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

Acute Pyelonephritis results from the following process: infectious.

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.

urogenital
Flank Pain
  • [bestpractice.bmj.com] In children, symptoms such as fever, lethargy, flank pain and nausea may be present.[symptoma.com]
  • Flank pain is nearly universal, and its absence should raise suspicion of an alternative diagnosis.[aafp.org]
  • Signs and symptoms include fever, chills, flank pain, painful and frequent urination, cloudy or bloody urine, and confusion.[fpnotebook.com]
  • Definition of Acute Pyelonephritis Acute pyelonephritis is a bacterial infection of the renal pelvis and the renal parenchyma with fever, flank pain and bacteriuria .[urology-textbook.com]
  • We consider a UTI to be complicated when there is concern for pyelonephritis or suspicion that the infection has otherwise extended beyond the bladder, such as when there is flank pain, groin or rectal pain, fever, and/or other signs of systemic illness[uptodate.com]
Dysuria
  • […] o Flank pain o Dysuria [learningradiology.com] Classic symptoms include dysuria , frequent voiding of small volumes, and urinary urgency.[symptoma.com]
  • She developed dysuria and urinary frequency 3 days prior and states that both have worsened.[smartypance.com]
  • Klebsiella § Proteus § Pseudomonas o Exception is S. aureus, which is spread hematogenously · Pathologic Causes o Vesicoureteral reflux o Obstruction in the collecting system usually due to a calculus · Signs and symptoms o Fever o Chills o Flank pain o Dysuria[learningradiology.com]
  • Classic symptoms include dysuria, frequent voiding of small volumes, and urinary urgency.[cdc.gov]
  • There may or may not be accompanying lower urinary tract symptoms with frequency, dysuria, gross haematuria or hesitancy.[patient.info]
Hematuria
  • [symptoma.com] Hematuria [www.symptoma.com] Hematuria 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]
  • 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]
  • Urinalysis will show bacteria, pyuria, and often hematuria.[pathwaymedicine.org]
  • Hematuria and suprapubic discomfort are less common.[cdc.gov]
Suprapubic Pain
  • [fpnotebook.com] Suprapubic Pain There is unilateral or bilateral loin pain, suprapubic pain or back pain.[symptoma.com]
  • There is unilateral or bilateral loin pain, suprapubic pain or back pain.[patient.info]
  • Diagnosis and differential diagnosis Establishing the diagnosis Clinical signs and symptoms of acute pyelonephritis includes the typical presentation of UTI, to include dysuria, frequency, urgency, hematuria and suprapubic pain.[clinicaladvisor.com]
Urinary Urgency
  • Classic symptoms include dysuria, frequent voiding of small volumes, and urinary urgency.[cdc.gov]
  • [clinicaladvisor.com] Urinary Urgency Classic symptoms include dysuria, frequent voiding of small volumes, and urinary urgency .[symptoma.com]
  • Symptoms Fever Chills and malaise Flank pain Nausea and Vomiting Acute Cystitis symptoms Dysuria Urinary frequency Urinary urgency X.[fpnotebook.com]
Cloudy Urine
  • Common symptoms include: a fever greater than 102 F (38.9 C) pain in the abdomen, back, side, or groin painful or burning urination cloudy urine pus or blood in the urine urgent or frequent urination fishy-smelling urine Other symptoms can include: shaking[healthline.com]
  • Urine Common symptoms include: a fever greater than 102 F (38.9 C) pain in the abdomen, back, side, or groin painful or burning urination cloudy urine pus or blood in the urine urgent or frequent urination fishy-smelling urine Other symptoms can include[symptoma.com]
Urinary Incontinence
  • [fpnotebook.com] Urinary Incontinence incontinence and urinary infection - C Dawson, H Whitfield - BMJ, 1996 - bmj.com Conn's Current Therapy 2008: Text with Online Reference - RE Rakel, ET Bope - 2007 - lavoisier.fr 6 Acute renal failure in pregnancy[symptoma.com]
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  • cardiovascular
    Tachycardia
    • [fpnotebook.com] Signs of sepsis (eg, tachypnoea, tachycardia , hypotension).[symptoma.com]
    • Signs Fever Tachycardia Hypotension Costovertebral angle tenderness Abdominal tenderness (esp. suprapubic tenderness) XI.[fpnotebook.com]
    • Signs of sepsis (eg, tachypnoea, tachycardia, hypotension).[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]
    • Hypotension, tachycardia and low urine output may be seen in association with acute pyelonephritis in pregnancy.[clinicaladvisor.com]
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  • musculoskeletal
    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]
    • [clinicaladvisor.com] Myalgia Two patients discontinued ciprofloxacin because of myalgia with 7 days of treatment and itching exanthema with 14 days.[symptoma.com]
    Back Pain
    • [clinicaladvisor.com] more... musculoskeletal Back Pain [www.symptoma.com] more... musculoskeletal Back Pain It is also possible that a patient first becomes symptomatic with symptoms originating from the acute pyelonephritis itself, such as back pain[symptoma.com]
    • There is unilateral or bilateral loin pain, suprapubic pain or back pain.[patient.info]
    • In addition, classic upper urinary tract symptoms to include flank or back pain may be accompanied by systemic symptoms (e.g. fever, chills, abdominal pain, nausea and vomiting).[clinicaladvisor.com]
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  • gastrointestinal
    Nausea
    • [cdc.gov] more... gastrointestinal Nausea Common symptoms include back or belly pain, fever, nausea and vomiting.[symptoma.com]
    • Common symptoms include back or belly pain, fever, nausea and vomiting.[ada.com]
    • Common signs and symptoms include acute-onset fever, chills, severe back or flank pain, nausea and vomiting, and costovertebral angle tenderness.[bestpractice.bmj.com]
    • Pyelonephritis PANCE Blueprint Genitourinary (6%) Presentation Pearls Diagnostic studies Treatment Patient will present as a 32-year-old female presents with fever, chills, nausea and flank pain for 24 hours.[smartypance.com]
    • It is characterized by ABDOMINAL PAIN; FEVER; NAUSEA; VOMITING; and occasionally DIARRHEA.[fpnotebook.com]
