Diagnosis and Management of Acute Pyelonephritis in Adults KALVANAKRISHNAW RAMAKRISHNAN, M.D. and DEWEY ¢ SCHEID, SD. M2 hry of Osha Heat Sees Cores Okihem is Ocho There ae spprocinately 250,00 cass of cts pytncps ich yen ting more ta £00.90 hopin ‘ine The most common alo case x infection with chr cal The combinton of th lay ese ‘stand th nite (with ether te prong postive as Seiya 75 wo percent and a pet) 282 {98 percent fo rinary tat nfecton Urine cares are postive 90 fect of patents wth ace pycanep, pd entre shouldbe obtained before atic hers inne. Fe wae of Mod cultures sald be roeved Ter ptiens with an uncertain hago tone who ae imimanocompromie, and hou who ae suspected f hing ‘netalogennsntesions. Outen orl antic therpy witha Muorquinolone is saccular patient with ‘ul neat pylons Other fee altered een apecram pein, aml le ‘uhnte posi, epenperin and rineioprin slanted Indians for input exe icode ‘uoplaled ints sens, poset voming,laledoxpatin extent, o exten of asf Hoptaied Patents netvenous estmen recommended witha Buorguinale, amunoghcode wh or wth! amp, ‘tA hed generation cphaenporin. The tndard duration of therapy i seven 14 days Use care sl be ‘pad oe to two weds afr emplein of abit therpy. Treatment fare may Deca y reas oA ‘sts, under/ingaatoicanconl abnormalities ot imamonippresed mats Lack resp shoul prompt ‘ep bod nd urine ture and pombly imaging sw A change attics sp interven ay Be ‘qu (Am Fam Mayan 20571993-42, Copii 2005 Amerian Academy o Fay Physics) likeupoer urinary act. spec ces repeal) Acute pylons icaly the real parenchyma and seats nto 2 percent of pregnant om seeal pele (Bgire 1 Acaleincrsing the sok fr rematcre bor and Dyson is Coded uncomgbisted weit nn {oben cused by 2 yl patho {gov in an imminocmmptet pet who Pathogenesis Sue aormal urinary act anatomy and ven Most renal parenchymal ifcons occur function. Misagnoss can lead to eps secondary to baci ascent hough the enal acer, ane chronic pysaneprt retrain rnry Bide In em. Poe (at may cane secondary hypertensnn duis and peorase hyperphy casing renal fe, Risk factors for complicated urea obtracion preps to bate fcae pelonepheis are hese tat increase ura® Hematogenous acute pyeloneprits Suscepibny or reduce host ssponse to occurs mos ofe in debilitated. chronically ‘atetion (Tabi A puente and those een niunonp- ‘Approinately 250.000 cases of acute prsve they. Metastatic stp yococl pyconepis occur each yea, esting oe fang infetons may sped to he Key {mare than 100,00 bospitaization,? fom ditt fsa te bone o di Seve A, aerromarestattci, tn 02 woe tren ‘Wornem ae appriaiely ive a sneha 88 perce o cae fate times toe lly than’ ren _pelanepitin the ele agent Biker Inmore than 9 perentof tp be hospitalized wth ths this ca” Other ealoge causes ihe fate of ste pyeonephit onion {117 very thors nercie pramnegtve, baci, Sell ticthestioloicagert ic. paliations per 1000 cane, ssw aprapgtian and eeroco. The Echochinco pctv however, women mrbal petra sce wth erent hse a lower mortality rate tpen of arinary tact incon (UTI) ie vet weianis ces ae uated a pega ag gato kt omStrength of Recommendations ada son ta pains hae pesos ‘ose nay teem nrc 2 unsrtrtey sacl 0 wc lcd es th {Splat pe eer ee, tm rely flow ard ‘so end yn ee lepine a one ‘ire el eonran enpars Rusoqunaere sgh Shiver ance a een depcran aptamer thee ‘ihc one = ee vide (Table 28 tn ely pains ck Patent ho have