Pyelonephritis

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Pyelonephritis
Other namesKidney infection [1]
Xanthogranulomatous pyelonephritis cd68.jpg
CD68 immunostaining on this photomicrograph shows macrophages and giant cells in a case of xanthogranulomatous pyelonephritis.
Pronunciation
Specialty Infectious disease, urology, nephrology
Symptoms Fever, flank tenderness, nausea, burning with urination, frequent urination [2]
Causes Bacterial infection [2]
Risk factors Sexual intercourse, prior urinary tract infections, diabetes, structural problems of the urinary tract, spermicide use [2] [3]
Diagnostic method Based on symptoms and supported by urinalysis [2]
Differential diagnosis Endometriosis, pelvic inflammatory disease, kidney stones [2]
PreventionUrination after sex, drinking sufficient fluids [1]
Medication Antibiotics (ciprofloxacin, ceftriaxone) [4]
FrequencyCommon [5]

Pyelonephritis is inflammation of the kidney, typically due to a bacterial infection. [3] Symptoms most often include fever and flank tenderness. [2] Other symptoms may include nausea, burning with urination, and frequent urination. [2] Complications may include pus around the kidney, sepsis, or kidney failure. [3]

Contents

It is typically due to a bacterial infection, most commonly Escherichia coli . [2] Risk factors include sexual intercourse, prior urinary tract infections, diabetes, structural problems of the urinary tract, and spermicide use. [2] [3] The mechanism of infection is usually spread up the urinary tract. [2] Less often infection occurs through the bloodstream. [1] Diagnosis is typically based on symptoms and supported by urinalysis. [2] If there is no improvement with treatment, medical imaging may be recommended. [2]

Pyelonephritis may be preventable by urination after sex and drinking sufficient fluids. [1] Once present it is generally treated with antibiotics, such as ciprofloxacin or ceftriaxone. [4] [6] Those with severe disease may require treatment in hospital. [2] In those with certain structural problems of the urinary tract or kidney stones, surgery may be required. [1] [3]

Pyelonephritis affects about 1 to 2 per 1,000 women each year and just under 0.5 per 1,000 males. [5] [7] Young adult females are most often affected, followed by the very young and old. [2] With treatment, outcomes are generally good in young adults. [3] [5] Among people over the age of 65 the risk of death is about 40%, though this depends on the health of the elderly person, the precise organism involved, and how quickly they can get care through a provider or in hospital. [5]

Signs and symptoms

Diagram showing the typical location of pain Pos-renal.png
Diagram showing the typical location of pain

Signs and symptoms of acute pyelonephritis generally develop rapidly over a few hours or a day. It can cause high fever, pain on passing urine, and abdominal pain that radiates along the flank towards the back. There is often associated vomiting. [9]

Chronic pyelonephritis causes persistent flank or abdominal pain, signs of infection (fever, unintentional weight loss, malaise, decreased appetite), lower urinary tract symptoms and blood in the urine. [10] Chronic pyelonephritis can in addition cause fever of unknown origin. Furthermore, inflammation-related proteins can accumulate in organs and cause the condition AA amyloidosis. [11]

Physical examination may reveal fever and tenderness at the costovertebral angle on the affected side. [12]

Causes

Most cases of community-acquired pyelonephritis are due to bowel organisms that enter the urinary tract. Common organisms are E. coli (70-80%) and Enterococcus faecalis . Hospital-acquired infections may be due to coliform bacteria and enterococci, as well as other organisms uncommon in the community (e.g., Pseudomonas aeruginosa and various species of Klebsiella ). Most cases of pyelonephritis start off as lower urinary tract infections, mainly cystitis and prostatitis. [9] E. coli can invade the superficial umbrella cells of the bladder to form intracellular bacterial communities (IBCs), which can mature into biofilms. These biofilm-producing E. coli are resistant to antibiotic therapy and immune system responses, and present a possible explanation for recurrent urinary tract infections, including pyelonephritis. [13] Risk is increased in the following situations: [9] [14]

