Pyelonephritis

Description

• Infection of the renal parenchyma and/or renal pelvis, often producing localized flank/back pain combined with systemic symptoms, such as fever, chills, nausea, and vomiting. There is a wide spectrum of illness ranging from mild symptoms to septic shock.
• Chronic pyelonephritis is the result of progressive inflammation of the renal interstitium and tubules due to recurrent infection, vesicoureteral reflux, or both.
• Considered uncomplicated if the infection is caused by a typical pathogen in an immunocompetent patient with normal urinary tract anatomy and renal function

Geriatric Considerations
May present as altered mental status; absence of fever is common in older adults. Older patients with diabetes and pyelonephritis are at higher risk of bacteremia, prolonged hospitalization, and mortality. The high prevalence of asymptomatic bacteriuria (ABU) in older adults makes the use of urine dipstick less reliable for diagnosing UTI. Culture and sensitivity (C&S) data are useful in guiding therapy for pyelonephritis in older adults and should be obtained.Pregnancy Considerations
Pyelonephritis affects 1–2% of pregnancies and is the most common medical complication requiring hospitalization in pregnancy. Pregnant patients with untreated ABU have a 20–30% risk of developing acute pyelonephritis. Patients with pyelonephritis are at increased risk for developing acute respiratory distress syndrome and spontaneous preterm labor. Pregnant women with acute pyelonephritis should be considered for hospitalization and treated initially with a 2nd or 3rd generation IV cephalosporin.Pediatric Considerations
UTI is present in ~5% of patients age 2 months to 2 years with fever and no apparent source on history and physical exam. A urine specimen, preferably by catheterization or suprapubic aspiration, should be obtained and sent for urinalysis prior to starting antibiotics. Treatment should be based on the clinical situation.

Epidemiology

Etiology and Pathophysiology

Escherichia coli (>80%); Klebsiella spp. second most common followed by:

• Other gram-negative pathogens: Proteus, Serratia, Clostridium, Pseudomonas, and Enterobacter spp.; Enterococcus spp.
• Staphylococcus epidermidis, Staphylococcus saprophyticus (second leading cause in young women), and Staphylococcus aureus
• Candida spp.

Risk Factors

Underlying urinary tract abnormalities, indwelling catheter/recent urinary tract instrumentation, nephrolithiasis, immunocompromised (diabetes), elderly, institutionalized patients (particularly women), prostatic enlargement, stress incontinence

Commonly Associated Conditions

Indwelling catheters, renal calculi; benign prostatic hyperplasia