    Vomiting
    • [fpnotebook.com] Vomiting Common symptoms include back or belly pain, fever, nausea and vomiting .[symptoma.com]
    • Common symptoms include back or belly pain, fever, nausea and vomiting.[ada.com]
    • 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.[fcm.unicamp.br]
    • You cannot stop vomiting.[drugs.com]
    • Malaise, nausea, vomiting, anorexia and occasionally diarrhoea occur.[patient.info]
    Abdominal Pain
    • [drugs.com] It is characterized by ABDOMINAL PAIN; FEVER ; NAUSEA; VOMITING; and occasionally DIARRHEA.[symptoma.com]
    • 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]
    • On physical exam you note suprapubic abdominal pain and CVA tenderness .[smartypance.com]
    • 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]
    Acute Abdomen
    • [clinicaladvisor.com] Acute Abdomen Causes of acute abdomen .[symptoma.com]
    • Causes of acute abdomen .[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]
    Suprapubic Pain
    • [fpnotebook.com] Suprapubic Pain There is unilateral or bilateral loin pain, suprapubic pain or back pain.[symptoma.com]
    • There is unilateral or bilateral loin pain, suprapubic pain or back pain.[patient.info]
    • Diagnosis and differential diagnosis Establishing the diagnosis Clinical signs and symptoms of acute pyelonephritis includes the typical presentation of UTI, to include dysuria, frequency, urgency, hematuria and suprapubic pain.[clinicaladvisor.com]
    Constipation
    • Causes Constipation Extrinsic obstruction occurs with chronic constipation (particularly in children), prostatic swelling/mass (eg, hypertrophy, infection, cancer), and retroperitoneal mass.[symptoma.com]
    • Extrinsic obstruction occurs with chronic constipation (particularly in children), prostatic swelling/mass (eg, hypertrophy, infection, cancer), and retroperitoneal mass.[emedicine.medscape.com]
    Loss of Appetite
    • Other symptoms include a loss of appetite, passing urine frequently, blood in the urine, and an unusual smell to the urine.[ada.com]
    • This then followed by pain, loss of appetite, headache.[forerunnershealthcare.com]
    Abdominal Tenderness
    • Signs Fever Tachycardia Hypotension Costovertebral angle tenderness Abdominal tenderness (esp. suprapubic tenderness) XI.[fpnotebook.com]
    • tenderness (esp. suprapubic tenderness) XI.[symptoma.com]
    Left Flank Pain
    • 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.[fcm.unicamp.br]
    • [emedicine.medscape.com] Left Flank Pain 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.[symptoma.com]
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  • neurologic
    Headache
    • By ANAHAD O’CONNOR Photo Credit Istock In the Flu Battle, Hydration and Elevation May Be Your Best Weapons Bring on the soup: Fluids will help diminish your headache and bolster your immune response.[nytimes.com]
    • Prominent cold symptoms include fever, cough, rhinorrhea, nasal congestion, postnasal drip, sore throat, headache, and myalgias.[cdc.gov]
    • This then followed by pain, loss of appetite, headache.[forerunnershealthcare.com]
    • [fpnotebook.com] Prominent cold symptoms include fever , cough, rhinorrhea, nasal congestion, postnasal drip, sore throat, headache, and myalgias.[symptoma.com]
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  • Entire body system
    Fever
    • [intechopen.com] Fever You have a fever and chills.[symptoma.com]
    • You have a fever and chills.[drugs.com]
    • It is characterized by ABDOMINAL PAIN; FEVER; NAUSEA; VOMITING; and occasionally DIARRHEA.[fpnotebook.com]
    • Prominent cold symptoms include fever, cough, rhinorrhea, nasal congestion, postnasal drip, sore throat, headache, and myalgias.[cdc.gov]
    • O Once the woman has been fever-free for 48 hours, give amoxicillin/ampicillin 500 mg by mouth three times a day to complete 14 days of treatment.[books.mcai.org.uk]
    Chills
    • [ada.com] Chills You have a fever and chills .[symptoma.com]
    • You have a fever and chills.[drugs.com]
    • Common signs and symptoms include acute-onset fever, chills, severe back or flank pain, nausea and vomiting, and costovertebral angle tenderness.[bestpractice.bmj.com]
    • Pyelonephritis PANCE Blueprint Genitourinary (6%) Presentation Pearls Diagnostic studies Treatment Patient will present as a 32-year-old female presents with fever, chills, nausea and flank pain for 24 hours.[smartypance.com]
    • […] bacteria § E. coli § Klebsiella § Proteus § Pseudomonas o Exception is S. aureus, which is spread hematogenously · Pathologic Causes o Vesicoureteral reflux o Obstruction in the collecting system usually due to a calculus · Signs and symptoms o Fever o Chills[learningradiology.com]
    Malaise
    • Signs and Symptomology Acute pyelonephritis is a deep infection and patients often display consitutional symptoms such as fever, chills, and malaise.[pathwaymedicine.org]
    • [fpnotebook.com] Malaise Signs and Symptomology Acute pyelonephritis is a deep infection and patients often display consitutional symptoms such as fever, chills, and malaise .[symptoma.com]
    • Malaise, nausea, vomiting, anorexia and occasionally diarrhoea occur.[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
    • fever ( 103 F) Severe flank or Abdominal Pain Debilitated condition Pregnancy (some cases may be treated outpatient) XVI.[fpnotebook.com]
    • Clinical presentation is fairly specific and classical in most cases, consisting of a rapid onset of high fever and flank pain and tenderness.[radiopaedia.org]
    • [fpnotebook.com] Clinical presentation is fairly specific and classical in most cases, consisting of a rapid onset of high fever and flank pain and tenderness.[symptoma.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
    • [aafp.org] Rigor [www.symptoma.com] Rigor Febrile patients commonly exhibit chills or rigor as well, alongside fatigue and weakness.[symptoma.com]
    • Fever is variable but can be high enough to produce rigors.[patient.info]
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  • 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].