Diagnosis

Laboratory examination

Analysis of the urine may show signs of urinary tract infection. Specifically, the presence of nitrite and white blood cells on a urine test strip in patients with typical symptoms are sufficient for the diagnosis of pyelonephritis, and are an indication for empirical treatment. Blood tests such as a complete blood count may show neutrophilia. Microbiological culture of the urine, with or without blood cultures and antibiotic sensitivity testing are useful for establishing a formal diagnosis, [9] and are considered mandatory. [15]

Imaging studies

If a kidney stone is suspected (e.g. on the basis of characteristic colicky pain or the presence of a disproportionate amount of blood in the urine), a kidneys, ureters, and bladder x-ray (KUB film) may assist in identifying radioopaque stones. [9] Where available, a noncontrast helical CT scan with 5 millimeter sections is the diagnostic modality of choice in the radiographic evaluation of suspected nephrolithiasis. [16] [17] [18] All stones are detectable on CT scans except very rare stones composed of certain drug residues in the urine. [19] In patients with recurrent ascending urinary tract infections, it may be necessary to exclude an anatomical abnormality, such as vesicoureteral reflux or polycystic kidney disease. Investigations used in this setting include kidney ultrasonography or voiding cystourethrography. [9] CT scan or kidney ultrasonography is useful in the diagnosis of xanthogranulomatous pyelonephritis; serial imaging may be useful for differentiating this condition from kidney cancer. [10]

Acute pyelonephritis with increased cortical echogenicity and blurred delineation of the upper pole Ultrasonography of acute pyelonephritis.jpg
Acute pyelonephritis with increased cortical echogenicity and blurred delineation of the upper pole

Ultrasound findings that indicate pyelonephritis are enlargement of the kidney, edema in the renal sinus or parenchyma, bleeding, loss of corticomedullary differentiation, abscess formation, or an areas of poor blood flow on doppler ultrasound. [21] However, ultrasound findings are seen in only 20–24% of people with pyelonephritis. [21]

A DMSA scan is a radionuclide scan that uses dimercaptosuccinic acid in assessing the kidney morphology. It is now[ when? ] the most reliable test for the diagnosis of acute pyelonephritis. [22]

Classification

Acute pyelonephritis

Acute pyelonephritis is an exudative purulent localized inflammation of the renal pelvis (collecting system) and kidney. The kidney parenchyma presents in the interstitium abscesses (suppurative necrosis), consisting in purulent exudate (pus): neutrophils, fibrin, cell debris and central germ colonies (hematoxylinophils). Tubules are damaged by exudate and may contain neutrophil casts. In the early stages, the glomerulus and vessels are normal. Gross pathology often reveals pathognomonic radiations of bleeding and suppuration through the renal pelvis to the renal cortex.[ citation needed ]

Chronic pyelonephritis

Chronic pyelonephritis implies recurrent kidney infections and can result in scarring of the renal parenchyma and impaired function, especially in the setting of obstruction. A perinephric abscess (infection around the kidney) and/or pyonephrosis may develop in severe cases of pyelonephritis. [23]

Xanthogranulomatous pyelonephritis

Xanthogranulomatous pyelonephritis is an unusual form of chronic pyelonephritis characterized by granulomatous abscess formation, severe kidney destruction, and a clinical picture that may resemble renal cell carcinoma and other inflammatory kidney parenchymal diseases. Most affected individuals present with recurrent fevers and urosepsis, anemia, and a painful kidney mass. Other common manifestations include kidney stones and loss of function of the affected kidney. Bacterial cultures of kidney tissue are almost always positive. [25] Microscopically, there are granulomas and lipid-laden macrophages (hence the term xantho-, which means yellow in ancient Greek). It is found in roughly 20% of specimens from surgically managed cases of pyelonephritis. [10]

