II. Definitions
- Pyelonephritis
- Upper Urinary Tract Infection involving Kidney
III. Epidemiology
- Accounts for 200,000 hospitalizations annually in U.S
- Highest Incidence in otherwise healthy women ages 15 to 29 years
IV. Causes
- Ascending infection via Bladder and ureter (most cases)
- Hematogenous spread
- Prostatitis or Benign Prostatic Hyperplasia
- Serious comorbid chronic illness
- Immunocompromised patients
- Hematogenous spread of staph. or fungal infection
V. Etiologies
- Normal host
- Escherichia coli (80%)
- KlebsiellaPneumoniae (3-6%)
- Staphylococcus saprophyticus (<3%)
- Other Gram Negative Bacteria (e.g. Proteus, Enterobacter)
- Enterococcus
- Elderly
- Escherichia coli (60%)
- Proteus
- Klebsiella
- Serratia
- Pseudomonas
-
Urinary Catheter associated infection
- Bacteriuria in 50% at 5 days, and 100% at 30 days
- Mixed Bacterial Infection
-
Diabetes Mellitus
- Klebsiella
- Enterobacter
- Clostridium
- Candida
- Immunosuppression
- Aerobic, Gram Negative Rods (non-enteric)
- Candida
VI. Risk Factors: Pyelonephritis in women
- Frequent sexual intercourse in prior month (3 times weekly)
- New sexual partner in the last year
- Recent Spermicide use
- Family History of Urinary Tract Infections (esp in patient's mother)
- Prior Urinary Tract Infections in the last year
- Diabetes Mellitus
- Stress Incontinence in the last 30 days
VII. Risk Factors: Antibiotic Resistance
- Frequent medical care
- Recent antibiotic use (esp. Fluoroquinolones, Cephalosporins)
- Advanced age
- Recurrent Urinary Tract Infections
- Diabetes Mellitus
VIII. Risk Factors: Complicated Pyelonephritis (with higher risk of complications such as abscess, Antibiotic Resistance)
- Age under 1 or over 60 years
- Abnormality (Polycystic Kidney, Vesicoureteral reflux)
- Obstruction (Nephrolithiasis, BPH, tumor)
- Immunocompromised (Diabetes, HIV, Corticosteroids)
- Indwelling Urinary Catheter
- Pregnancy
IX. Symptoms
- Fever
- Chills and malaise
- Flank Pain
- Nausea and Vomiting
-
Acute Cystitis symptoms
- Dysuria
- Urinary Frequency
- Urinary urgency
X. Signs
- Fever
- Tachycardia
- Hypotension
- Costovertebral Angle Tenderness
- Abdominal tenderness (esp. suprapubic tenderness)
XI. Diagnosis
-
Fever over 100.4 F
- May be absent early in course
- Not uniformly present in elderly (only in 80%)
- Not uniformly present in catheter-associated UTI
- Flank Pain
- Urinalysis with bacteriuria and pyuria
XII. Labs
-
Urinalysis
- Leukocyte esterase or nitrite positive
- Microscopic Hematuria may be present (contrast with Gross Hematuria in Acute Cystitis)
- Microscopic examination may show WBC Casts
- Consider urine Gram Stain where available
- Gram Positive Cocci suggests Enterococcus or Staphylococcus saprophyticus
-
Urine Culture (positive in 90% of Pyelonephritis)
- Manditory in all suspected cases of Pyelonephritis
- Diagnosis requires at least 10,000 CFU/mm3
- Consider lower threshold in men and in pregnancy
-
Blood Culture indications (positive in up to 30% cases, obtain in severe infection or hospitalized patients)
- Immunocompromised patient
- Unclear diagnosis
- Hematogenous source suspected
- Other labs
- Urine Pregnancy Test
- Serum Creatinine
- Complete Blood Count
- Other testing as indicated by differential diagnosis in unclear cases
XIII. Imaging
- Modalities
- CT Abdomen with contrast (preferred in non-pregnant patients)
- Renal Ultrasound (pregnant patients)
- Renal MRI (specific indications as directed by local Consultation)