    Laboratory

    Urine
    Pyuria
    • . · Clinical Findings o CBC § Elevated white blood cell count. o Urinalysis § Bacteriuria § Pyuria § White blood cell casts o Acute pyelonephritis is clinical diagnosis, § Radiographic imaging is used to evaluate underlying pathology § Rule out any complications[learningradiology.com]
    • […] injuries; some UTIs; independent risk factor for renal scar formation after acute pyelonephritis in infants ( J Urol 2012;187:1032 ) Signs / symptoms: sudden onset of costovertebral angle pain, symptoms of systemic infection or urinary tract infection, pyuria[pathologyoutlines.com]
    • Urinalysis will show bacteria, pyuria, and often hematuria.[pathwaymedicine.org]
    • [pathologyoutlines.com] Laboratory Urine Pyuria 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: Considerable pyuria[symptoma.com]
    • The presence of white blood cell casts indicates renal-origin pyuria, supporting the diagnosis of acute pyelonephritis, but casts are not often seen.[aafp.org]
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  • Serum
    Abnormal Renal Function
    • Serum Abnormal Renal Function Spontaneous resolution of the abnormal renal function should be expected as the acute infection clears, although there is some evidence that a minority of women will have permanent renal impairment following a bout of pyelonephritis[symptoma.com]
    • Spontaneous resolution of the abnormal renal function should be expected as the acute infection clears, although there is some evidence that a minority of women will have permanent renal impairment following a bout of pyelonephritis in pregnancy.[clinicaladvisor.com]
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  • Microbiology
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  • Imaging

    X-ray
    Nephrolithiasis
    • [en.wikipedia.org] [www.symptoma.com] Nephrolithiasis Should it reveal a possible nephrolithiasis , a computed tomography (CT) scan and urogram need to be carried out for fear of hydronephrosis.[symptoma.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]
    • […] 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]
    • "Chapter 135: Approach to the Paient with Nephrolithiasis".[en.wikipedia.org]
    • Patients with nephrolithiasis and ureterolithiasis, which also cause flank pain, do not usually present with costovertebral angle tenderness.[aafp.org]
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  • 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].