disbetes melo tnd isn iss camiman (60 parent) ese of sate to have ‘infestans caus? BY Nel DPrloephets The iacesed we of ete Enterobacter Clotriarn, or Cade ‘este incumectsstvog thre pets They alpare tan increased ak of develop Dupes than to lecons with ther ng empha pylonephrtis and pp amreatie organs ouch as Proteus, ay 2 res Seat ePeadomonas. fre Bact a Dat eae a aria which sqsecty 1s polymicrobil develops in move than Timunossperesion So pecet of patients who require ctheter ‘etn foe more than ie days, ania vite Aliya pent who have indwelling inary Catheter fr mor than one moat fire the deco nent of sbelncl (alent) ponents nd inecons caused by monet se Ihe, grm-negatine rods and Candis Acie pelonepitis occurs win to months folowing renal Ganaplant in 3010 50 pe ent of patents heense of cncomstant sto ‘Sane ond pssra onder coilicaed amen beac bey ave a igher probability of wrinary act noma, prostatic elargeen aur: ing atethal obatoction vith incomplete “a The spectrum of acute pyckonephritin is de Fnging Kem a nd lent epi tae 934 amon Ray Py Sacra’ To dapaose aut pyonesPyelonephritis sk Factors fr Complicated Acute Pyelonephis SontsSoymneeéag) Ste See coat snvonichactand remy tanganaton Aer cen oes ey Choma ge pate peony Forbes ‘wc isrties "apap Us pyscans must ely on evidence of UT are suggsive of ets dura, urinary From urinalysis or culture along with sige bladder frequency and urge) and spr snc symptom suggesting upper UTI (eer publ ai) alo ee be preset ily anh pein meses vodicg coer La nated Your ed lard ‘eda agle endemen) Symptoms tat women prseating foam emergency per Microbial Organisms Causing Specific Types of Urinary Tae Infctons Gearptcted arphted | imple Cutan Mestalanonan Simro preanwatiy Ui" Smecras ° * a cesire {rdf pnt. int mab gett me nd $3 a eptapetnn ovens haan serene seeatpaaile erin Fay Py 995em seth Sve, pyr and ter festanes oF epper OTF, 98 pera ad sete py eps Tn the abvence of ever percent sr ion serrate ignores! However, ptonne thir fey pavers wt eae Drelanphrts have ver 20 percent of "dey pens, he predominant pmptoms ‘ve eaftoimestin! or pulmonary Fever {nt leaocytosr ae of ile value in diag ‘osingacte pyelonephritis in patients wo ase indvelling Nader eaters especialy when nections ae caused by granite ‘ocr Cami’ The df diagno is of acute pyelonephritis indudes pec inflammatory sas, colecytisssppem Actin lower lobe pneumonts, perforated ‘isa and the prodrome o herpes 2st, "Upto percent of wren psig wh csi ike sypora bate upper ae tet smolvement (ei elon bat hese fever andioacrossre Tyce ay so ative nanos ap ths me ee Shane ptneptain ommon in progant women Sndpatentrhreaerent TT Sabet, mmunonupprenin, feral ras patolgy pew us OTT oesuring bore 12 year of ape Inthe sence af abstraction (tua Ladder eck bntruchonclarged prot), sete peoners an be extrema sree federated ay Png tars ho have nda Ing oader cothete. The Authors Sate tem ene re ety hone ‘Soest te neal rats tabernacle oy recency tow Umaty Ono oth Seana ore (SS kere te snp © ey pay ey ‘Seger athe os hopin Serb Shot aca as coragondene EfironSamaernan MD, ety {ra ren tone i et a 936 Anois iy Pin stadt Diagnostic Testing Urinals and ain cure confi the ‘lagaons of cue pylons The com tsntut definion of pyeonephii sal Tika bythe lactis Diseass Society of America [IDSA is ine clare sowing let 10,000 cloy-forming unis (CFE) fer mn and symptoms compatible wih