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Acute Pyelonephritis

Acute pyelonephritis is a condition incited by a bacterial infection that affects the parenchymal tissue of the kidneys. It is, most frequently, a complication of a lower urinary tract infection that has allowed pathogens to further infiltrate the kidneys; alternatively, bacteria can access the kidney through the bloodstream. Acute pyelonephritis can eventuate in septic phenomena, abscess of the kidney or a chronic state of inflammation and secondarily, kidney failure


Presentation

An episode of acute pyelonephritis typically presents with three symptoms: fever, nausea and costovertebral angle pain. Although this is termed as the classic symptomatology of pyelonephritis, these three symptoms may not be simultaneously present or some may not be manifested at all. Fluctuation in the severity of the symptoms is naturally expected, and may even develop gradually, instead of acutely. Even though acute pyelonephritis usually develops as a result of a prior, complicated lower UTI infection, the latter's symptoms may not be present at the time of diagnosis.

A lower UTI infection exhibits a characteristic symptomatology, including hematuria, fever, dysuria and frequent, urgent urination. Approximately 1/3 of female patients with pyelonephritis exhibit the symptom of hematuria; should the patient be male, an investigation of other causes of hematuria should promptly be investigated. Febrile patients commonly exhibit chills or rigor as well, alongside fatigue and weakness. Temperature is not expected to exceed an average of 103°F (39.4°C).

The pain felt at the costovertebral angle is characteristically triggered by percussion and it is usually experienced at the side of the affected kidney. Gastrointestinal symptoms, such as vomiting or anorexia may also be present.

Children may lack the typical symptoms of acute pyelonephritis, a fact which renders the diagnosis considerably more difficult. Particularly infants or neonates who cannot yet express themselves verbally may evince anorexia, lethargy, fever and vomiting. Senior patients may experience symptoms that are identical to those of a lower UTI infection, or clinical manifestations that include a mental status impairment, fever and organ failure.