    Complications

    Constipation
    • Causes Constipation Extrinsic obstruction occurs with chronic constipation (particularly in children), prostatic swelling/mass (eg, hypertrophy, infection, cancer), and retroperitoneal mass.[symptoma.com]
    • Extrinsic obstruction occurs with chronic constipation (particularly in children), prostatic swelling/mass (eg, hypertrophy, infection, cancer), and retroperitoneal mass.[emedicine.medscape.com]
    Proteinuria
    • […] per hpf Proteinuria ; up to 2 g per [symptoma.com] Urine: leukocytes ( ), proteinuria ( ), urea 55mg/dl, creatinine 1.2mg/dl, total proteins 5.1g/dl and CRP 69mg/dl.[symptoma.com]
    • Urine: leukocytes ( ), proteinuria ( ), urea 55mg/dl, creatinine 1.2mg/dl, total proteins 5.1g/dl and CRP 69mg/dl.[revistanefrologia.com]
    • A study of nephropathy resulted in an association of the 869 CC genotype with heavy proteinuria and a higher score of mesangial cell proliferation [ 84 ]. 2.5.5.[intechopen.com]
    Fever
    • [intechopen.com] Fever You have a fever and chills.[symptoma.com]
    • You have a fever and chills.[drugs.com]
    • It is characterized by ABDOMINAL PAIN; FEVER; NAUSEA; VOMITING; and occasionally DIARRHEA.[fpnotebook.com]
    • Prominent cold symptoms include fever, cough, rhinorrhea, nasal congestion, postnasal drip, sore throat, headache, and myalgias.[cdc.gov]
    • O Once the woman has been fever-free for 48 hours, give amoxicillin/ampicillin 500 mg by mouth three times a day to complete 14 days of treatment.[books.mcai.org.uk]
    Acute Kidney Failure
    • Other complications include: recurring kidney infections the infection spreading to areas around the kidneys acute kidney failure kidney abscess Preventing pyelonephritis Pyelonephritis can be a serious condition.[healthline.com]
    • [ada.com] Acute Kidney Failure Back to Top Possible Complications Acute kidney failure Kidney infection returns Infection around the kidney (perinephric abscess) Severe blood infection (sepsis) Back to Top When to Contact a Medical Professional Call your[symptoma.com]
    Endometritis
    • [healthline.com] Endometritis However, blood cultures may be the only method of identifying the causative organism in cases of suspected acute pyelonephritis that turn out to be another disorder, such as endometritis , intraabdominal or psoas abscess,[symptoma.com]
    • However, blood cultures may be the only method of identifying the causative organism in cases of suspected acute pyelonephritis that turn out to be another disorder, such as endometritis, intraabdominal or psoas abscess, or cholangitis.[aafp.org]
    Shock
    • Key Words: acute pyelonephritis ; computed tomography ; septic shock[kjccm.org]
    • [aafp.org] Shock Key Words: acute pyelonephritis ; computed tomography ; septic shock [kjccm.org] O If shock is present or suspected, initiate immediate ABC treatment.[symptoma.com]
    • O If shock is present or suspected, initiate immediate ABC treatment.[books.mcai.org.uk]
    • Leukocytosis and resistance to septic shock in intercellular adhesion molecule 1-deficient mice.[intechopen.com]
    • A serious complication of urosepsis is septic shock and disseminated intravascular coagulation (DIC), and these patients require close monitoring in an intensive care unit, often with pulmonary artery catheterization.[clinicaladvisor.com]
    Renal Abscess
    • Renal abscess in a young woman after delivery.[revistanefrologia.com]
    • Jr and Perkins T. : Presentation, diagnosis and treatment of renal abscesses.[fcm.unicamp.br]
    • Rarely, the kidney may be seeded haematogenously, in which case renal abscesses develop rather than pyelonephritis.[radiopaedia.org]
    • Renal abscess has a favorable prognosis after drainage and antibiotic treatment.[urology-textbook.com]
    • [intechopen.com] Renal Abscess Renal abscess in a young woman after delivery.[symptoma.com]
    Septicemia
    • Infection spreads through the blood-stream from distant foci (bronchopneumonia, otitis, endocarditis or septicemia) causing abscesses.[pathologyatlas.ro]
    • Complications included anemia (23%), septicemia (17%), transient renal dysfunction (2%), and pulmonary insufficiency (7%).[journals.lww.com]
    • [lecturio.com] Septicemia Infection spreads through the blood-stream from distant foci (bronchopneumonia, otitis, endocarditis or septicemia ) causing abscesses.[symptoma.com]
    Renal Papillary Necrosis