he dings? Cowen count 000798999 (CHU per?) ae of concer in sen ad reqant rome. Ureespecieas gene Sy are obtained by 2 mista lan Catch technique amd one sly" sowed Uh dcansing des not dezeare conta tion rates nada yuri ie prem almost ll patie wich acute pyelonephritis and canbe eat apy th he oakoeyte esterase tes orth nite tot The combination of the lucy eters i ite et th 4 postive elt un ete fee UTT Gore ‘resi but let senate than eter teat lone (Tale 3.5%" although white ell ‘Gate may be obervod nor condtions, they ary along wit ober fetuses of UTE, speci for acute pylnep hei Hemataria say be preset ations wth sis nd Prdoneseis? in some complicated cases, Gram stain nly of eine can aid i the cee of inal sabi therapy Another option fe the ae ofthe antbedy-outed bacteria ss wich maybe Help e Joaiing ‘blnicl upper UTIs ‘Urine caltes re postivein 0 percent of pants eth ate plone and cle ‘uespecimenssoaldbeebtinedbeoeln- tation of antibie thersp. Blood caluzes Tve been recommended for hospitalized patents up to 20 percent of these paints Ee postne care two ston omever, completion of Bod clare i otreautin changes management sate fies inpatient with sate pylonepri ‘Theres no evidence that poste local ‘ure indicate x more piste course in thers eal persons ith pelonephr ths Therefore, lod exter are sndeted ‘ont if there ss ingeoie uncertain, the lent isimmanosippesid rhea Sane ware pect—_————$—————— Laboratory Diagnosis of Urinary Tract Infection me Prag Senay Os Seah eran 5 acer Tess see lesen es? Pie hem Stoo ves Peat seas srt ‘a wr doe hp oman on trea rh ——$———— ‘Treatment vel eur far a alowap an have de Although pains wih acute pylonephst. gate roca suppart™ [Pigue2). Patents ts eudtonally have been hospalzed snd wit completed sate pytonepisite no treated with ineavenousantblovs, tpae Me more iot hve not spend footy Peat oral sheapy i sacesfa 90 percent Ue apy shou be beptaed. Ung ofeeleted patents uncompleted sate spec hopiaton eter Tae 4)! op Pieloephits who can alate rl ithe, 1970 percent of patents can be lected or ‘albecomplant whe werimenrepimen, ouput asaprent. Another opto is Inial thespy ty parenteral snips in eee 0 Halt Hien i, Solow Ep Fae ‘eal therapy aa tpt" eee ences ‘Of the cmmon uropsthngens resistance aie sane Fats t© Duoroquinolanes remains my ow to ith Acute Pyeloneh 3 percent” Paeoguiolas ae abrbed ‘mets arose ‘el rm he patrons act and ave Posten ents ‘allen dey peettion In ‘ete patents wth moderate Pogeten oncom seis severe acute pyeloneprlis i eee Gln oateomes ere gui eet Tent with irre aol Relate indore ‘pofnacin (ipo heap" ams Therefore, fr emplr thepy in wrap Desomc ury va saat cated aut yelanepit, he IDSA reo remsocinpomeed dates mas ‘ends the wo ofa oral anroquinione™ ‘rensdisctcceen cranonsind (Table Sh Oral scsi clavulanate rectum anon tdoour Potion (Augaentn). + cephaprin, fan sowie aoe nd trimethoprim sltrcthowszle (TM NOK ete, Sepa) pre acepesble rawenr wnt erates fr surepieorenima” eto eee ‘The US. Food and Drog dination laid Harequinloes ss pregnancy Pyelonepivitis Urine ctu shou be sbtined betes rion ar 208 ane Ke epay bri Ps 937Evaluation and Management of Acute Pyelonephritis [Raman iteaspentarene cama | romano arma [apace eect | cpt toga» oaemme | Fire 2 Agorth fr the ealsion ond mangarant of cute prone (UT = wary Wat fen Ween sme of salto caused by gram-positive Organi. Some pysicans administer 