Fever
  • In multivariate analysis, initial CRP levels, nausea/vomiting symptoms, and fever duration after admission were independent variables with statistical significance to predict ALN.[ncbi.nlm.nih.gov]
  • Non-enhanced MRI in children with suspected APN 7 days from fever onset might be a suitable replacement for 99m Tc-DMSA scintigraphy for the detection of APN.[ncbi.nlm.nih.gov]
  • The clinical parameters analyzed were the age and body mass index of the patients as well as the degree and duration of fever.[ncbi.nlm.nih.gov]
  • None of the patients presented the 'classic' diagnostic tetrad (i.e. fever, positive urine cultures, low urinary tract symptoms and serum creatinine increase); although, at diagnosis, two of five patients presented with fever, one had increased creatinine[ncbi.nlm.nih.gov]
  • An episode of acute pyelonephritis typically presents with three symptoms: fever, nausea and costovertebral angle pain.[symptoma.com]
Chills
  • Signs and symptoms at presentation were similar between the two groups except a higher proportion of patients with chills in the sitafloxacin group (68.4% vs. 29.4%, p 0.019). At day 10, all but one patient in the ertapenem group had clinical cure.[ncbi.nlm.nih.gov]
  • General signs of inflammation may accompany both cases and patients may be febrile and experience nausea, frequent vomiting and chills.[symptoma.com]
  • Common signs and symptoms include acute-onset fever, chills, severe back or flank pain, nausea and vomiting, and costovertebral angle tenderness. Urinalysis and urine culture confirm the diagnosis of pyelonephritis.[bestpractice.bmj.com]
  • […] urinary tract infection from gram-negative bacteria § E. coli § Klebsiella § Proteus § Pseudomonas o Exception is S. aureus, which is spread hematogenously o Vesicoureteral reflux o Obstruction in the collecting system usually due to a calculus o Fever o Chills[learningradiology.com]
  • Signs and Symptomology Acute pyelonephritis is a deep infection and patients often display consitutional symptoms such as fever, chills, and malaise.[pathwaymedicine.org]
Malaise
  • Signs and Symptomology Acute pyelonephritis is a deep infection and patients often display consitutional symptoms such as fever, chills, and malaise.[pathwaymedicine.org]
  • Malaise, nausea, vomiting, anorexia and occasionally diarrhoea occur. There may or may not be accompanying lower urinary tract symptoms with frequency, dysuria, gross haematuria or hesitancy.[patient.info]
  • Symptoms Fever Chills and malaise Flank pain Nausea and Vomiting Acute Cystitis symptoms Dysuria Urinary Frequency Urinary urgency X.[fpnotebook.com]
  • ., fever, chills, malaise) Gastrointestinal symptoms (e.g., nausea, vomiting, anorexia, abdominal pain) Physical examination Fever (temperature 100.4 F [38.0 C]), tachycardia, hypotension Costovertebral angle tenderness Possible abdominal or suprapubic[aafp.org]
High Fever
  • In babies and toddlers, a high fever may be the only symptom. In men and women older than 65 years of age, the above-mentioned symptoms may be absent and additional symptoms may include: Confusion Jumbled speech Hallucinations.[ada.com]
  • Clinical presentation is fairly specific and classical in most cases, consisting of a rapid onset of high fever, flank pain and tenderness.[radiopaedia.org]
  • fever ( 103 F) Severe flank or Abdominal Pain Debilitated condition Pregnancy (some cases may be treated outpatient) XVI.[fpnotebook.com]
  • ., renal dysfunction, acidosis) Pregnancy Severe flank or abdominal pain Toxic appearance Unable to take liquids by mouth Very high fever ( 103 F [39.4 C]) Table 5.[aafp.org]
Rigor
  • Febrile patients commonly exhibit chills or rigor as well, alongside fatigue and weakness. Temperature is not expected to exceed an average of 103 F (39.4 C).[symptoma.com]
