificity (%) : 92 to 100
Nitrite test
A nitrite test is a chemical test used to determine the presence of nitrite ion in solution. A positive nitrite test indicates that the cause of the urinary tract infection ( UTI ) is a gram negative organism, most commonly Escherichia coli. The reason for nitrites' existence in the presence of a UTI is due to a bacterial conversion of endogenous nitrates to nitrites.
Sensitivity (%) : 35 to 85
Specificity (%) : 92 to 100
Urine culture and antibiotic sensitivity testing To detect the causative organism and sensitive antibiotics.
Urine cultures are positive in 90 percent of patients with acute pyelonephritis, and culture specimens should be obtained before initiation of antibiotic therapy.
The consensus definition of pyelonephritis established by the Infectious Diseases Society of America (IDSA) is a urine culture showing at least 10,000 colony-forming units (CFU) per mm3 and symptoms compatible with the diagnosis.
Most common organisms are :
Escherichia coli ,
Staphylococcus saprophyticus ,
Proteus ,
Klebsiella ,
Enterococci
Urine culture and antibiotic sensitivity testing
To detect the causative organism and sensitive antibiotics.
Urine cultures are positive in 90 percent of patients with acute pyelonephritis, and culture specimens should be obtained before initiation of antibiotic therapy.
The consensus definition of pyelonephritis established by the Infectious Diseases Society of America (IDSA) is a urine culture showing at least 10,000 colony-forming units (CFU) per mm3 and symptoms compatible with the diagnosis.
Most common organisms are :
Escherichia coli ,
Staphylococcus saprophyticus ,
Proteus ,
Klebsiella ,
Enterococci

Investigations - Management

Fact Explanation
Ultra sound scan - abdomen Ultrasound examination identifies acute bacterial nephritis, abscesses, ureteral obstruction, and hydronephrosis Ultra sound scan - abdomen
Ultrasound examination identifies acute bacterial nephritis, abscesses, ureteral obstruction, and hydronephrosis
Serum creatinine Infection can damage the kidneys thus it is important to assess the renal functions Serum creatinine
Infection can damage the kidneys thus it is important to assess the renal functions
Computed tomographic (CT) scan; magnetic resonance imaging; and intravenous pyelography May identify complicating factors such as anatomic abnormalities, obstruction, acute bacterial nephritis (localized, non liquefied interstitial inflammation) Computed tomographic (CT) scan; magnetic resonance imaging; and intravenous pyelography
May identify complicating factors such as anatomic abnormalities, obstruction, acute bacterial nephritis (localized, non liquefied interstitial inflammation)
Full blood count Will show neutrophilic leukocytosis due to the infection Full blood count
Will show neutrophilic leukocytosis due to the infection
Ultra sound scan -abdomen Ultrasound examination identifies acute bacterial nephritis, abscesses, ureteral obstruction, and hydronephrosis Ultra sound scan -abdomen
Ultrasound examination identifies acute bacterial nephritis, abscesses, ureteral obstruction, and hydronephrosis
Computed tomographic (CT) scan ; magnetic resonance imaging; and intravenous pyelography May identify complicating factors such as anatomic abnormalities, obstruction, acute bacterial nephritis (localized, nonliquified interstitial inflammation) Computed tomographic (CT) scan ; magnetic resonance imaging; and intravenous pyelography
May identify complicating factors such as anatomic abnormalities, obstruction, acute bacterial nephritis (localized, nonliquified interstitial inflammation)
Full blood count Will show neutrophilic lueukocytosis due to the infection Full blood count
Will show neutrophilic lueukocytosis due to the infection

Management - Supportive

Fact Explanation
Increase fluid intake More urine will be passed with more fluid intake and there will be a good urine flow without stagnation of urine Increase fluid intake
More urine will be passed with more fluid intake and there will be a good urine flow without stagnation of urine
Catheter care Sterile insertion and care of the catheter, minimizing the duration of catheterization, intermittent catheterization, closed drainage systems Catheter care
Sterile insertion and care of the catheter, minimizing the duration of catheterization, intermittent catheterization, closed drainage systems

Management - Specific

Fact Explanation
Antibiotics Indications for Hospitalization in Patients with Acute Pyelonephritis:
Persistent vomiting
Progression of uncomplicated UTI
Suspected sepsis
Uncertain diagnosis
Urinary tract obstruction

Oral ciprofloxacin for 7 days, (with or
without an initial intravenous dose) is
an appropriate choice for therapy in patients not requiring
hospitalization.

Patients who requiring hospitalization
should be initially treated with an intravenous antimicrobial
regimen, such as a fluoroquinolone; an aminoglycoside, with
or without ampicillin; an extended-spectrum cephalosporin
or extended-spectrum penicillin, with or without an
aminoglycoside; or a carbapenem.
Antibiotics
Indications for Hospitalization in Patients with Acute Pyelonephritis:
Persistent vomiting
Progression of uncomplicated UTI
Suspected sepsis
Uncertain diagnosis
Urinary tract obstruction

Oral ciprofloxacin for 7 days, (with or
without an initial intravenous dose) is
an appropriate choice for therapy in patients not requiring
hospitalization.

Patients who requiring hospitalization
should be initially treated with an intravenous antimicrobial
regimen, such as a fluoroquinolone; an aminoglycoside, with
or without ampicillin; an extended-spectrum cephalosporin
or extended-spectrum penicillin, with or without an
aminoglycoside; or a carbapenem.

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