Prevention

In people who experience recurrent urinary tract infections, additional investigations may identify an underlying abnormality. Occasionally, surgical intervention is necessary to reduce the likelihood of recurrence. If no abnormality is identified, some studies suggest long-term preventive treatment with antibiotics, either daily or after sexual activity. [26] In children at risk for recurrent urinary tract infections, not enough studies have been performed to conclude prescription of long-term antibiotics has a net positive benefit. [27] Cranberry products and drinking cranberry juice appears to provide a benefit in decreasing urinary tract infections for certain groups of individuals. [28]

Management

In people suspected of having pyelonephritis, a urine culture and antibiotic sensitivity test is performed, so therapy can eventually be tailored on the basis of the infecting organism. [5] As most cases of pyelonephritis are due to bacterial infections, antibiotics are the mainstay of treatment. [5] The choice of antibiotic depends on the species and antibiotic sensitivity profile of the infecting organism, and may include fluoroquinolones, cephalosporins, aminoglycosides, or trimethoprim/sulfamethoxazole, either alone or in combination. [15]

Simple

A 2018 systematic review recommended the use of norfloxacin as it has the lowest rate of side effects with a comparable efficacy to commonly used antibiotics. [29]

In people who do not require hospitalization and live in an area where there is a low prevalence of antibiotic-resistant bacteria, a fluoroquinolone by mouth such as ciprofloxacin or levofloxacin is an appropriate initial choice for therapy. [5] In areas where there is a higher prevalence of fluoroquinolone resistance, it is useful to initiate treatment with a single intravenous dose of a long-acting antibiotic such as ceftriaxone or an aminoglycoside, and then continuing treatment with a fluoroquinolone. Oral trimethoprim/sulfamethoxazole is an appropriate choice for therapy if the bacteria is known to be susceptible. [5] If trimethoprim/sulfamethoxazole is used when the susceptibility is not known, it is useful to initiate treatment with a single intravenous dose of a long-acting antibiotic such as ceftriaxone or an aminoglycoside. Oral beta-lactam antibiotics are less effective than other available agents for treatment of pyelonephritis. [15] Improvement is expected in 48 to 72 hours. [5]

Complicated

People with acute pyelonephritis that is accompanied by high fever and leukocytosis are typically admitted to the hospital for intravenous hydration and intravenous antibiotic treatment. Treatment is typically initiated with an intravenous fluoroquinolone, an aminoglycoside, an extended-spectrum penicillin or cephalosporin, or a carbapenem. Combination antibiotic therapy is often used in such situations. The treatment regimen is selected based on local resistance data and the susceptibility profile of the specific infecting organism(s). [15]

During the course of antibiotic treatment, serial white blood cell count and temperature are closely monitored. Typically, the intravenous antibiotics are continued until the person has no fever for at least 24 to 48 hours, then equivalent antibiotics by mouth can be given for a total of two-week duration of treatment. [30] Intravenous fluids may be administered to compensate for the reduced oral intake, insensible losses (due to the raised temperature) and vasodilation and to optimize urine output. Percutaneous nephrostomy or ureteral stent placement may be indicated to relieve obstruction caused by a stone. Children with acute pyelonephritis can be treated effectively with oral antibiotics (cefixime, ceftibuten and amoxicillin/clavulanic acid) or with short courses (2 to 4 days) of intravenous therapy followed by oral therapy. [31] If intravenous therapy is chosen, single daily dosing with aminoglycosides is safe and effective. [31]

Fosfomycin can be used as an efficacious treatment for both UTIs and complicated UTIs including acute pyelonephritis. The standard regimen for complicated UTIs is an oral 3g dose administered once every 48 or 72 hours for a total of 3 doses or a 6 grams every 8 hours for 7 days to 14 days when fosfomycin is given in IV form. [32]

Treatment of xanthogranulomatous pyelonephritis involves antibiotics as well as surgery. Removal of the kidney is the best surgical treatment in the overwhelming majority of cases, although polar resection (partial nephrectomy) has been effective for some people with localized disease. [10] [33] Watchful waiting with serial imaging may be appropriate in rare circumstances. [34]