  • Fever is variable but can be high enough to produce rigors. Malaise, nausea, vomiting, anorexia and occasionally diarrhoea occur.[patient.info]
Nausea
  • In multivariate analysis, initial CRP levels, nausea/vomiting symptoms, and fever duration after admission were independent variables with statistical significance to predict ALN.[ncbi.nlm.nih.gov]
  • Early clinical manifestations were sudden onset of left flank pain, fever, hematuria and pyuria, and following admission, severe abdominal pain, nausea, vomiting, reduced urine output and renal function deterioration.[ncbi.nlm.nih.gov]
  • An episode of acute pyelonephritis typically presents with three symptoms: fever, nausea and costovertebral angle pain.[symptoma.com]
  • Common signs and symptoms include acute-onset fever, chills, severe back or flank pain, nausea and vomiting, and costovertebral angle tenderness. Urinalysis and urine culture confirm the diagnosis of pyelonephritis.[bestpractice.bmj.com]
  • It is characterized by ABDOMINAL PAIN; FEVER; NAUSEA; VOMITING; and occasionally DIARRHEA.[fpnotebook.com]
Vomiting
  • In multivariate analysis, initial CRP levels, nausea/vomiting symptoms, and fever duration after admission were independent variables with statistical significance to predict ALN.[ncbi.nlm.nih.gov]
  • Early clinical manifestations were sudden onset of left flank pain, fever, hematuria and pyuria, and following admission, severe abdominal pain, nausea, vomiting, reduced urine output and renal function deterioration.[ncbi.nlm.nih.gov]
  • Particularly infants or neonates who cannot yet express themselves verbally may evince anorexia, lethargy, fever and vomiting.[symptoma.com]
  • Most common clinical manifestations include fever, chills, lumbar pain, nausea and vomiting. (1 ) Computerized tomography is the ideal method of imaging to precisely confirm the diagnosis.[fcm.unicamp.br]
  • Malaise, nausea, vomiting, anorexia and occasionally diarrhoea occur. There may or may not be accompanying lower urinary tract symptoms with frequency, dysuria, gross haematuria or hesitancy.[patient.info]
Abdominal Pain
  • Early clinical manifestations were sudden onset of left flank pain, fever, hematuria and pyuria, and following admission, severe abdominal pain, nausea, vomiting, reduced urine output and renal function deterioration.[ncbi.nlm.nih.gov]
  • Proper utilization of sonography and computed tomography in patients with abdominal pain helps to clarify ambiguous diagnoses in an emergency department and avoid unnecessary surgical procedures.[tzuchi.com.tw]
  • It is characterized by ABDOMINAL PAIN; FEVER; NAUSEA; VOMITING; and occasionally DIARRHEA.[fpnotebook.com]
  • ., nausea, vomiting, anorexia, abdominal pain) Physical examination Fever (temperature 100.4 F [38.0 C]), tachycardia, hypotension Costovertebral angle tenderness Possible abdominal or suprapubic tenderness Laboratory tests Urinalysis showing positive[aafp.org]
  • On physical exam you note suprapubic abdominal pain and CVA tenderness . The urinalysis reveals white blood cell casts. To watch this and all of Joe Gilboy PA-C's video lessons you must be a member. Members can log in here or join now .[smartypance.com]
Left Flank Pain
  • A 60-year-old diabetic woman was admitted with a 3 day history of fever and left flank pain due to acute pyelonephritis.[ncbi.nlm.nih.gov]
  • Early clinical manifestations were sudden onset of left flank pain, fever, hematuria and pyuria, and following admission, severe abdominal pain, nausea, vomiting, reduced urine output and renal function deterioration.[ncbi.nlm.nih.gov]