    • [journals.lww.com] Renal Papillary Necrosis You're also at increased risk for a kidney infection if you have any of the following conditions: Backflow of urine into the ureters or kidney pelvis Kidney stones Ostructive uropathy Renal papillary necrosis[symptoma.com]
    Appendicitis
    • Appendicitis was suspected initially.[tzuchi.com.tw]
    • Differential diagnosis: Pelvic inflammatory disease (PID) , appendicitis , urolithiasis, biliary tract disease, acute pancreatitis, basal pneumonia.[hopkinsguides.com]
    • 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]
    Pelvic Inflammatory Disease
    • [hopkinsguides.com] Pelvic inflammatory disease .[symptoma.com]
    • Pelvic inflammatory disease .[patient.info]
    • Differential diagnosis: Pelvic inflammatory disease (PID) , appendicitis , urolithiasis, biliary tract disease, acute pancreatitis, basal pneumonia.[hopkinsguides.com]
    • inflammatory disease / / Pulmonary infarctions / Renal corticomedullary necrosis Renal vein thrombosis Retroperitoneal disorders (e.g., hemorrhage, abscess) / / / Shingles Splenic abscess or infarct / Urinary tract obstruction / Vascular pathology Table[aafp.org]
    Perinephric Abscess
    • Complications of acute pyelonephritis : Papillary necrosis - frequently seen in diabetics and those with urinary obstruction Pyonephrosis Perinephric abscess Macroscopy : The size of the affected kidneys is normal or slighted enlarged.[pathologyatlas.ro]
    • […] or white blood cell casts Complications Papillary necrosis: more common with diabetes and urinary tract obstruction; usually bilateral; variable number of pyramids involved; coagulative necrosis of tubules; usually limited white blood cell response Perinephric[pathologyoutlines.com]
    • [fcm.unicamp.br] Perinephric abscess (more common if there is urinary tract abnormality).[symptoma.com]
    • . : Perinephric abscess, current concepts.[fcm.unicamp.br]
    • Perinephric abscess (more common if there is urinary tract abnormality).[patient.info]
    Hydronephrosis
    • Pictures Hydronephrosis: Hydronephrosis, Macro, autopsy (71055) Unilateral hydronephrosis, Macro, autopsy (71056) Hydronephrosis, Macro, autopsy (71057) Hydronephrosis, Macro, autopsy (71058) Hydronephrosis, hydroureter, Macro, autopsy (71054) Kidney[atlases.muni.cz]
    • [aafp.org] Hydronephrosis Pictures Hydronephrosis : Hydronephrosis , Macro, autopsy (71055) Unilateral hydronephrosis , Macro, autopsy (71056) Hydronephrosis , Macro, autopsy (71057) Hydronephrosis , Macro, autopsy (71058) Hydronephrosis , hydroureter[symptoma.com]
    • […] with ureteropelvic junction obstruction N13.1 Hydronephrosis with ureteral stricture, not elsewhere classified N13.2 Hydronephrosis with renal and ureteral calculous obstruction Reimbursement claims with a date of service on or after October 1, 2015[icd10data.com]
    • Patient will present with ( ) CVA Tenderness If severe symptoms or unable to take PO will need to be hospitalized White blood cell casts in urine is pathognomonic pyelonephritis If complicated pyelonephritis order a renal ultrasound may show hydronephrosis[smartypance.com]
    • . · Complications o Abscess o Emphysematous pyelonephritis § Most often occurs in diabetics · Can produce gas in the collecting system and renal parenchyma · Imaging Findings o Enlarged kidneys (U/S and CT) o Hydronephrosis (U/S and CT) o Wedge shaped[learningradiology.com]
    Preterm Labor
    • If someone comes in with acute pyelonephritis and preterm labor, you don't want to use tocolytics such as terbutaline because terbutaline itself is associated with increased risk of pulmonary edema, which in turn can result in adult respiratory distress[thefreedictionary.com]
    • More research should be done to elucidate each risk factor for preterm labor independently.[clinicaladvisor.com]
    • [revistanefrologia.com] Preterm Labor If someone comes in with acute pyelonephritis and preterm labor , you don't want to use tocolytics such as terbutaline because terbutaline itself is associated with increased risk of pulmonary edema, which in turn[symptoma.com]
    Acute Glomerulonephritis
    • glomerulonephritis acute nephritis Type 1 Excludes acute tubulo-interstitial nephritis ( N10 ) nephritic syndrome NOS ( N05.- ) Nephritis, nephritic (albuminuric) (azotemic) (congenital) (disseminated) (epithelial) (familial) (focal) (granulomatous)[icd10data.com]
    • [clinicaladvisor.com] Acute Glomerulonephritis glomerulonephritis acute nephritis Type 1 Excludes acute tubulo-interstitial nephritis ( N10 ) nephritic syndrome NOS ( N05.- ) Nephritis, nephritic (albuminuric) (azotemic) (congenital) (disseminated) (epithelial[symptoma.com]
