Acute Pyelonephritis

Aka: Acute Pyelonephritis, Pyelonephritis

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II. Definitions

  1. Pyelonephritis
    1. Upper Urinary Tract Infection involving Kidney

III. Epidemiology

  1. Accounts for 200,000 hospitalizations annually in U.S
  2. Highest Incidence in otherwise healthy women ages 15 to 29 years

IV. Causes

  1. Ascending infection via Bladder and ureter (most cases)
  2. Hematogenous spread
    1. Prostatitis or Benign Prostatic Hyperplasia
    2. Serious comorbid chronic illness
    3. Immunocompromised patients
    4. Hematogenous spread of staph. or fungal infection

V. Etiologies

  1. Normal host
    1. Escherichia coli (80-90%)
    2. Klebsiella Pneumoniae (3-6%)
    3. Staphylococcus Saprophyticus (<3%)
    4. Other Gram Negative Bacteria (e.g. Proteus, Enterobacter)
    5. Enterococcus
  2. Elderly
    1. Escherichia coli (60%)
    2. Proteus
    3. Klebsiella
    4. Serratia
    5. Pseudomonas
  3. Urinary Catheter associated infection
    1. Bacteriuria in 50% at 5 days, and 100% at 30 days
    2. Mixed Bacterial Infection
  4. Diabetes Mellitus
    1. Klebsiella
    2. Enterobacter
    3. Clostridium
    4. Candida
  5. Immunosuppression
    1. Aerobic, Gram Negative Rods (non-enteric)
    2. Candida

VI. Risk Factors: Pyelonephritis in women

  1. Frequent sexual intercourse in prior month (3 times weekly)
  2. New sexual partner in the last year
  3. Recent Spermicide use
  4. Family History of Urinary Tract Infections (esp in patient's mother)
  5. Prior Urinary Tract Infections in the last year
  6. Diabetes Mellitus
  7. Stress Incontinence in the last 30 days

VII. Risk Factors: Antibiotic Resistance (Multi-Drug Resistance)

  1. Frequent medical care
  2. Advanced age
  3. Diabetes Mellitus
  4. Recurrent Urinary Tract Infections
  5. Indwelling Urinary Catheter
  6. Urologic Abnormalities
  7. Hospitalization within last 3 months
  8. Travel outside the United States in last 30 days
  9. Recent Antibiotic use within last 3 months
    1. Fluoroquinolones
    2. Cephalosporins
    3. Antipseudomonal Penicillins
  10. History of multi-drug resistant urine isolates
    1. Extended-Spectrum Beta Lactamase Producing Organisms (ESBL Resistance)

VIII. Risk Factors: Complicated Pyelonephritis (with higher risk of complications such as abscess, Antibiotic Resistance)

  1. Age under 1 or over 60 years
  2. Urologic Abnormality
    1. Polycystic Kidney
    2. Vesicoureteral reflux
  3. Urinary Tract Obstruction
    1. Ureterolithiasis
    2. Benign Prostatic Hyperplasia
    3. Urinary tract tumor
  4. Immunocompromised State
    1. Diabetes Mellitus
    2. HIV Infection
    3. Corticosteroids
    4. Sickle Cell Anemia
    5. Organ Transplant
  5. Indwelling Urinary Catheter
  6. Pregnancy
  7. Male gender

IX. Symptoms

  1. Fever
  2. Chills and malaise
  3. Flank Pain
  4. Nausea and Vomiting
  5. Abdominal Pain or Suprapubic Pain
  6. Acute Cystitis symptoms (absent in 20% of cases)
    1. Dysuria
    2. Urinary Frequency
    3. Urinary urgency

X. Signs

  1. Fever
  2. Costovertebral Angle Tenderness
  3. Abdominal tenderness (esp. suprapubic tenderness)
  4. Sepsis signs
    1. Tachycardia
    2. Hypotension

XI. Diagnosis

  1. Fever over 100.4 F
    1. May be absent early in course
    2. Not uniformly present in elderly (only in 80%)
    3. Not uniformly present in catheter-associated UTI
  2. Flank Pain
  3. Urinalysis with bacteriuria or pyuria