  • Language English Discipline of Urology, FCM - UNICAMP Fifty four year-old female patient comes to Urology office with a complaint of nocturnal fever, episodes of vomiting and left flank pain for 3 months. She lost 10 kg in this period.[fcm.unicamp.br]
Acute Abdomen
  • Causes of acute abdomen . Causes of loin pain . Diverticulitis . Ectopic pregnancy . Endometritis . Interstitial cystitis . Nephrocalcinosis . Nephrolithiasis . Oophoritis. Papillary necrosis. Pelvic inflammatory disease . Prostatitis .[patient.info]
  • Diagnoses to Consider in Patients with Flank Pain and Costovertebral Angle Tenderness Disorder Flank pain* Costovertebral angle tenderness* Fever and leukocytosis* Abdominal abscess / / Acute abdomen / / / Acute pyelonephritis Appendicitis / / / Basilar[aafp.org]
Tachycardia
  • Within 3 h of admission, the patient developed acute respiratory distress associated with tachycardia and shock, and he was transferred to the intensive care unit.[ncbi.nlm.nih.gov]
  • Signs Fever Tachycardia Hypotension Costovertebral angle tenderness Abdominal tenderness (esp. suprapubic tenderness) XI.[fpnotebook.com]
  • Tachypnoea (rapid breathing) Tachycardia (rapid heartbeat) Hypotension (low blood pressure) Edema Mottled skin Dizziness Confusion, sleepiness, lethargy and/or irritability In some cases, an affected person may run a fever and their body temperature then[ada.com]
  • Signs of sepsis (eg, tachypnoea, tachycardia, hypotension). Dehydration or inability to take fluids/medication. Severe pain or debility. Failure of response to treatment in primary care within 24 hours. [ 8 ] Urinary tract obstruction.[patient.info]
  • ., nausea, vomiting, anorexia, abdominal pain) Physical examination Fever (temperature 100.4 F [38.0 C]), tachycardia, hypotension Costovertebral angle tenderness Possible abdominal or suprapubic tenderness Laboratory tests Urinalysis showing positive[aafp.org]
Back Pain
  • Spike fever with severe back pain continued despite empiric antibiotic treatment at a local hospital. Hypotension with a sudden hemoglobin drop was observed on the second hospitalization day.[ncbi.nlm.nih.gov]
  • Between 3 to 5 days after discharge the patient was telephoned to assess c1inical course (resolution of fever, longer back pain, and urinary ract symptoms). If symptoms persisted, the patient was called again between 7 and 10 days after discharge.[dialnet.unirioja.es]
  • It is also possible that a patient first becomes symptomatic with symptoms originating from the acute pyelonephritis itself, such as back pain at the renal level and flank pain.[symptoma.com]
  • If flank, belly or back pain is not present, doctors should consider other diagnoses.[ada.com]
  • There is unilateral or bilateral loin pain, suprapubic pain or back pain. Fever is variable but can be high enough to produce rigors. Malaise, nausea, vomiting, anorexia and occasionally diarrhoea occur.[patient.info]
Myalgia
  • Two patients discontinued ciprofloxacin because of myalgia with 7 days of treatment and itching exanthema with 14 days.[portal.research.lu.se]
  • Prominent cold symptoms include fever, cough, rhinorrhea, nasal congestion, postnasal drip, sore throat, headache, and myalgias.[cdc.gov]
Headache
  • This then followed by pain, loss of appetite, headache.[forerunnershealthcare.com]
  • Prominent cold symptoms include fever, cough, rhinorrhea, nasal congestion, postnasal drip, sore throat, headache, and myalgias.[cdc.gov]
Flank Pain
  • A 60-year-old diabetic woman was admitted with a 3 day history of fever and left flank pain due to acute pyelonephritis.[ncbi.nlm.nih.gov]
  • Clinically, it is difficult to distinguish between acute pyelonephritis and RVT because both present with fever, flank pain, and hematuria. We report a case of acute pyelonephritis with RVT and IVCT with underlying hyperhomocysteinemia.[ncbi.nlm.nih.gov]