Follow-up

If no improvement is made in one to two days post therapy, inpatients should repeat a urine analysis and imaging. Outpatients should check again with their doctor. [35]

Epidemiology

There are roughly 12-13 cases annually per 10,000 population in women receiving outpatient treatment and 3-4 cases requiring admission. In men, 2-3 cases per 10,000 are treated as outpatients and 1-2 cases/10,000 require admission. [36] Young women are most often affected. Infants and the elderly are also at increased risk, reflecting anatomical changes and hormonal status. [36] Xanthogranulomatous pyelonephritis is most common in middle-aged women. [25] It can present somewhat differently in children, in whom it may be mistaken for Wilms' tumor. [37]

Research

According to a 2015 meta analysis, vitamin A has been shown to alleviate renal damage and/or prevent renal scarring. [38]

Terminology

The term is from Greek πύελο|ς pýelo|s, "basin" + νεφρ|ός nepʰrós, "kidney" + suffix -itis suggesting "inflammation".[ citation needed ]

A similar term is "pyelitis", which means inflammation of the renal pelvis and calyces. [39] [40] In other words, pyelitis together with nephritis is collectively known as pyelonephritis.[ citation needed ]

Etymology

The word pyelonephritis is formed by the Greek roots pyelo- from πύελος (púelos) renal pelvis and nephro- from νεφρός (nephrós) kidney together with the suffix -itis from -ῖτις (-itis) used in medicine to indicate diseases or inflammations.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Ciprofloxacin</span> Fluoroquinolone antibiotic

Ciprofloxacin is a fluoroquinolone antibiotic used to treat a number of bacterial infections. This includes bone and joint infections, intra-abdominal infections, certain types of infectious diarrhea, respiratory tract infections, skin infections, typhoid fever, and urinary tract infections, among others. For some infections it is used in addition to other antibiotics. It can be taken by mouth, as eye drops, as ear drops, or intravenously.

<span class="mw-page-title-main">Urinary tract infection</span> Infection that affects part of the urinary tract

A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. Lower urinary tract infections may involve the bladder (cystitis) or urethra (urethritis) while upper urinary tract infections affect the kidney (pyelonephritis). Symptoms from a lower urinary tract infection include suprapubic pain, painful urination (dysuria), frequency and urgency of urination despite having an empty bladder. Symptoms of a kidney infection, on the other hand, are more systemic and include fever or flank pain usually in addition to the symptoms of a lower UTI. Rarely, the urine may appear bloody. Symptoms may be vague or non-specific at the extremities of age.

The excretory system is a passive biological system that removes excess, unnecessary materials from the body fluids of an organism, so as to help maintain internal chemical homeostasis and prevent damage to the body. The dual function of excretory systems is the elimination of the waste products of metabolism and to drain the body of used up and broken down components in a liquid and gaseous state. In humans and other amniotes, most of these substances leave the body as urine and to some degree exhalation, mammals also expel them through sweating.

<span class="mw-page-title-main">Levofloxacin</span> Antibiotic

Levofloxacin, sold under the brand name Levaquin among others, is a broad-spectrum antibiotic of the fluoroquinolone drug class. It is the left-handed isomer of the medication ofloxacin. It is used to treat a number of bacterial infections including acute bacterial sinusitis, pneumonia, H. pylori, urinary tract infections, Legionnaires' disease, chronic bacterial prostatitis, and some types of gastroenteritis. Along with other antibiotics it may be used to treat tuberculosis, meningitis, or pelvic inflammatory disease. It is available by mouth, intravenously, and in eye drop form.