XII. Labs

  1. Urinalysis
    1. Leukocyte esterase or nitrite positive
    2. Microscopic Hematuria may be present (contrast with Gross Hematuria in Acute Cystitis)
    3. Microscopic examination may show WBC Casts
    4. Consider urine Gram Stain where available
      1. Gram Positive Cocci suggests Enterococcus or Staphylococcus Saprophyticus
  2. Urine Culture (positive in 90% of Pyelonephritis)
    1. Manditory in all suspected cases of Pyelonephritis (before Antibiotics given)
    2. Diagnosis requires at least 10,000 CFU/mm3
    3. Consider lower threshold in men and in pregnancy
  3. Blood Culture indications (positive in 10-40% cases, obtain in severe infection or hospitalized patients)
    1. Immunocompromised patient
    2. Unclear diagnosis
    3. Hematogenous source suspected
    4. Failure to improve after 48-72 hours
    5. Predominant organism not clear with Urine Culture
      1. Indwelling catheterization
      2. Antibiotic use preceded Urine Culture
  4. Other labs
    1. Urine Pregnancy Test
    2. Basic metabolic panel with Serum Creatinine
    3. Complete Blood Count
    4. Other testing as indicated by differential diagnosis in unclear cases

XIII. Imaging

  1. Indications
    1. Not routinely indicated in uncomplicated Pyelonephritis
    2. Recurrent or refractory infections
    3. Critical Illness (i.e. Sepsis)
    4. New Acute Renal Failure (GFR <40 ml/min)
    5. Suspected Ureteral Stone (infected Ureteral Stone requires emergent intervention)
    6. Known urologic abnormalities
    7. Failed response to Antibiotics after 48 to 72 hours
  2. Modalities
    1. CT Abdomen with contrast (preferred in non-pregnant patients)
    2. Renal Ultrasound (pregnant patients)
    3. Renal MRI (specific indications as directed by local Consultation)

XIV. Differential Diagnosis

  1. Pelvic Inflammatory Disease
  2. Acute Cholecystitis
  3. Appendicitis
  4. Pneumonia

XV. Disposition: Hospitalization indications

  1. Inability to stay hydrated and take medications orally
  2. Failed outpatient management
  3. Pregnancy (some cases may be treated outpatient)
    1. High morbidity and mortality compared with other cohorts (Sepsis occurs in up to 17% of cases)
    2. High risk of recurrence
  4. Severe illness
    1. Sepsis or Toxic appearance
    2. High fever (>103 F)
  5. Severe, intractable flank or Abdominal Pain
  6. Comorbidity, esp. if unstable (relative indications)
    1. Diabetes Mellitus
    2. Underlying urologic or renal disorder
    3. Severe liver disease
    4. Severe heart disease
    5. Debilitated condition
  7. Other (relative indications)
    1. Noncompliance
    2. Uncertain diagnosis
    3. Male gender

XVI. Management: Pregnancy

  1. See Pyelonephritis in Pregnancy

XVII. Management: General Measures

  1. Treat as Sepsis if consistent with presentation
  2. Oral or Intravenous Fluid hydration
  3. Analgesics and antipyretics
    1. NSAIDs
    2. Acetaminophen
  4. Antiemetics
    1. Ondansetron

XVIII. Management: Oral agents for acute uncomplicated non-pregnant cases

  1. Outpatient management with oral Antibiotic indications
    1. Tolerating oral Antibiotics and oral fluids (with or without oral Antiemetics)
    2. No signs of Sepsis
    3. Non-pregnant
    4. No absolute hospitalization indications (see above)
  2. Treatment course
    1. Course 7 days
      1. Uncomplicated Pyelonephritis
      2. Fluoroquinolones course is typically 7 days in all Pyelonephritis cases
        1. Eliakim-Raz (2013) J Antimicrob Chemother 68(10):2183-91 [PubMed]
    2. Course 10-14 days
      1. Complicated Pyelonephritis
        1. Urinary Tract Obstruction
        2. Male gender
        3. Immunosuppression
      2. Beta-Lactams (Augmentin, Cephalosporins) course is typically 10-14 days
      3. Trimethoprim-Sulfamethoxazole course is typically 14 days
  3. Consider a single initial dose of IV Antibiotics if Emesis or community Antibiotic Resistance>10% (see below)
    1. Ceftriaxone 1-2 g IV or
    2. Ertapenem (Invanz) 1 g IV or
    3. Gentamicin 5 mg/kg IV or
    4. Plazomicin (Zemdril) 15 mg/kg
  4. Preferred agents: Fluoroquinolones (if community E. coli resistance rate <10%)
    1. See Fluoroquinolone for associated adverse effects (Informed Consent with patient)
    2. Ciprofloxacin 500 mg orally twice daily for 7 days
    3. Ciprofloxacin XR 1000 mg daily for 7 days
    4. Levofloxacin 750 mg orally daily for 7 days
  5. Preferred agent: Trimethoprim-Sulfamethoxazole
    1. Trimethoprim-Sulfamethoxazole (Bactrim) twice daily for 14 days
  6. Alternative agents (higher resistance rates, accompany with initial dose of a broad spectrum IV Antibiotic)
    1. Amoxicillin-Clavulanate (Augmentin) twice daily for 10-14 days
    2. Cefixime (Suprax) 400 mg orally daily for 10-14 days
    3. Cefpodoxime 200 mg orally twice daily for 10-14 days
    4. Cephalexin (Keflex) 500 mg orally twice daily for 10-14 days
  7. Precautions
    1. Do NOT use Nitrofurantoin or fosfomycin
      1. Inadequate renal penetration to treat Pyelonephritis