  • She was admitted to our hospital due to fever and flank pain which had developed 10 days earlier. Urinalysis showed many WBC and urine culture revealed Escherichia coli.[ncbi.nlm.nih.gov]
  • Early clinical manifestations were sudden onset of left flank pain, fever, hematuria and pyuria, and following admission, severe abdominal pain, nausea, vomiting, reduced urine output and renal function deterioration.[ncbi.nlm.nih.gov]
  • On day 9, 30 patients were completely asymptomatic, while 7 exhibited clinical improvement though persistence of bladder irritation or flank pain.[ncbi.nlm.nih.gov]
Hematuria
  • Clinically, it is difficult to distinguish between acute pyelonephritis and RVT because both present with fever, flank pain, and hematuria. We report a case of acute pyelonephritis with RVT and IVCT with underlying hyperhomocysteinemia.[ncbi.nlm.nih.gov]
  • Early clinical manifestations were sudden onset of left flank pain, fever, hematuria and pyuria, and following admission, severe abdominal pain, nausea, vomiting, reduced urine output and renal function deterioration.[ncbi.nlm.nih.gov]
  • Approximately 1/3 of female patients with pyelonephritis exhibit the symptom of hematuria; should the patient be male, an investigation of other causes of hematuria should promptly be investigated.[symptoma.com]
  • Urinalysis will show bacteria, pyuria, and often hematuria.[pathwaymedicine.org]
  • 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[fpnotebook.com]
Dysuria
  • Before the man developed his symptoms his wife had complained of urinary frequency and dysuria for a 2-week period. Two weeks after a 10-day course with trimethoprim he experienced a relapse manifesting as acute febrile pyelonephritis.[ncbi.nlm.nih.gov]
  • […] from gram-negative bacteria § E. coli § Klebsiella § Proteus § Pseudomonas o Exception is S. aureus, which is spread hematogenously o Vesicoureteral reflux o Obstruction in the collecting system usually due to a calculus o Fever o Chills o Flank pain o Dysuria[learningradiology.com]
  • There may or may not be accompanying lower urinary tract symptoms with frequency, dysuria, gross haematuria or hesitancy.[patient.info]
  • A lower UTI infection exhibits a characteristic symptomatology, including hematuria, fever, dysuria and frequent, urgent urination.[symptoma.com]
  • Symptoms Fever Chills and malaise Flank pain Nausea and Vomiting Acute Cystitis symptoms Dysuria Urinary Frequency Urinary urgency X.[fpnotebook.com]
Urinary Urgency
  • Symptoms Fever Chills and malaise Flank pain Nausea and Vomiting Acute Cystitis symptoms Dysuria Urinary Frequency Urinary urgency X.[fpnotebook.com]
  • Other symptoms of pyelonephritis include: Urine that has an unusual or unpleasant smell Hematuria (blood in the urine) Urinary frequency Urinary urgency Dysuria (painful or difficult urination) Oliguria (lack of urine) Hypotension (low blood pressure)[ada.com]
  • Classic symptoms include dysuria, frequent voiding of small volumes, and urinary urgency. Hematuria and suprapubic discomfort are less common.[cdc.gov]
Urinary Incontinence
  • During the follow-up days, the mean frequency of fever (P .01), urinary frequency (P .001), urgency (P .003), dribbling (P .001), and urinary incontinence (P .006) were significantly lower in the intervention group compared to the control group.[ncbi.nlm.nih.gov]
  • Other factors that increase an individual’s risk of developing acute pyelonephritis include: Diabetes mellitus Stress urinary incontinence A structurally or functionally abnormal genitourinary tract, such as might result from infected cysts, underdeveloped[ada.com]