- Indications
- Not routinely indicated in uncomplicated Pyelonephritis
- Reserve for recurrent or refractory infections, critcial illness, new Renal Failure, suspected ureteral stone
XIV. Differential Diagnosis
XV. Disposition: Hospitalization indications
- Inability to stay hydrated and take medications orally
- Comorbidity
- Diabetes Mellitus
- Underlying urologic or renal disorder
- Severe liver disease
- Severe heart disease
- Noncompliance
- Uncertain diagnosis
- Male gender
- Toxic appearance
- Severe illness with high fever (>103 F)
- Severe flank or Abdominal Pain
- Debilitated condition
- Pregnancy (some cases may be treated outpatient)
XVI. Management: Pregnancy
XVII. Management: Oral agents for acute uncomplicated non-pregnant cases
- Treatment course
- Uncomplicated Pyelonephritis: 7 days
- Complicated Pyelonephritis: 14 days
- Indicated in Urinary Tract Obstruction, male gender, immunosuppression
- Consider a single initial dose of IV antibiotics if Emesis (see below)
- Example: Ceftriaxone 1 g IV in Emergency Department
- Preferred agents: Fluoroquinolones (if community E. coli resistance rate <10%)
- Ciprofloxacin 500 mg orally twice daily for 7 days
- Ciprofloxacin XR 1000 mg daily for 7 days
- Levofloxacin 750 mg orally daily for 7 days
- Alternative agents (higher resistance rates, accompany with initial dose of a broad spectrum IV antibiotic)
- Amoxicillin-Clavulanate (Augmentin) twice daily for 14 days
- Trimethoprim-Sulfamethoxazole (Bactrim) twice daily 14 days
- Cefixime 400 mg orally daily
XVIII. Management: IV agents in non-pregnant patients
- Duration of treatment
- Convert from IV to oral in first 48-72 hours
- Preferred Agents: LOW risk for Bacterial resistance
- Ciprofloxacin 400 mg IV twice daily
- Levofloxacin (Levaquin) 750 mg IV daily
- Ceftriaxone (Rocephin) 1000 mg IV q24 hours
- Preferred Agents: HIGH risk for Bacterial resistance
- Ertapenem 1 g IV every 24 hours
- Meropenem 1 g IV every 8 hours
- Piperacillin-Tazobactam (Zosyn) 3.375 g IV every 6 hours
- Cefepime 2 g IV every 12 hours
- Alternative regimens
- Gentamicin 5 mg/kg IV every 24 hours
XIX. Complications
-
Perinephric Abscess
- May also occur secondary to Staphylococcus aureus bacteremia
-
Emphysematous Pyelonephritis
- Occurs in older women with Diabetes Mellitus
- Infection produces intraparenchymal gas
- Associated with papillary necrosis and Renal Failure
-
Urinary Tract Infection due to obstruction
- Associated with Nephrolithiasis, BPH, or tumor
- May result in renal abscess and severe infection
- Malacoplakia (rare)
XX. References
- (2019) Sanford Guide, accessed on IOS 10/19/2019
- Escobar in Marx (2002) Rosen's Emergency Med, p. 1401
- Colgan (2011) Am Fam Physician 84(5): 519-26 [PubMed]
- Gupta (2011) Clin Infect Dis 52(5):e103-20 +PMID:21292654 [PubMed]
- Hooton (2003) Infect Dis Clin North Am 17(2):303-32 [PubMed]
- Ramakrishnan (2005) Am Fam Physician 71(5):933-42 [PubMed]
- Roberts (1999) Urol Clin North Am 26:753-63 [PubMed]
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Related Studies
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, ジンウジンエンNOS, ジンウジンエン, ジンウジ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 |
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, キュウセイジンウジンエン, キュウセイジンウジンエンNOS |
Czech | Akutní pyelonefritida NOS, Akutní pyelonefritida |
Hungarian | Acut pyelonephritis, Acut pyelonephritis k.m.n., acut pyelonephritis |