XIX. Management: IV agents in non-pregnant patients

  1. Duration of treatment
    1. Convert from IV to oral in first 48-72 hours
  2. Preferred Agents: Patients at LOW risk for Bacterial resistance
    1. Ciprofloxacin 400 mg IV every 12 hours
    2. Levofloxacin (Levaquin) 750 mg IV every 24 hours
    3. Ceftriaxone (Rocephin) 1 to 2 g IV q24 hours
  3. Preferred Agents: Patients at HIGH risk for multi-drug Bacterial resistance
    1. Ertapenem 1 g IV every 24 hours
    2. Meropenem 1 g IV every 8 hours
    3. Piperacillin-Tazobactam (Zosyn) 3.375 to 4.5 g IV every 6 hours
    4. Cefepime 2 g IV every 12 hours
    5. Ceftazidime/Avibactam (Avycaz) 2.5 g every 8 hours
    6. Ceftolozane/Tazobactam 1.5 g IV every 8 hours
    7. Imipenem/Cilastin (Primaxin) 500 mg every 6 hours
    8. Meropenem/Vaborbactam (Vabomere) 2 g every 8 hiurs
    9. Plazomicin (Zemdril) 15 mg/kg IV every 24 hours
  4. Alternative regimens
    1. Gentamicin 5 mg/kg IV every 24 hours

XX. Complications

  1. Perinephric Abscess
    1. May also occur secondary to Staphylococcus Aureus bacteremia
  2. Emphysematous Pyelonephritis
    1. Occurs in older women with Diabetes Mellitus
    2. Infection produces intraparenchymal gas
    3. Associated with papillary necrosis and Renal Failure
  3. Urinary Tract Infection due to obstruction
    1. Associated with Ureterolithiasis, BPH, or tumor
    2. May result in renal abscess and severe infection
    3. Infected Ureteral Stone requires emergent surgical intervention (decompression, e.g. Ureteral Stenting)
  4. Malacoplakia (rare)

XXI. References

  1. (2019) Sanford Guide, accessed on IOS 10/19/2019
  2. Escobar in Marx (2002) Rosen's Emergency Med, p. 1401
  3. Colgan (2011) Am Fam Physician 84(5): 519-26 [PubMed]
  4. Gupta (2011) Clin Infect Dis 52(5):e103-20 +PMID:21292654 [PubMed]
  5. Herness (2020) Am Fam Physician 102(3):173-80 [PubMed]
  6. Hooton (2003) Infect Dis Clin North Am 17(2):303-32 [PubMed]
  7. Ramakrishnan (2005) Am Fam Physician 71(5):933-42 [PubMed]
  8. Roberts (1999) Urol Clin North Am 26:753-63 [PubMed]

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Related Studies

Ontology: Pyelonephritis (C0034186)