3 ‘dnp preteral dose ofan anit (et Cateory Cdeugs and ther we shou be {Noid ia prgaant women. Amoxilia oe Ssmoselin-daulaste poassusn is Tee ed ing gamity nad toe tee 938 Ameien Fmd Msi eons [Roce get [GarayPyelonephrits sinh oes Suorogeinoloe) belorenting the putin ceqicesboptlation, the fa therapy bu there litle evidence IDSA gullies” commend one of hee that his Sep improves outcome Table $ intial raves beri (1) ero reviews ttimicrebial ager wed in the aloe; (2) aa sminoivosce wth or th treatment of sate plone ut ump or 3) am ertended specu ‘Antimicrob Agents Used inthe Treatment of Acute Pyelonephitis oat font Dasrosieaie into comets maui ceuina ben b6 Bho bas Gialeetest sngciinsibetan— Garytsha = ‘0 io200m —hdectece tra eke) cron fanzan] Sie Bhows vers Pros: se atc roster snl) ey stows 053 Nove Focssinemol Eeyshows Be Sisbestecs: procs Porectnasccam — Eaysivanovs sarsgisy — Gineeetecs a ‘e oes rrr Tepclndaninate Be Ateshows = ae late tec aes ‘nen epntepone close (exer) Ean/9t0 Dans — ters ‘mromtebis Corin eed ey Shue siasewtaaet Foreuiotones Spotonen(cht) Bey ews so UO Nach rai eminem mun ifereied) fp 2hnous agp prorve easy cud Geen) yess — 0m Frege soy Lewin inenn) beet 50 aang tng loratbacriMsagin eer 2hous 4D regune cesey Stoner iewn) Say hewn 200ie Ase mg eure eatiey © Arinehrsies Aviso famiin) ey Rhos — ‘smapertg nro eprnty eer2sros Stoimgperig Oneal repnty Beaks = Sto7mgperiy Oma reply TWmsiO wacrm, ey I2tows enw IO mBpATAD CD een aa ste, ‘cobs games staat e se ates enh 205 one Kar eeainenity Aner any Pisa $39huloporn wi or without an amiaogy Soni, Wit gram-pouive ccs, amp Ti-ubctam TUnasy) with or thot an aminogyemside ss eormmended Amino ‘Orne sold be ede inpatient wit Dreerising cena dieue: Oral teatment ‘Sublets toon ay the patient becomes febrile, has improved cnc and an Colt ofl draten and medication. Tit otnecesazy toa the ne agent for Dh Parenter! and oral therapy Thee i 0 bene oe additonal hota beeen so determine the success of switching 0a oral ante" 1 ever to Hy ous of anit is flv in women who are nmunocage. fect ané donot have undrig Mnes = Stubs" Sgt hat tay asta oly Shortt abiotic ‘therapy re ay) ie ‘sapproprite nthe weet nent of ti rere in Dates wo hve seb {loutepylonepts. {ve co seven dass comparable (oveven te Hay in tes Sf cinta! and tectelope (utore in pais with ld Drlonpv and oe fp drat tal sapere Uorbeapy cate plage pepe geome SUt tozhaayenane of fio. sogpinolane or TMPSNOE® P-rentent “winecatresarereconmendedinallatens te flor ie ne to tw wos et ‘Smpletion of ane teepy™ eer generally rests win 72 houts of urting anc therapy. asd of hosialined patients who had no oxi tions, however 36 pete ed eee 148 hour, and 13 percent were ble a 72 hous Tus pertsece of eter fer 7 (etn nos ahr stb ad ogrring tint may sot aceney nranta ange [ncherapy o further investigation, “The 190 tod. commen crocs 9 i til treatment, Sms and ephrliasie ta the abuence of clini pone, meny phan bain = Sod count rinses and od ana urne lore, seking a indian of peitng {nection and ait eines nor, ‘heres crdeneto ppt heroine fi of thew tent ect arvana 0 ation shoul be performed 340 amin Fan Myon cnt ogaty Teaging ste may identify compli tog ctor such a anatomic abnormal ‘sex obstruction, sate bacterial nop (localized: nontigeiedinterstilsae ‘aaton) or sabjcent infections such a Appendicits. cholecystitis or pernephrc Sheen [Figure 