acute pyelonephritis

1. Acute Pyelonephritis and Chronic Pyelonephritis

2. Urinary tract infection
• Commonly involves lower urinary tract .
• Occurs more commonly in female
• Two types;
1. Complicated UTI
2. Uncomplicated UTI
• Complicated UTI is defined as an episodes of infection with an increased risk of serious
complication or treatment failure.
• Uncomplicated UTI is episodes of infection with less risk of serious complication

3. • Pyelonephritis is defined as inflammation affecting the
tubules,interstitium and renal pelvis.
Two forms - Acute pyelonephritis
-Chronic pyelonephritis
Acute pyelonephritis;
suppurative inflammation of the kidney caused by bacterial
infection.

4. Etiology and Pathogenesis
• More than 85% of cases of UTI are caused by the gram negative bacilli that are normal
inhabitant of intestinal tract.
• Most common organism involved are E. Coli, Proteus, klebsiella, and Enterobacter.
• Routes of infection;
1.Hematogenous route( primary site in the tonsils, teeth caries , boils,carbuncle)
2.Ascending infection ( urinary stasis in presence of calculi)

5. Pathogenesis;
• Colonization by coliform bacteria of distal urethra and introitus(In Female)
• From urethra to the bladder during urethral catheterization or other
instrumentation.
• From bladder to kidney;
• Urinary tract obstruction and stasis of urine.
• Vesico-ureteral reflux (incompetence of vesicoureteral valve)
• Intrarenal reflux

6. Clinical feature
• More common in females especially during childhood,
• At puberty after intercourse and during pregnancy.
• Symptoms;
• Fever with chills and rigors
• Flank pain, Nausea and vomiting
• Cystitis symptom may or may not be present
Sign;
• Costovertebral angle tenderness
• Flank fullness
• Symptoms may vary from a mild illness to a severe illness with septic shock, renal failure
and threat to life

7. Investigation;
• Blood – Hb%, CBC ( leukocytosis), Differential count
• Urine – Routine and microscopic examination, culture and sensitivity
Pyuria is almost always present.
• RFT- Serum Creatinine, Serum Urea

8. • USG Abdomen and pelvis- To rule out pyonephrosis , Perirenal
abscess, and obstruction of collecting system by renal calculi .
• CECT- decreased opacification of affected Parenchyma, typically in
patchy, wedge shaped or linear distribution

9. Management;
• Plenty of fluid intake
• Antipyretic and Analgesic can be given for fever and lower abdominal pain
• Antibiotic are recommended in all case of proven UTI
• If urine culture has been performed treatment may be started while awaiting the result.
• Initially broad spectrum antibiotic coverage using Cefalexin , Ciprofloxacin can be used.
• Later Antibiotic can be switched according to culture and sensitivity report.
.

10. Acute Pyelonephritis in children
• In the age group <3 month, it is more common in boys.
• In the age group >1 year , it is more common in girls.
Underlying causes are;
• Urinary stasis due to Vesico-ureter reflux,
• detrusor-sphincter dyssynergia ,
• poor bladder emptying habit
• Outlet obstruction ,
• Neurological disorder secondary to spina bifida
.

11. • Scarring can be detected on IVU,DMSA (dimercaptosuccinic acid) scan.
• 10-20% of children with renal scarring will develop hypertension.
• VUR Graded as;
Grade1: reflux into ureter
•
Grade 2:Reflux into ureter and renal pelvis
•
Grade 3: Reflux assosciated with moderate dilatation on an IVU
•
Grade 4:Additional blunting of Fornices
•
Grade 5:Absent Papillary impressions

12. • VUR is confirmed by micturating Cystogram
• Grade 1-3 generally resolves spontaneously.
• Ureteric re-implantation, peri-ureteric injection of Teflon should be considered
if episode of acute pyelonephritis recur despite antibiotic therapy.

13. Pyelonephritis complicating pregnancy
• most often presents between 20 and 28 week of gestation.
• Pyelonephritis is more common in pregnant women with underlying urological
abnormality or diabetes.
• Malaise, fever, loin pain and rigors are major complaints.
• Pyonephrosis and perirenal abscess are rare complication but should be
suspected when treatment fails.

14. Emphysematous Pyelonephritis
• Emphysematous pyelonephritis is a fulminant , necrotising, life-threatening , variant of acute
Pyelonephritis.
• Caused by E.coli, Klebsiella pneumonia , Pseudomonas aeruginosa and Proteus Mirabilis.
•
• Up to 90% cases occur in diabetic patients and urinary tract obstruction may be present.

15. • Symptoms are similar of acute pyelonephritis, and there may be loin
mass.
• Gas can be detected on a plain film, on USG,
and CT scan.
• IV broad spectrum antibiotic and percutaneous nephrostomy tube
with DJ stenting
• Nephrectomy may be needed in most severely ill patient

16. Renal cortical Abscess ,Corticomedullary abscess
• Caused by Staph. Aureus via hematogenous route.
• Commonly seen in Diabetics, IV drug abusers, acquired immunodeficiency
• Corticomedullary abscess – results from ascending UTI

17. Clinical feature
• Insidious and non specific
• Fever ,abdominal pain, costovertebral tenderness
• There may be no urinary symptom if abscess doesnot communicate
with collecting system

18. Management;
• CT scan is investigation of choice.
• Empirical antibiotic
• For Small abscess- Antibiotic without drainage is effective
• In Many case two percutaneous drain needed ;
1. To drain perirenal collection
2. To decompress the collecting system

19. Xanthogranulomatous pyelonephritis (XGP)
• Uncommon
• Severe chronic ,destructive granulomatous inflammation of renal Parenchyma.
• Typically seen in middle aged women.
• Chronic symptom- Flank pain ,pyrexia, malaise
• Flank tenderness , a palpable mass, voiding symptoms are common.

20. • Urine culture is positive for E.coli or other gram negative Bacilli.
• CT scan - an enlarged ,non-functioning kidney,
- presence of calculi,
-low density masses (xanthomatous tissue)
Nephrectomy is definitive treatment.

21. Chronic Pyelonephritis
It is a disorder in which chronic tubulointerstitial inflammation and scarring
involve the calyces and pelvis.
Important cause of kidney destruction in children with severe lower urinary tract
abnormalities.
Two form;
• Reflux Nephropathy
• Chronic obstructive Pyelonephritis

22. Clinical feature
• Gradual onset
• Present with acute recurrent pyelonephritis such as loin pain, fever, pyuria and
bacteriuria
• Reflux nephropathy causes hypertension in children .
• Imaging studies ;
shows asymmetrically contracted kidneys with coarse scars, blunting and
deformity of calyceal system.

23. Investigation;
• Complete blood profile
• Urinalysis - pyuria.
• Urine culture- E. coli, Proteus species
• Serum Creatinine and Blood urea nitrogen level.
• IVU- calceal dilatation and blunting with cortical scars.
• Voiding cystourethrogram- reflux of urine to renal pelvis and ureteral dilatation
• DMSA Scan-detect renal scars

24. Management;
Goal of management are
1.Prevent recurrent febrile Urinary tract infection.
2.Prevent Renal injury
3.Minimize Morbidity of treatment and follow up
Preventive strategies -prophylactic antibiotic.
Medical care- Antibiotic , fluid and electrolyte management
Surgical care- Ureteral Re-implantation

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