Acute Pyelonephritis
Nyoman Paramita Ayu
Nephrology and Hypertension Division
Internal Medicine Departement/Faculty of Medicine
Udayana University/Sanglah General Hospital
INTRODUCTION
Introduction
• Acute pyelonephritis is an infectious inflammatory disease involving
the kidney parenchyma and renal pelvis.
• Gram-negative bacteria are the most common causative agents
including E coli, Proteus, Klebsiella, Enterobacter, and Pseudomonas.
• Gram-positive bacteria are less commonly seen but include
Enterococcus faecalis and Staphylococcus aureus.
• The infection usually ascends from the lower urinary tract—with the
exception of S aureus, which usually is spread by a hematogenous
route.
Classification of Urinary Tract Infections
According to Epidemiologic Characteristics
Epidemiologic charecteristicss
Place of acquisition Host factors
Community-acquired UTIs UTIs in diabetes
Healthcare-associated UTIs UTIs in the elderly
Community-onset healthcare-associated UTIs UTIs in pregnancy
UTIs in kidney transplantation
UTIs in patients with spinal cord injuries
Öztürk R. World Journal of Urology. 2019
Classification
Uncomplicated Acute Pyelonephritis Complicated Pyelonephritis
• There is one or several such
• Pyelonephritis limited to: complicating factors→Next Tabel
• non-pregnant,
• pre-menopausal women with no
known relevant urological
abnormalities or comorbidities
Categories of Urinary Tract Infection in Adults
• Acute uncomplicated cystitis in healthy women
• Recurrent acute uncomplicated cystitis in healthy women
UTI in Adults •
•
Acute uncomplicated pyelonephritis in healthy women
Complicated urinary tract infection*
• Male sex
• Pregnancy
• Poorly controlled diabetes mellitus
• Obstruction or other structural factor: Urolithiasis, malignancies,
ureteral and urethral strictures, bladder diverticula, renal cysts,
fistulas, ileal conduits, other urinary diversions
• Functional abnormality: Neurogenic bladder, vesicoureteral
reflux
• Foreign bodies: Indwelling catheter, ureteral stent,
nephrostomy tube
• Other conditions: Renal failure, renal transplantation,
immunosuppression, multidrug-resistant uropathogens, health
care-associated (includes hospital-acquired/LTCF-acquired)
infection, prostatitis-related infection, upper tract infection in
an adult other than a healthy woman, other functional or
anatomic abnormality of urinary tract)
• Asymptomatic bacteriuria
Feehally J. Comprehensive Clinical Nephrology. 2019
Common Factors Associated with Complicated UTI
• Complicated UTI is defined as UTI that increases the risk for serious complications or
treatment failure
• Vesicoureteral reflux (VUR) is a congenital or acquired abnormality in which there is
retrograde flow of urine from the bladder to the kidneys.
• Bonkat G et al. European Association of Urology. 2021
Classification
Main factors associated with complicated UTI
ETIOLOGY AND PATHOGENESIS
• Uncomplicated upper and lower UTI
are most often caused by E. coli, Uro-
pathogenic E. coli (UPEC), present in
70% to 95%, and
• Staphylococcus saprophyticus, 5% to
more than 20%.
Hooton, T. In: Feehally et al. Comprehensive Clinical
Nephrology. 6th ed. Philadelphia: Elsevier; 2018. p. 626-37
National Kidney Fondation, Primer in Kidney disease
1. Mireles et al. Nat Rev Microbiol. 2015 May ; 13(5): 269–284
2.
DIAGNOSIS
The diagnosis of a Acute Pyelonephritis is based on the combination of symptoms
and laboratory findings.
Essentials of Diagnosis
• Fever
• Flank Pain
• Irrittative voiding symptoms
• Positive urine culture
Symptoms and Signs
• Symptoms include fever, flank pain, shaking chills,
and irritative voiding symptoms (urgency, frequency,
dysuria).
• Associated nausea and vomiting and diarrhea are
common.
• Signs include fever and tachycardia.
• Costovertebral angle tenderness is usually
pronounced.
Laboratory findings
• Complete blood cell count shows leukocytosis and a
left shift.
• Urinalysis shows pyuria, bacteriuria, and varying
degrees of hematuria.
➢ White cell casts may be seen.
• Urine culture demonstrates heavy growth of the
offending organism, and blood culture may also be
positive.
Imaging
• In complicated pyelonephritis, renal ultrasound may
show hydronephrosis from a stone or other source of
obstruction.
• CT scan may demonstrate decreased perfusion of the
kidney or focal areas within the kidney and
nonspecific perinephric fat stranding.
Differential Diagnosis
• The differential diagnosis includes acute cystitis or a lower
urinary source.
• Acute intraabdominal disease
• appendicitis, cholecystitis, pancreatitis, or diverticulitis must be
distinguished from pyelonephritis.
• Lowerlobe pneumonia is distinguishable by the abnormal
chest radiograph.
MANAGEMENT
There are three main aims in the management of UTI:
1. Effective therapeutic response
2. Prevention of recurrence
3. Reduce the development of resistance of bacterial
strains
General Approach in Management Acute
Pyelonephritis
• Urine and blood cultures are obtained to identify
the causative agent and to determine antimicrobial
sensitivity.
• Antibiotics are adjusted according to sensitivities.
• If local antibiograms demonstrate local resistance
rates for the oral regimen exceed 10%, an initial 24-
hour intravenous dose of antibiotic is required.
General Approach in Management Acute
Pyelonephritis
• Fevers may persist for up to 72 hours even with appropriate
antibiotics; failure to respond within 48 hours warrants imaging
(CT or ultrasound) to exclude complicating factors that may
require intervention.
• Catheter drainage may be necessary in the face of urinary
retention and nephrostomy drainage if there is ureteral
obstruction.
• In inpatients, intravenous antibiotics are continued for 24 hours
after the fever resolves, and oral antibiotics are then given to
complete a 14-day course of therapy.
Hooton, T. In: Feehally et al. Comprehensive Clinical
Nephrology. 6th ed. Philadelphia: Elsevier; 2018. p. 626-37
National Kidney Fondation, Primer in Kidney disease
National Kidney Fondation, Primer in Kidney disease
Complications
• Sepsis with shock can occur with acute pyelonephritis.
• In diabetic patients, emphysematous pyelonephritis
resulting from gas-producing organisms may be
lifethreatening if not adequately treated.
• Healthy adults usually recover complete kidney function, yet
if coexistent kidney disease is present, scarring or chronic
pyelonephritis may result.
• Inadequate therapy could result in abscess formation.
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