2) Options inde plain ography of the Laleeys, aneer and Dade: renal ultrasonography; computed ‘omographie(CT) an; magetc resonance Invging td intavenoue petogeapy. (0 ‘ontptients ltrsounderamieution en: fies cute acter nephritis, abscess Atte obstruction, an hyronephrel ‘Acute acter nepits may progress co ‘rank abscess aed reguees a protected cure of tatbitee rena ulrasonege- yas tn defines son ul shows marked eal enlargerent, or invitee tion is being camsidred » CT scam can ‘eld renal and penne abcetes Dierences beeween UTI in men and women Sapper ect of ae {nts pyelonephritis st complentd. Men onge thar yea witout aration, Fetal sboormalii, ue pati eopon slo 1 qe of snbinctheapy Meno ve rearent UTs rege «sewed rep nen. Men with act pst requ oar wes of eaten with ana ha as Tigh penetaton ino pesatc sue, sich ss aeylice (Viera), TMP-SMX, oe Fhoroguinotne; ea with hn pros request to 12 weak of auch dheapy> “The optimal duration of texte for hospi (see patents days ‘Shorter anti therapy he ay), ‘which apropeize in he weet of tts, ess in 5D percent repeat tents eth ube! seat poner fis The mos rol instr of rement Hike i pectic Slog cabeee patents with reamed ee? 1 ape Bote afer two-week cours of ant. ice andro urge somal found fon imaging, the aropatogen and srs Gites should be cnfrmed and treatment ‘tended toscwece, Trthe pathogen casing eitetion is deen from the oral pathogen, 0 seeks of treaaent ae slider: Ieate reese fay exiting bsteuctan com bad wih a H-daycoare of spproprate tethiedes,inttcs oe sed oa ence? Rel abtuction snd antboie hespy may be saccel ia exphyse aE! preteepctriy bal aera) Sst be onghy considered ip pains Soth unresponsive itetons paren Chal involvement incoding abscesses Si aberved, Longer cours of antics finuavenous or ora or sequential theapy saybenecstry Pregnant women with pysonephetis require bospilization (for atest + sort ‘bien period) for aggresive yar tion and parenteral antec. Annie teeteat ie sila to the treatments of oer aul regineas. Duras pregeancy, 85 percent of Women have atin con traction in the fit how afer nation of antiicrbaltherpy, and 50 perce entiaue to bate comrctons after Bre hours af they" One stacy" found m0 ieee in clinil responer song Pee aot women trv ah soins feamicn, clin (Anco elise fae, Fluoroquinolone should be awided becase of concerns about thee teratogenic sfc on hee! ‘Most pins with wild acae pyelone- pcs wi ar pegoant (9 percent ean lostedauceeflywihpaeneral anit Tes under bei (to 24 hates) obser ‘on. fllowe by outpatient eral heap ough some experts tte that selected fens uy betes saely witha l= Tots thee hetcbenten tpn alta vc eral therapy aloe war ued” Because 25 pecent of pant wl daca Peo ‘epee are pregranthavesrecurtence, ‘ture or animsrbil supprenion is Srl nheouraios (Maerodsmtin, 109 mg ath ntl fue lox weeks parts All pegnct women, pec Une wie lbs diabetes and haa previous UTHsbould Ye serene fr asymptomatic bacteria op cee eet ‘No antibiotic prophyase is etetve in reducing. complications associated with Indweling eather. Sele tsertion and cave ofthe catbete,minimitng the dure ‘om of eatheteaton interment cath Bette: Geel desis fries al Sher allay-conted eather may reduce the ‘aot eympomaiinfsion mes daniel ee ese ‘Sea monpaua” eas re oer eats eosin hreene inet way sheesh es El a rte swe Tom a Sec sae kre. enol ramen rer ee in Bromessem oate ereapayale Ame ami sci 944