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Pyelonephritis
- 1. PYELONEPHRITIS CASE STUDY #2 CS 4. 18 KIDNEY DISEASE TRACY K HO
- 2. ACUTE PYELONEPHRI TIS • INFECTION OF RENAL PELVIS AND KIDNEY • INCIDENCE IS HIGHEST IN HEALTHY WOMEN 15 TO 29 YEARS FOLLOWED BY INFANTS AND OLDER PERSONS • SYMPTOMS: URINARY FREQUENCY, URGENCY AND PAIN FLANK PAIN AND FEVER
- 3. Diagnosis History and physical exam Urine culture Costovertebral pain fever
- 4. Treatment Antibiotics 10- 14 days Severe infection requires admission Increase fluid intake
- 5. CASE STUDY • 53 YO FEMALE C/O FLANK PAIN AND FEVER • PYURIA X 1 WEEK • HX: IDDM, TOTAL ABDOMINAL HYSTERECTOMY, HTN, OBESITY • VITALS: 105.8 F, 155/95, 84, 26RR • LEFT COSTOVERTEBRAL ANGLE TENDERNESS • LAB WORK INDICATIVE OF ACUTE INFECTION • KUB SHOWS STONE IN LEFT RENAL PELVIS • ADMITTED FOR TREATMENT
- 6. HOD 2 • BED REST • BLOOD AND URINE CULTURES OBTAINED • EMPIRIC ANTIBIOTICS • IVF THERAPY • WORSENING LEFT FLANK PAIN • REMAINS FEBRILE • IV PYELOGRAM SHOWS NON FUNCTIONING LEFT KIDNEY • LEFT NEPHRECTOMY PERFORMED • BIOPSY OF LEFT KIDNEY SHOWED STONE OBSTRUCTING PROXIMAL URETER, DILATION OF PELVICALYCEAL SYSTEM AND SCATTERED PAPILLAE WITH GRAY WHITE DISCOLORATION • TREATED FOR NEXT 2 WEEKS WITH ANTIBIOTICS AND THEN DISCHARGED
- 7. QUESTIONS TO PONDER • WHY ARE WBC CASTS SEEN ONLY IN ACUTE PYELONEPHRITIS? • WBC (NEUTROPHILS) INDICATES ACUTE INFLAMMATION
- 8. NECROTIZING PAPILLITIS • PREDISPOSING FACTORS • COMPROMISED BLOOD SUPPLY • ANALGESIC ABUSE.
- 9. PATHOGENESIS OF NECROTIZING PAPILLITIS • ACUTE PYELONEPHRITIS • OBSTRUCTION TO URINE FLOW • COMPROMISED BLOOD SUPPLY • RESULTS IN COMBINATION OF ISCHEMIA AND INFECTION
- 10. PATIENT’S RISK FACTORS • FEMALE SEX • DIABETES MELLITUS • HISTORY OF BLADDER INFECTIONS • RENAL STONE
- 11. Kidney Stones Calcium Oxalate 75% Hard, single, brown, mulberry stones Phosphate 10-15% Smooth, round, white Staghorn calculus Uric Acid 5% Multiple, yellowish, radioluscent Seen in gout Cystine 2% Seen in cystinuria Hard, radio- opaque due to sulphur
- 12. CASE STUDY 1 • USING 7 DAY COURSE OF TMP-SMX AND CIPROFLOXACIN IN TREATMENT • 272 WOMEN BETWEEN 2010- 2016 WERE DIAGNOSED AND TREATED FOR PYELONEPHRITIS, RETROSPECTIVE OBSERVATIONAL STUDY • 30% WERE GIVEN TMP-SMX • 70% WERE GIVEN CIPROFLOXACIN • RESULTS SHOWED SIMILAR RESULTS IN CLINICAL OUTCOMES • DUE TO FREQUENCY OF PYELONEPHRITIS AND RISK OF ANTIBIOTIC RESISTANCE AND ASSOCIATED TOXICITIES, USE OF CIPROFLOXACIN AS AN ALTERNATIVE CHOICE FOR TREATMENT
- 13. CASE STUDY 2 • 69 PATIENTS STUDIED RETROSPECTIVELY WITH OBSTRUCTIVE ACUTE PYELONEPHRITIS WITH UPPER URINARY TRACT CALCULI • IDENTIFY RISK FACTORS FOR SEPTIC SHOCK • MANAGEMENT OF OBSTRUCTIVE UROPATHY ACUTE PYELONEPHRITIS IS PROMPT DECOMPRESSION OF THE RENAL COLLECTING SYSTEM WITH PERCUTANEOUS NEPHROSTOMY TUBE OR URETERAL STENTING • UROSEPSIS ACCOUNTS FOR 20-30% OF ALL SEPTIC PATIENTS
- 14. CASE STUDY 3 • UTI IN HEALTHY CHILD DUE TO SALMONELLA • COMMON CAUSATIVE AGENT IS E COLI • SALMONELLA IS RARE AND DEVELOPS IN THOSE WITH STRUCTURAL ABNORMALITIES OR IMMUNE SUPPRESSIVE STATUS • UTI DUE TO SALMONELLA IS UNCOMMON AND ACCOUNTED FOR 0.65% OF ALL UTI’S
- 15. REFERENCES Colgan, R., & Williams, M. (2011). Diagnosis and treatment of acute pyelonephritis in women. American Family Physician, 84 (5), 519- 526. Fox, M. T., Melia, M. T., Same, R. G., Conley, A. T., & Tamma, P. D. (2017). A seven-day course of trimethoprim-sulfamethoxazole may be as effective as a seven-day course of ciprofloxacin for the treatment of pyelonephritis. American Journal of Medicine, 130 (7), 842-845. Tambo, M., Okegawa, T., Shishido, T., Higashihara, E., & Nutahara, K. (2014). Predictors of septic shock in obstructive acute pyelonephritis. World Journal of Urology, 32, 803-811. Trivedi, S. C., Phatak, S. R., & Trivedi, R. S. (2016). Retrospective comparison of clinical characteristics and in-hospital outcomes among diabetic and non-diabetic adults with acute yyelonephritis. Journal of Clinical and Diagnostic Research, 10 (10), OC26- OC29. Yosefi, P., & Dorreh, F. (2014). Urinary tract infection due to salmonella in an otherwise healthy child. Iranian Journal of Kidney Diseases, 8 (2), 154- 157.