<span class="mw-page-title-main">Hematuria</span> Presence of blood in urine

Hematuria or haematuria is defined as the presence of blood or red blood cells in the urine. "Gross hematuria" occurs when urine appears red, brown, or tea-colored due to the presence of blood. Hematuria may also be subtle and only detectable with a microscope or laboratory test. Blood that enters and mixes with the urine can come from any location within the urinary system, including the kidney, ureter, urinary bladder, urethra, and in men, the prostate. Common causes of hematuria include urinary tract infection (UTI), kidney stones, viral illness, trauma, bladder cancer, and exercise. These causes are grouped into glomerular and non-glomerular causes, depending on the involvement of the glomerulus of the kidney. But not all red urine is hematuria. Other substances such as certain medications and foods can cause urine to appear red. Menstruation in women may also cause the appearance of hematuria and may result in a positive urine dipstick test for hematuria. A urine dipstick test may also give an incorrect positive result for hematuria if there are other substances in the urine such as myoglobin, a protein excreted into urine during rhabdomyolysis. A positive urine dipstick test should be confirmed with microscopy, where hematuria is defined by three or more red blood cells per high power field. When hematuria is detected, a thorough history and physical examination with appropriate further evaluation can help determine the underlying cause.

<span class="mw-page-title-main">Nitrofurantoin</span> Antibacterial drug

Nitrofurantoin, sold under the brand name Macrobid among others, is an antibacterial medication of the nitrofuran class used to treat urinary tract infections (UTIs), although it is not as effective for kidney infections. It is taken by mouth.

<span class="mw-page-title-main">Amoxicillin/clavulanic acid</span> Combination antibiotic medication

Amoxicillin/clavulanic acid, also known as co-amoxiclav or amox-clav, sold under the brand name Augmentin, among others, is an antibiotic medication used for the treatment of a number of bacterial infections. It is a combination consisting of amoxicillin, a β-lactam antibiotic, and potassium clavulanate, a β-lactamase inhibitor. It is specifically used for otitis media, streptococcal pharyngitis, pneumonia, cellulitis, urinary tract infections, and animal bites. It is taken by mouth or by injection into a vein.

<span class="mw-page-title-main">Norfloxacin</span> Chemical compound, antibiotic

Norfloxacin, sold under the brand name Noroxin among others, is an antibiotic that belongs to the class of fluoroquinolone antibiotics. It is used to treat urinary tract infections, gynecological infections, inflammation of the prostate gland, gonorrhea and bladder infection. Eye drops were approved for use in children older than one year of age.

<span class="mw-page-title-main">Pyonephrosis</span> Infection and accumulation of pus within the kidney

Pyonephrosis is a dangerous kidney infection that is characterized by pus accumulation in the renal collecting system. It is linked to renal collecting system blockage and suppurative renal parenchymal destruction, which result in complete or nearly complete kidney failure.

<span class="mw-page-title-main">Interstitial nephritis</span> Medical condition

Interstitial nephritis, also known as tubulointerstitial nephritis, is inflammation of the area of the kidney known as the renal interstitium, which consists of a collection of cells, extracellular matrix, and fluid surrounding the renal tubules. It is also known as intestinal nephritis because the clinical picture may in some cases of acute pyelonephritis include mesenteric lymphadenitis. More specifically, in case of recurrent urinary tract infection, secondary infection can spread to adjacent intestine. In addition to providing a scaffolding support for the tubular architecture, the interstitium has been shown to participate in the fluid and electrolyte exchange as well as endocrine functions of the kidney.

<span class="mw-page-title-main">Vesicoureteral reflux</span> Backwards flow of urine from the bladder into the ureters and kidneys

Vesicoureteral reflux (VUR), also known as vesicoureteric reflux, is a condition in which urine flows retrograde, or backward, from the bladder into one or both ureters and then to the renal calyx or kidneys. Urine normally travels in one direction from the kidneys to the bladder via the ureters, with a one-way valve at the vesicoureteral (ureteral-bladder) junction preventing backflow. The valve is formed by oblique tunneling of the distal ureter through the wall of the bladder, creating a short length of ureter (1–2 cm) that can be compressed as the bladder fills. Reflux occurs if the ureter enters the bladder without sufficient tunneling, i.e., too "end-on".

