Pyelonephritis is an inflammation of the kidney that is usually caused by a bacterial infection ascending from the bladder. It is more common in women due to their shorter urethra. Risk factors include urinary tract abnormalities, pregnancy, diabetes, and frequent sexual intercourse. Common symptoms are fever and flank pain. Diagnosis involves urine testing and culture. Treatment is usually oral fluoroquinolone antibiotics for a week. Chronic or recurring pyelonephritis can lead to kidney damage and renal failure if not properly treated.

1. PYELONEPHRITIS
DR. LANDO ELVIS O

2. OUTLINE
 Definition
 Epidemiology and Risk Factors
 Etiology
 Pathogenesis
 Clinical feature
 Lab diagnosis
 Treatment

3. DEFINITION:
 Inflammation of the parenchyma and lining of renal pelvis of kidney

4. EPIDEMIOLOGY AND RISK FACTORS:
 Host factor:
 Female :Shorter urethra
 Male : uncircumcised infant bacterial colonization
 inside prepuce and urethra
 Catherization
 DIRECT: Bacteria carried directly into bladder during
 insertion
 INDIRECT: Facilitation of bacterial access via
 lumen of catheter
 Tracking up between outside catheter and urethral
 wall

5. EPIDEMIOLOGY AND RISK FACTORS
Host factor:
 Normal urine flow disruption ( obstruction ) Incomplete bladder emptying >
2-3ml residual urine infection ascent of infection pyelonephritis
 Pregnancy
 Prostatic hypertrophy
 Renal calculi
 Tumor
 Stricture
 Loss of neurological control of bladder and sphincter(spina bifida , paraplegia,
multiple sclerosis)
 Vesicourethral reflux ( urine reflux from bladder to ureter, renal pelvis and
parenchyma)
 Diabetes Mellitus diabetic neuropathy interfere
with bladder function
 Diabetes Mellitus Impaired cytokine secretion

6. EPIDEMIOLOGY AND RISK FACTORS:
Host factor:
 genetic background of the host
 familial disposition to pyelonephritis
 women with recurrent UTI
 Have had their first UTI before the age of 15 years
 persistent vaginal colonization
 Mutations in host response genes(those coding for Tolllike
receptors and the interleukin 8 receptor)

7. EPIDEMIOLOGY AND RISK FACTORS:
Host factor:
Factors independently associated with pyelonephritis in young healthy
women include:
 Frequent sexual intercourse
 New sexual partner，
 UTI in the previous 1 2 months，
 Maternal history of UTI，
 Diabetes
 Incontinence.
 spermicide use
 And cystoceles ,incontinence and residual urine in postmenopausal
women，

8. ETIOLOGY:
 The uropathogens causing Pyelonephritis vary by clinical syndrome but are usually
enteric gram-negative rods that have migrated to the urinary tract.
 The susceptibility patterns of these organisms vary by clinical syndrome and by
geography.
 Gram negative organism
E.coli (common)
Proteus mirabilis, Citrobacter, klebsiella, enterobacter,
proteus pseudomonas aeruginosa
 Gram positive organism
Staph.saprophyticus, Staph. Epidermidis enterococcus,
Corynebacteria and lactobacilli

9. ETIOLOGY:
VIRUSES
 Rare
 Virus Human polymaviruses , JC and BK
 Cytomegalovirus and rubella
 Korean hemorrhagic fever virus
 Mumps and HIV
 Recovered in urine in absence of UTI
PARACITES
 Fungi :
candida spp and histoplasma capsulatum
 Protozoa :
trichomonas vaginalis
 Helminth:
Schistosoma haematobium

10. PATHOGENESIS
 The urinary tract can be viewed as an anatomic unit united by a continuous column of
urine extending from the urethra to the kidneys.
 In the majority of UTIs bacteria establish infection by ascending from the urethra to the
bladder.
 Continuing ascent up the ureter to the kidney is the pathway for most renal parenchymal
infections.