Editor's Notes
- An infection of the renal pelvis and kidney resulting in the ascent of a bacterial pathogen usually E coli, up the ureters from the bladder to the kidney Pseudomonas aeruginosa, group B streptococci, and enterococci are other causative agents Accounts for 250,000 office visits and 200,000 hospital admissions annually Pyelonephritis is one of the most common reasons women visit emergency departments or ambulatory care clinics, frequently resulting in hospitalization Risk factors include female anatomy, increasing age, diabetes, obesity, and frequent intercourse (although UTI is not defined as a sexually transmitted infection). symptoms (increased urinary frequency, urgency, hematuria, dysuria, suprapubic or flank pain
- History and physical exam are best for diagnosis, a urine culture and antimicrobial susceptibility testing should be performed in women suspected with acute pyelonephritis. Initial empiric therapy should be selected based on the likely infectious agent and changed to a more targeted focus after urine culture results return
- Outpatient treatment options: 500mg Cipro BID PO for 7 days; 1000mg extended release Cipro Q day for 7 days, 750mg Levaquin Q day for 5 days PO Bactrim or Septra of 160mg/800mg BID for 14 days for patients with known susceptibility Inpatient treatment: IV antibiotics to include a fluoroquinolone (Levaquin, Cipro) , aminoglycoside (Gentamicin, tobramycin) with or without ampicillin, an extended spectrum cephalosporin (Cefipime) or penicillin with or without an aminoglycoside or a carbapenem (Invanz, Merrem)
- Acute inflammation has neutrophils only chronic- lymphocytes and macrophages
- Necrotizing papillitis is also called necrotizing pyelonephritis, our patient has complicated acute pyelonephritis This is a catastrophic complication that results in coagulative necrosis of the renal papillae It is the result of 2 injuries- stress on the renal medulla and insufficient perfusion causing the renal medulla to necrosis, this is commonly seem in patients with DM or analgesic nephropathy
- Necrotizing papillitis is a severe complication of acute pyelonephritis, after the causative agent has invaded and caused damage to the kidney, the urine flow becomes obstructed with kidney stone or neurogenic bladder where the bladder is flaccid or spastic, along with a compromised blood supply, like diabetes. This results in a combination of ischemia and infection, the degree of damage is determined by the degree of impaired vascularity In our patient having diabetes caused decreased blood flow, due to damage to the small blood vessels and also being diabetic makes her more prone to infection
- Usage of cipro more likely in women requiring hospitalization or concomitant E coli blood stream infections
- 69 patients studied retrospectively with obstructive acute pyelonephritis with upper urinary tract calculi Acute pyelonephritis with obstruction can progress to urosepsis and can cause septic shock and DIC (disseminated intravascular coagulopathy) Identify risk factors for septic shock Management of obstructive uropathy acute pyelonephritis is prompt decompression of the renal collecting system with percutaneous nephrostomy tube or ureteral stenting They were treated with a cephalosporin, penicillin with a beta lactamase inhibitor an aminoglycoside, carbapenem and followed up with oral antimicrobial therapy The average age of the patients was 67 years, with an almost 50/50 split on male and female patients All patients had the following underlying diseases: DM, cardiovascular or neurologic diseases, immunocompromised status and urinary tract abnormalities Out of the 69 patients, 23 patients progressed to septic shock, there were no significant difference in age, other underlying diseases, or decompression placement in the septic and non septic groups. The difference was the platelet count and serum albumin in the septic shock group was significantly lower. They showed that decreases in platelet count and serum albumin level might be predictors of the development of septic shock in patients with obstructive APN. It was thought that platelets and neutrophils are actively involved in sepsis and together cooperate to contribute to the inflammatory response Serum albumin is known to decrease in response to inflammation as a consequence of increased protein catabolism and decreased hepatic synthesis and leakage into the extravascular space due to increased vascular permeability.
- A 7 year old boy presents to the ED with signs and symptoms of a UTI, history showed no unusual findings, otherwise normal healthy child No recent exposures, travels or infections Urine culture showed growth of Salmonella and was sensitive to ampicillin, cefotaxim, nalidix-acid, and ceftriaxone The patient was treated with 75 mg/kg of ceftriaxon for 3 days and continued with cefexim for 7 days Patient was treated without complication, but UTI caused by salmonella can cause future complications In conclusion Salmonella UTI is not common but diagnosis should trigger the provider to look for possible occult urologic problems or immunosuppressive disorders