Workup

A detailed medical history and clinical examination, alongside confirmation by urinalysis usually suffice in order to diagnose acute pyelonephritis. Radiologic depiction is usually employed in infants and children or adults who do not manifest characteristic symptoms. Should the symptomatology match the typical clinical picture of acute pyelonephritis, the analysis of the urine is expected to produce the following results to confirm an infection:

A nitrite test can also be used; nevertheless, it can be falsely negative in various cases. A urine culture is also mandatory in order to eliminate antibiotic resistance. A blood culture can confirm the bacterial strain, should the pathogens have reached the renal parenchyma through the bloodstream.

A physician may perform imaging techniques if a patient continues to deteriorate despite treatment, if toxicity persists for >72 hours and if fever does not subside after 2 days. The optimal imaging technique is considered to be the contrast-enhanced helical/spiral computed tomography (CECT). Should it reveal a possible nephrolithiasis, a computed tomography (CT) scan and urogram need to be carried out for fear of hydronephrosis [9].

Nephrolithiasis
  • […] kidney collecting system as well as renal parenchyma Affects infants and young children with congenital lesions, women of childbearing age, men and women age 60 years (due to nodular hyperplasia of prostate, cystoceles in women, cervical carcinoma, nephrolithiasis[pathologyoutlines.com]
  • 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[fpnotebook.com]
  • Should it reveal a possible nephrolithiasis, a computed tomography (CT) scan and urogram need to be carried out for fear of hydronephrosis. Prompt treatment of acute pyelonephritis is the key to achieving optimal therapeutic results.[symptoma.com]
  • Patients with nephrolithiasis and ureterolithiasis, which also cause flank pain, do not usually present with costovertebral angle tenderness. Enlarge Print Table 2.[aafp.org]
  • These included nephrolithiasis, renal enlargement, and ureteral duplication. Renal scars were detected by ultrasonography in only 1 woman.[academic.oup.com]
Pyuria
  • Significant positive correlations were found with pyuria grade (Spearman's rho   0.62; p   0.001), neutrophil count (rho   0.38; p   0.03), and platelet count (rho   0.39; p   0.03).[ncbi.nlm.nih.gov]
  • A longer duration of fever, higher CRP level, and grade of pyuria were related with perirenal fat infiltration (p 0.010, p 0.003, and p 0.049, respectively).[ncbi.nlm.nih.gov]
  • Early clinical manifestations were sudden onset of left flank pain, fever, hematuria and pyuria, and following admission, severe abdominal pain, nausea, vomiting, reduced urine output and renal function deterioration.[ncbi.nlm.nih.gov]
  • No significant differences were found between the two groups in the day of resolving pyuria (P .46), day of resolving bacteriuria (P .81), or reductions in leukocyte count (P .64) and neutrophil count (P .49).[ncbi.nlm.nih.gov]
  • […] collecting system usually due to a calculus o Fever o Chills o Flank pain o Dysuria o Increased frequency of urination. o On exam, costovertebral angle tenderness may be present. o CBC § Elevated white blood cell count. o Urinalysis § Bacteriuria § Pyuria[learningradiology.com]
Creatinine Increased
  • None of the patients presented the 'classic' diagnostic tetrad (i.e. fever, positive urine cultures, low urinary tract symptoms and serum creatinine increase); although, at diagnosis, two of five patients presented with fever, one had increased creatinine[ncbi.nlm.nih.gov]
Blood Culture Positive
  • Clinical findings included fever (temperature, 37.8 C) or hypothermia (temperature, 8 WBCs/mL urine), a positive urine culture with 10 4 cfu/mL of a uropathogen, or a sterile urine culture but a blood culture positive for a uropathogen.[academic.oup.com]

Treatment

Prompt treatment of acute pyelonephritis is the key to achieving optimal therapeutic results. Since blood and urine cultures need some days to produce the results and pyelonephritis should be treated as early as possible, empirical treatment is usually administered from the start, which may be subject to adaptations if the cultures show a resistant microorganism. Local studies of pathogen resistance should be consulted prior to choosing the antimicrobial agent. Patients may need to be hospitalized, receive parenteral treatment and then complete their regime with oral agents [10] or could be treated at home from the beginning. A patient can be allowed to remain at home and receive oral treatment if they are in a good health status other than pyelonephritis, if they can abide by the doctor's direction, they display no septic phenomena or further complications.

Empirical treatment includes the administration of a selection of the following agents:

• Meropenem 
• Imipenem
• Ampicillin and an aminoglycoside
• Piperacillin-tazobactam
• Ticarcillin-clavulanate

A penicillin allergy prompts its replacement with vancomycin. Hospital therapy is continued for 10 to 14 days, starting with IV administration of antibiotics fro at least 1 or 2 days or until the patient's condition ameliorates.

Prognosis

An episode of acute pyelonephritis is a treatable condition, which, if addressed appropriately, can heal completely; if mistreated or untreated, however, it can cause serious damage and threaten the kidney and potentially the life of the patient as well.

Healthy individuals, both men and non-pregnant women, tend to recover to a full extent with no renal impairment, given that their health status is other than that normal. On the other hand, pregnant women do run a higher risk of going into labor prematurely and patients over the age of 65, immunodeficient people and people with a generally poor status of health display an increased mortality. Patients with an underlying diabetes mellitus were also shown to suffer from severer attacks of pyelonephritis and have increased mortality [8].

Etiology

The greater majority of pyelonephritis cases are triggered by bacteria, which have infiltrated the renal parenchyma via the lower parts of the urinary tract. A crucial risk factor that increases susceptibility to such a condition is anatomic variability: strictures at any part of the lower tract or ureters increase the possibility of developing a renal inflammation. This risk factor primarily affects men. The condition frequently affects young women and women who have undergone catheterization.

Another pathway, through which bacteria can infiltrate the kidney, is the bloodstream itself. Aggressive pathogens such as Staphylococcus aureus, pseudomonas aeruginosa and various Candida species are known to posses the ability to enter the renal parenchyma in such a way.

