PYELONEPHRITIS

Nauman Khalid
 Etiology
• Inflammation of the
structures of the kidney:
– the renal pelvis
– renal tubules
– interstitial tissue
• Almost always caused by
E.coli
Klebisella, proteus
enterobacter,
pseudomonas, serratia
 Etiology
• Usually seen in association with:
– Pregnancy
– diabetes mellitus
– Polycystic
– hypertensive kidney disease
– insult to the urinary tract from catheterization,
infection, obstruction or trauma
What happens to the kidney?

• The kidney becomes

edematous and inflamed
and the blood vessel are
congested
• The urine may be cloudy and
contain pus, mucus and
blood
• Small abscesses may form in
the kidney
 Clinical Manifestations

• Acute pyelonephritis may be unilater or bilateral,

causing chills, fever, prostration and flank pain.
• Studies has shown that chronic pyelonephritis may
develop in association with other renal disease
unrelated to infection processes
• Azotemia (the retention in the blood of excessive
amounts of nitrogenous compounds) develops if
enough nephrons are nonfunctional
 Signs and Symptoms
• Subjective Data in acute pyelonephritis:
– pt will become acutely ill, w/ malaise and pain
in the costovertebral angle (CVA)
– CVA tenderness to percussion is a common
finding
• In the chronic phase the pt may show
unremarkable symptoms such as nausea and
general malaise
Costovertebral Angle (CVA)
      Chronic Pyelonephritis
The autopsy specimen
consists of a bisected
kidney which is
markedly shrunken
because of chronic
inflammation and
Scarring.
(B) multiple calculi in
the proximal ureter
(A) Calyceal system 
 Signs and Symptoms
• Objective data includes assessing the pt for:
– Elevated Temperature
– Chills
– Pus in the urine
• Systemic signs may show chronic disease:
– elevated BP
– Vomiting
– Diarrhea
Physical Examination
• Vital signs
• Appearance
variable.commonly, the patient is uncomfortable or
appears ill.
• Patients usually do not have a toxic
appearance unless an underlying problem,
such as sepsis, perinephric abscess, or
significant dehydration, is present.
• Abdominal examination
• Suprapubic tenderness
– mild to moderate without rebound.
– Abdominal tenderness other than in the suprapubic area
suggests another diagnosis.
• Bowel sounds

• Flank or costovertebral angle (CVA) tenderness

– Usually unilateral over the involved kidney,

– Discomfort ….from absent to severe.

– usually not subtle and may be elicited with mild or moderately firm
palpation.
• Pelvic examination
– Tenderness of the cervix, uterus, and adnexa should be
absent. Any positive finding suggests an additional or
alternative diagnosis.
– If any doubt remains as to the diagnosis, if any signs or
symptoms of urethritis or vaginitis are present, or if a
history of dyspareunia is present, a gynecologic cause of
the symptoms should be pursued and excluded.
 Diagnostic Tests

• Urine analysis
• Urine culture
• Complete blood counts
• Blood cultures
 Imaging studies
• Imaging may be warranted if the presentation is atypical or confusing
• also warranted if the patient deteriorates or does not respond to therapy.
– The patient has a fever or positive blood culture results that
persist for longer than 48 hours.
– The patient’s condition suddenly worsens.
– Toxicity persists for longer than 72 hours.
– The patient has a complicated UTI
• Contrast-enhanced helical/spiral computed tomography
scan (CECT) is the imaging study of choice when there
is suspicion for the development of a complication of acute
pyelonephritis, both in adults and in children
• CECT
• MRI
• 99mTc-DMSA scintigraphy

equivalent in their sensitivity and reliability to

detect acute pyelonephritis
• IVP will Identify the
presence of obstruction
or degenerative changes
caused by the infection
process
• BUN and Creatine levels
of the blood and urine
may be used to monitor
kidney function
 Treatment

• Supportive care
– Rest
– Antipyretics as needed
– Oral or parenteral pain medications as needed
– Oral or parenteral antiemetics as needed
– Urinary tract analgesics to relieve dysuria (up to 3 d)
– Intravenous or oral fluids to maintain hydration status
• Reasons for hospital admission
– Cannot tolerate oral intake
– Unstable social situation (eg, possibility of poor
compliance or poor follow-up)
– Unstable vital signs
– Severe signs and symptoms systemic illenss
– Pregnancy
– Comorbid disorders that increase the complexity of
management or the complication rate (eg, diabetes
mellitus, chronic lung disease, congenital or acquired
immunodeficiency syndrome)
 Accepted outpatient regimens
• Administer ceftriaxone (1 g IV/IM) or gentamicin (single 24-h
dose or divided q8h) or tobramycin (single 24-h dose or
divided q8h) on day 1, followed by an oral fluoroquinolone
from day 2 to days 10-14.
• Prescribe oral fluoroquinolone for 10-14 days.5,6
• Prescribe amoxicillin-clavulanate potassium for 14 days.
• Prescribe trimethoprim-sulfamethoxazole or trimethoprim
or oral cephalosporin for 14 days. Use only if the organism is
known to be sensitive.
• If beta-lactam drugs and fluoroquinolones are
contraindicated, administer aztreonam parenterally; as such,
the patient will need to be admitted.
 If enterococci are suggested based on Gram stain
results, then ampicillin or vancomycin can replace
fluoroquinolone.
 Available Combinations
 ampicillin and an aminoglycoside,
 Cefepime
 Imipenem
 Meropenem
 piperacillin-tazobactam
 ticarcillin-clavulanate. If the patient is allergic to penicillin,
substitute vancomycin
 Oral Or needle?
• Both regimens are equally efficacious. If the patient can
tolerate oral medication, there is no indication for
admission, and the patient can be monitored closely to
ensure good compliance. An oral antibiotic therapy only
regimen appears to have increasing efficacy
 Prognosis
• Prognosis is dependent upon early detection
and successful treatment
• Baseline assessment for every pt must include
urinary assessment because pyelonephritis
may occur as a primary or secondary disoder