In urology, voiding cystourethrography (VCUG) is a frequently performed technique for visualizing a person's urethra and urinary bladder while the person urinates (voids). It is used in the diagnosis of vesicoureteral reflux, among other disorders. The technique consists of catheterizing the person in order to fill the bladder with a radiocontrast agent, typically diatrizoic acid. Under fluoroscopy the radiologist watches the contrast enter the bladder and looks at the anatomy of the patient. If the contrast moves into the ureters and back into the kidneys, the radiologist makes the diagnosis of vesicoureteral reflux, and gives the degree of severity a score. The exam ends when the person voids while the radiologist is watching under fluoroscopy. Consumption of fluid promotes excretion of contrast media after the procedure. It is important to watch the contrast during voiding, because this is when the bladder has the most pressure, and it is most likely this is when reflux will occur. Despite this detailed description of the procedure, at least as of 2016 the technique had not been standardized across practices.

<span class="mw-page-title-main">Acute prostatitis</span> Serious bacterial infection of the prostate gland

Acute prostatitis is a serious bacterial infection of the prostate gland. This infection is a medical emergency. It should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and chronic pelvic pain syndrome (CPPS).

<span class="mw-page-title-main">Loin pain hematuria syndrome</span> Medical condition

Loin pain hematuria syndrome (LPHS) is the combination of debilitating unilateral or bilateral flank pain and microscopic or macroscopic amounts of blood in the urine that is otherwise unexplained.

<span class="mw-page-title-main">Bacteriuria</span> Presence of bacteria in urine

Bacteriuria is the presence of bacteria in urine. Bacteriuria accompanied by symptoms is a urinary tract infection while that without is known as asymptomatic bacteriuria. Diagnosis is by urinalysis or urine culture. Escherichia coli is the most common bacterium found. People without symptoms should generally not be tested for the condition. Differential diagnosis include contamination.

<span class="mw-page-title-main">Chronic bacterial prostatitis</span> Bacterial infection of the prostate gland

Chronic bacterial prostatitis (CBP) is a bacterial infection of the prostate gland and a form of prostatitis. It should be distinguished from other forms of prostatitis such as acute bacterial prostatitis (ABP) and chronic pelvic pain syndrome (CPPS).

Urologic diseases or conditions include urinary tract infections, kidney stones, bladder control problems, and prostate problems, among others. Some urologic conditions do not affect a person for that long and some are lifetime conditions. Kidney diseases are normally investigated and treated by nephrologists, while the specialty of urology deals with problems in the other organs. Gynecologists may deal with problems of incontinence in women.

<span class="mw-page-title-main">Plazomicin</span> Antibiotic medication

Plazomicin, sold under the brand name Zemdri, is an aminoglycoside antibiotic used to treat complicated urinary tract infections. As of 2019 it is recommended only for those in whom alternatives are not an option. It is given by injection into a vein.

<span class="mw-page-title-main">Urinary anti-infective agent</span> Medication for urinary tract infections

Urinary anti-infective agent, also known as urinary antiseptic, is medication that can eliminate microorganisms causing urinary tract infection (UTI). UTI can be categorized into two primary types: cystitis, which refers to lower urinary tract or bladder infection, and pyelonephritis, which indicates upper urinary tract or kidney infection. Escherichia coli is the predominant microbial trigger of UTIs, accounting for 75% to 95% of reported cases. Other pathogens such as Proteus mirabilis, Klebsiella pneumoniae, and Staphylococcus saprophyticus can also cause UTIs.

<span class="mw-page-title-main">Methenamine</span> Urinary antiseptic drug

Methenamine, also known as hexamine or hexamethylenetetramine and sold under the brand names Hiprex, Urex, and Urotropin among others, is a urinary tract antiseptic and antibacterial medication which is used in the prevention of recurrent urinary tract infections (UTIs). It is not an antibiotic, and unlike antibiotics, has no risk of bacterial resistance. Methenamine can reduce the risk of UTIs by 44 to 86% and has been found to be non-inferior to low-dose prophylactic antibiotics. It is taken by mouth. The drug is available both by prescription and at lower doses over the counter. Besides for UTI prevention, methenamine is also available in a topical form to treat hyperhidrosis.

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