11. .
Vaginal Ecology:
 Colonization of the vaginal introitus and periurethral area with
organisms from the intestinal flora (usually E. coli)
 Sexual intercourse is associated with an increased risk of vaginal
colonization with E. coli
 Nonoxynol-9 in spermicide is toxic to the normal vaginal microflora and
thus is likewise associated with an increased risk of E. coli vaginal
colonization and bacteriuria

12. .
Anatomical And Functional Abnormalities
 urinary stasis or obstruction
 Foreign bodies:stones or urinary catheters
 vesicoureteral reflux
 ureteral obstruction secondary to prostatic hypertrophy
 neurogenic bladder
 urinary diversion

13. .
Microbial Fators:
 Uropathogenic E. Coli (UPEC)
◦ Pyelonephritis associated pili (PAP) adhesion to urethral and bladder
epithellium in
◦ K antigen that help E coli to be phagocytosisresistant
◦ Hemolysin ( membrane damaging toxin)

14. CLINICAL FEATURE
 Mild pyelonephritis:
 low-grade fever
 with or without lower-back or costovertebral-angle pain
 severe pyelonephritis:
 High fever “picket-fence” 72hr
 Nausea
 vomiting
 flank and/or loin pain

15. .
Emphysematous pyelonephritis:
 exclusively in diabetic patients
 production of gas in renal and perinephric tissues
 bilateral papillary necrosis
 rise in the serum creatinine level
Xanthogranulomatous pyelonephritis
 chronic urinary obstruction (often by staghorn calculi)
 chronic infection
 Suppurative destruction of renal tissue
Pyelonephritis can also be complicated by intraparenchymal abscess formation; this
situation should be suspected when a patient has continued fever
and/orbacteremia despite antibacterial therapy.

16. LABORATORY DIAGNOSIS:
The Urine Dipstick Test:
 Rapid diagnostic test
 Appearance of WBC in urine
 test for nitrite & leukocyte esterase
 ( family Enterobacteriaceae, in detected in urine PMN )
 Negative outcome ,it s not sufficient for pregnancy women
Urinalysis:
 WBC in Cast shape due to of pyelonephritis
 No WBC ,No Infection

17. .
Urine Culture:
 Method of Sampling:
 Clean Catch:
 Straight Catheterization:
 foley cathatere:
 Suprapubic Aspiration:
Urine culture interpretation:
 It is positve with colony count equal or more than 10
 power 2 In women with dysuria & pyuria
 It is positve with colony count > 10 power 3 In Men

18. Radiological investigations
CT scan
IVP=intra venous pyelogram
Radionucleotide imaging with gallium
citrate and indium-111-labeled WBCs
.

19. Micturiting
cystourethrogram
(MCW showing
bilateral VUR,
grade IV on right
and grade III on
left-side. There is
bilateral ureteral
and pelvic dilation
with blunting of
fornices in the
right kidney.
.

20. Bilateral reflux
extending into the
pelvicalyceal systems
of the kidney without
dilatation of the
calyces or ureters.
(Note catheter in
bladder)
.

21. TREATMENT:
 Fluoroquinolones the first- line therapy for acute uncomplicated pyelonephritis
 A randomized clinical trial demonstrated that a 7-day course of therapy with oral
ciprofloxacin (500 mg twice daily with or without an initial IV 400-mg dose) Was
highly effective for the initial management of pyelonephritis in the outpatient
setting
 Oral TMP-SMX (one double-strength tablet twice daily for14 days) also is effective
for treatment of acute uncomplicated pyelonephritis if the uropathogen is known
to be susceptible.
 If the pathogen's susceptibility is not known and TMP SMX is used an initial IV l -g
dose of ceftriaxone is recommended

22. .
 Options for parenteral therapy for uncomplicated pyelonephritis include
fluoroquinolones an extendedspectrum cephalosporin with or without
anaminoglycoside
o r
 acarbapenem. Combinations of a ß-Iactam and a ß- Iacta mase inhibitor (e.g
.ampicillin-sulbactam， ticarcillinc Lavulanate piperacillin-tazobactam)
or
 imipenem-cilastatin can be used in patients with more complicated histories
previous episodes of pyelonephritis or recent urinary tract manipulations

23. PROBLEM
 Chronic or recurring symptomless infection persisting for months or years
 Another 6 weeks course if relapse
 Follow up urine culture 2 weeks after completion of therapy
.

24. CHRONIC PYELONEPHRITIS
Repeated bouts of acute pyelonephritis may lead to
chronic pyelonephritis
Clinical manifestations
No symptoms of infection unless an acute
exacerbation occurs
Fatigue
Head ache
Poor appetite
Polyuria
Excessive thirst
Weight loss
Progressive scarring  renal failure .

25. Assessment and diagnostic findings
 IVP
 Serum creatinine
 Blood urea
 Culture and sensitivity
Complications
ESRD=end stage renal disease
Hypertension
Kidney stones
Medical management
 According to C&S result
 Drugs carefully titrated if renal function is impaired
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26. END