Epidemiology

Studies conducted in the USA confirmed that women tend to be more frequently affected by pyelonephritis than men. Researchers observed that, per year, around 16 cases of acute pyelonephritis were diagnosed amongst 10,000 women, in contradistinction to a considerably lower number, 3-4, per 10,000 men [3]. Even in women, the susceptibility to pyelonephritis varies with age: incidence increases at the periods of 0-4 years old, 15 to 35 years old and then again after the 80th year of age [3]. Treatment of acute pyelonephritis costs approximately $2.14 billion annually [3] [4].

Pregnant women run a higher risk of being affected by acute pyelonephritis. Data exhibited a staggering 20-30% of pyelonephritis cases in pregnant women, resulting from asymptomatic bacteriuria, for which the patients received no therapy. Women are also more frequently hospitalized with acute pyelonephritis than men, at a rate of 5:1, but do, however, maintain a lower mortality rate [5].

Pyelonephritis affects people of all ethnicities and its incidence seems to fluctuate additionally, according to the season. July, August and September were shown to be the months with an increased incidence of acute pyelonephritis, according to a study conducted in the state of Washington.

Sex distribution
Age distribution

Pathophysiology

A lower urinary tract infection (lower UTI) that is complicated with the ascendance of bacteria to the kidneys causes acute pyelonephritis; it is possible to outline a partial profile of patients who are in higher risk of developing such a condition, based on patient characteristics and bacterial traits [6].

The bloodstream pathway is another possibility for bacterial infiltration of the kidney. Bacteremia due to gram (+) pathogens, combined with other underlying systemic conditions or iatrogenic immunosuppression can lead to acute pyelonephritis, where the bacteria have been transferred to the kidney parenchyma through the bloodstream. This pathway, however, is reserved almost exclusively for the immunodeficient.

Most cases of lower or upper UTI can be traced back to the Escherichia coli pathogen, and more specifically, the uropathogenic E. coli (UPEC), which is one of the bacterium's strains. This bacterium latches on to the epithelial layers, causing a glycosphingolipid- and TLR4-mediated inflammation. This results to the activation of the immune system; chemokines such as IL-8 are activated, and connect to the interleukin 8 receptor (CXCR1). As a result, polymorphonuclear leukocytes are allowed to access the urine.

Infection is initiated at the pelvis, proceeding to the medulla and the cortex as it expands, while separate non-infected regions may still appear inbetween. An abscess may form and other papillary necrosis is reserved for patients with an underlying systemic disease (diabetes, analgesic neuropathy, sickle cell disease). Men who have an anatomic urinary tract obstruction, including prostatitis and hypertrophy, are in increased danger of suffering from acute pyelonephritis [7].

Prevention

Pyelonephritis can be prevented by adaptations in one's routine and behavior, in order to eliminate the possibility of being affected by a urinary tract infection. Contraceptive behavior should be reevaluated, frequent urination is encouraged and any case of cystitis should be identified and treated early, so as to avoid its being complicated with acute pyelonephritis. Patients who do proceed to these adaptations but still experience recurrent phenomena of UTI or pyelonephritis or do not respond to appropriate treatment should be examined for the existence of an obstructing anatomic variation.

Specifically women who are affected by a urinary tract infection more than three times per year should consider the following measures:

  • Drinking larger amounts of fluids, preferably water.
  • Urinating frequently.
  • Urinating before and after coitus.
  • Avoiding the use of a diaphragm or spermicide.
  • Wiping from the front to the back after defecation.
  • Prophylactic antibiotics administered either continuously or after sexual intercourse. This scheme is recommended after failure of the aforementioned methods.

Proper hydration is generally the key to avoiding frequent urinary tract infections and reducing the risk of acute pyelonephritis.

Summary

Acute pyelonephritis poses a considerable threat on the life of the affected patient and the functionality of the kidneys, as it can induce severe renal impairment. Possible complications resulting from acute pyelonephritis include septic phenomena or even septic shock, renal scarring, abscesses located on the kidney or on adjacent tissue and failure of multiple organs. Individuals who are immunosuppressed run a significantly higher risk of developing any of those complications [1] [2].