    Nephrolithiasis
    • [en.wikipedia.org] [www.symptoma.com] Nephrolithiasis Should it reveal a possible nephrolithiasis , a computed tomography (CT) scan and urogram need to be carried out for fear of hydronephrosis.[symptoma.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]
    • […] 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]
    • "Chapter 135: Approach to the Paient with Nephrolithiasis".[en.wikipedia.org]
    • Patients with nephrolithiasis and ureterolithiasis, which also cause flank pain, do not usually present with costovertebral angle tenderness.[aafp.org]
    Septic Shock
    • Key Words: acute pyelonephritis ; computed tomography ; septic shock[kjccm.org]
    • [aafp.org] Septic Shock Key Words: acute pyelonephritis ; computed tomography ; septic shock [kjccm.org] Shock Possible complications resulting from acute pyelonephritis include septic phenomena or even septic shock , renal scarring, abscesses located[symptoma.com]
    • A serious complication of urosepsis is septic shock and disseminated intravascular coagulation (DIC), and these patients require close monitoring in an intensive care unit, often with pulmonary artery catheterization.[clinicaladvisor.com]
    • Leukocytosis and resistance to septic shock in intercellular adhesion molecule 1-deficient mice.[intechopen.com]
    Ureterolithiasis
    • [intechopen.com] Ureterolithiasis "Diagnosis and Management of Acute Ureterolithiasis : CT Is Truth" (PDF) .[symptoma.com]
    • "Diagnosis and Management of Acute Ureterolithiasis: CT Is Truth" (PDF) .[en.wikipedia.org]
    • Patients with nephrolithiasis and ureterolithiasis, which also cause flank pain, do not usually present with costovertebral angle tenderness.[aafp.org]
    Chronic Pyelonephritis
    • Chronic Pyelonephritis Scarring of the glomeruli and tubular atrophy are characteristic of chronic pyelonephritis.[lecturio.com]
    • Chronic pyelonephritis is more common in children than in adults.[healthline.com]
    • Presentation Chronic pyelonephritis is often asymptomatic.[patient.info]
    • Chronic pyelonephritis and Ask-Upmark kidney may develop.[urology-textbook.com]
    • Hereditary nephropathy, not elsewhere classified with unspecified morphologic lesions N08 Glomerular disorders in diseases classified elsewhere N10 Acute pyelonephritis N11 Chronic tubulo-interstitial nephritis N11.0 Nonobstructive reflux-associated chronic[icd10data.com]
    Renal Colic
    • For example, if renal colic is suspected then a non-contrast scan is often required to assess for renal calculi.[radiopaedia.org]
    • [aafp.org] Renal Colic For example, if renal colic is suspected then a non-contrast scan is often required to assess for renal calculi.[symptoma.com]
    • Acute papillary necrosis, which is more likely in the elderly and those with diabetes (suggested by associated symptoms of renal colic).[patient.info]
    Perinephritis
    • [pathologyoutlines.com] . : Perinephric abscess , current concepts.[symptoma.com]
    • Complications of acute pyelonephritis : Papillary necrosis - frequently seen in diabetics and those with urinary obstruction Pyonephrosis Perinephric abscess Macroscopy : The size of the affected kidneys is normal or slighted enlarged.[pathologyatlas.ro]
    • […] and renal parenchyma · Imaging Findings o Enlarged kidneys (U/S and CT) o Hydronephrosis (U/S and CT) o Wedge shaped areas of low attenuation secondary to decreased perfusion (CT) o Loss of the ability to distinguish the corticomedullary border (CT) o Perinephric[learningradiology.com]
    • Perinephric abscess (more common if there is urinary tract abnormality).[patient.info]
    • […] or white blood cell casts Complications Papillary necrosis: more common with diabetes and urinary tract obstruction; usually bilateral; variable number of pyramids involved; coagulative necrosis of tubules; usually limited white blood cell response Perinephric[pathologyoutlines.com]
    Urosepsis
    • Urosepsis is a potentially fatal complication that results from bacteremia.[clinicaladvisor.com]
    • Complications of obstruction with superimposed infection include hydronephrosis, pyonephrosis, urosepsis, and xanthogranulomatous pyelonephritis .[emedicine.medscape.com]
    • [aafp.org] Urosepsis Urosepsis is a potentially fatal complication that results from bacteremia.[symptoma.com]