Definition (NCI_CTCAE) A disorder characterized by an infectious process involving the kidney.
Definition (NCI) An acute or chronic inflammatory process affecting the kidney. It is caused by bacteria and in most cases it is the result of a urinary tract infection. Signs and symptoms include fever, chills, flank pain, painful and frequent urination, cloudy or bloody urine, and confusion.
Definition (CSP) inflammation of the kidney and its pelvis due to infection.
Definition (MSH) Inflammation of the KIDNEY involving the renal parenchyma (the NEPHRONS); KIDNEY PELVIS; and KIDNEY CALICES. It is characterized by ABDOMINAL PAIN; FEVER; NAUSEA; VOMITING; and occasionally DIARRHEA.
Concepts Disease or Syndrome (T047)
MSH D011704
ICD9 590.80
ICD10 N10-N16 , N16, N12
SnomedCT 197779009, 197784003, 45816000
English Pyelonephritides, PYELONEPHRITIS, Pyelonephritis unspecified, Pyelonephritis, unspecified, Unspecified pyelonephritis NOS, pyelonephritis (diagnosis), pyelonephritis, Pyelonephritis NOS, Kidney Infection, Pyelonephritis, Pyelonephritis [Disease/Finding], bacterial infection of the kidney, Pyelonephritis unspecified (disorder), Unspecified pyelonephritis NOS (disorder), Kidney infection, Pyelonephritis (disorder), Pyelonephritis, NOS
French PYELONEPHRITE, Pyélonéphrite, non précisée, Pyélonéphrite SAI, Pyélonéphrite
Portuguese PIELONEFRITE, Pielonefrite NE, Pielonefrite
Spanish PIELONEFRITIS, Pielonefritis NEOM, Pielonefritis no especificada, pielonefritis no especificada, SAI, pielonefritis no especificada, pielonefritis no especificada, SAI (trastorno), pielonefritis no especificada (trastorno), pielonefritis (trastorno), pielonefritis, Pielonefritis
German PYELONEPHRITIS, Pyelonephritis, unspezifisch, Pyelonephritis NNB, Pyelonephritis
Dutch pyelonefritis NAO, pyelonefritis, niet-gespecificeerd, pyelonefritis, Nefritis, pyelo-, Pyelonefritis
Italian Pielonefrite NAS, Pielonefrite, non specificata, Pielonefrite
Japanese 腎盂腎炎、詳細不明, 腎盂腎炎ＮＯＳ, ｼﾞﾝｳｼﾞﾝｴﾝNOS, ｼﾞﾝｳｼﾞﾝｴﾝ, ｼﾞﾝｳｼﾞﾝｴﾝｼｮｳｻｲﾌﾒｲ, 急性壊死性腎盂腎炎, 腎盂腎炎-急性壊死性, 壊死性腎盂腎炎, 腎盂腎炎
Swedish Pyelonefrit
Czech pyelonefritida, Pyelonefritida, Pyelonefritida blíže neurčená, Pyelonefritida NOS
Finnish Pyelonefriitti
Russian PIELONEFRIT, ПИЕЛОНЕФРИТ
Croatian PIJELONEFRITIS
Polish Zapalenie nerek odmiedniczkowe, Pielonefryt, Zakażenie górnego odcinka układu moczowego
Hungarian pyelonephritis k.m.n., pyelonephritis, Pyelonephritis, nem meghatározott
Norwegian Pyelonefritt
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acute pyelonephritis (C0520575)

Concepts Disease or Syndrome (T047)
ICD9 590.1
ICD10 N10
SnomedCT 197771007, 155862004, 266620001, 36689008, 22352007
English Acute pyelonephritis NOS, PYELONEPHRITIS ACUTE, Acute pyelonephritis, Pyelonephritis acute NOS, acute pyelonephritis, Acute pyelonephritis NOS (disorder), Pyelonephritis acute, Acute PN - pyelonephritis, APN - Acute pyelonephritis, Acute pyelonephritis (disorder), acute; pyelonephritis, pyelonephritis; acute, Pyelonephritis;acute
Italian Pielonefrite acuta, Pielonefrite acuta NAS
Dutch acute pyelonefritis, pyelonefritis acuut NAO, acuut; pyelonefritis, pyelonefritis; acuut, pyelonefritis acuut
French Pyélonéphrite aiguë SAI, Pyélonéphrite aiguë
German Pyelonephritis akut NNB, akute Pyelonephritis
Portuguese Pielonefrite aguda NE, Pielonefrite aguda
Spanish Pielonefritis aguda NEOM, pielonefritis aguda, SAI, pielonefritis aguda, SAI (trastorno), pielonefritis aguda (trastorno), pielonefritis aguda, Pielonefritis aguda
Japanese 急性腎盂腎炎ＮＯＳ, 急性腎盂腎炎, ｷｭｳｾｲｼﾞﾝｳｼﾞﾝｴﾝ, ｷｭｳｾｲｼﾞﾝｳｼﾞﾝｴﾝNOS
Czech Akutní pyelonefritida NOS, Akutní pyelonefritida
Hungarian Acut pyelonephritis, Acut pyelonephritis k.m.n., acut pyelonephritis
Derived from the NIH UMLS (Unified Medical Language System)

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