In the majority of the cases, acute pyelonephritis is preceded by an episode of infection of the urinary tract's lower parts. Patients report the classic symptomatology: frequent and urgent urination, pain during the action, hematuria and suprapubic pain. It is also possible that a patient first becomes symptomatic with symptoms originating from the acute pyelonephritis itself, such as back pain at the renal level and flank pain. General signs of inflammation may accompany both cases and patients may be febrile and experience nausea, frequent vomiting and chills. Acute pyelonephritis may also present with symptoms that are non-specific; therefore, clinical doctors should be always suspicious in cases of inflammations which are hard to trace. 

Patient Information

Acute pyelonephritis is an inflammation of one or both kidneys, caused by a bacterial infection. The bacteria may ascend to the kidneys from lower parts of the urinary tract, such as the bladder, due to a previous infection affecting those parts (cystitis).

The bacterium that most commonly causes cystitis and subsequent pyelonephritis is the Escherichia coli, normally found in the intestines, excrement and transiently the anal area. Poor genital hygiene or wrong toilet habits may lead to these bacteria entering the bladder and further moving up to the kidneys.

Women tend to be more frequently affected by pyelonephritis that men. Generally, there are sub-categories of people who run a higher risk of developing pyelonephritis, such as people who suffer from diabetes mellitus, transplant receivers, HIV patients, people who receive medication that weakens their immune system and pregnant women.

Pyelonephritis produces symptoms that involve fever with chills, pain at the back (low), nausea and vomiting. The condition will be diagnosed based on the symptomatology, urine test and urine culture. A urine test helps to confirm the inflammation, as it can detect the number of white blood cells currently present in the urine and the red blood cells. A urine culture will reveal the bacterium responsible for the inflammation. Treatment should be administered promptly in order to avoid possible complications and may be carried out in a hospital or at home, depending on the person's general health status and clinical manifestations. Treatment regimes last for 6-14 days.

References

Article

  1. Bass PF 3d, Jarvis JA, Mitchell CK. Urinary tract infections. Prim Care. 2003;30:41–61.
  2. Bergeron MG. Treatment of pyelonephritis in adults. Med Clin North Am. 1995;79:619–49.
  3. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis. 2007 Aug 1. 45(3):273-80.
  4. National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC). Kidney and Urologic Diseases Statistics for the United States. Available at http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/#urologic. Accessed: October 31, 2011.
  5. Foxman B, Klemstine KL, Brown PD. Acute pyelonephritis in US hospitals in 1997: hospitalization and in-hospital mortality. Ann Epidemiol. 2003;13:144–50.
  6. Mazaki-Tovi S, Vaisbuch E, Romero R, et al. Maternal plasma concentration of the pro-inflammatory adipokine pre-B-cell-enhancing factor (PBEF)/visfatin is elevated in pregnant patients with acute pyelonephritis. Am J Reprod Immunol. 2010 Mar 1. 63(3):252-62.
  7. Stamm WE. Urinary tract infections and pyelonephritis. In: Harrison TR, Braunwald E, eds. Harrison’s Principles of internal medicine. 15th ed. New York: McGraw-Hill, 2001:1620–6.
  8. Kofteridis DP, Papadimitraki E, Mantadakis E, et al. Effect of diabetes mellitus on the clinical and microbiological features of hospitalized elderly patients with acute pyelonephritis. J Am Geriatr Soc. 2009 Nov. 57(11):2125-8.
  9. Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008 Mar. 22(1):73-87, vi.
  10. van Nieuwkoop C, van't Wout JW, Spelt IC, et al. Prospective cohort study of acute pyelonephritis in adults: safety of triage towards home based oral antimicrobial treatment. J Infect. 2010 Feb. 60(2):114-21.

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Last updated: 2018-06-22 03:48