    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.

    Causes

    Constipation
    • Causes Constipation Extrinsic obstruction occurs with chronic constipation (particularly in children), prostatic swelling/mass (eg, hypertrophy, infection, cancer), and retroperitoneal mass.[symptoma.com]
    • Extrinsic obstruction occurs with chronic constipation (particularly in children), prostatic swelling/mass (eg, hypertrophy, infection, cancer), and retroperitoneal mass.[emedicine.medscape.com]
    Suppurative Inflammation
    • Acute pyelonephritis is an acute suppurative inflammation of the kidney caused by bacterial infections ( Escherichia coli in 70 - 80 % of cases, Proteus mirabilis , Klebsiella pneumoniae , Enterococus fecalis , Staphylococcus ).[pathologyatlas.ro]
    • inflammation, primarily cortical, with edema, neutrophils in interstitium and tubular lumina, and tubular necrosis Cortical abscesses and necrosis Glomeruli and vessels usually normal (Candida affects glomeruli) Microscopic (histologic) images Images[pathologyoutlines.com]
    • [emedicine.medscape.com] Suppurative Inflammation Acute pyelonephritis is an acute suppurative inflammation of the kidney caused by bacterial infections ( Escherichia coli in 70 - 80 % of cases, Proteus mirabilis , Klebsiella pneumoniae , Enterococus[symptoma.com]
    Bacteria

    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.

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    References

    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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