History

Fact Explanation
Dysuria [1] Pyelonephritis is an infection of the upper urinary tract, specifically the renal parenchyma and renal pelvis. Dysuria occurs due to inflammation [1]
Urinary bladder frequency and urgency [5] Occurs due to the irritation caused by the inflammatory process [1]
Backache [1] Kidneys are retroperitoneal organs. The left kidney is approximately at the vertebral level T12 to L3 and the right slightly lower.Inflammation of these organs give rise to backache [2]
Fever with chills [2] Pyelonephritis is an infection of the upper urinary tract, specifically the renal parenchyma and renal pelvis.Inflammatory process give rise to fever with chills [1]
Hematuria [1] During the inflammatory process, the cells in the urinary tract can get damage and bleed [2]
Severely ill with altered consciousness [7] Pyelonephritis can give rise to septicemia and shock [4]
Nausea and Vomiting [4] Occurs due to the inflammatory mediators which are released due to ongoing inflammatory process [1]
Anatomic/functional abnormality: Polycystic kidney disease Horseshoe kidney Double ureter Ureterocele Vesicoureteric reflux [3] More prone to get infections as these abnormalities interrupts the urinary flow.Stagnation of urine causes more infection [1]
Foreign body: Urinary, ureteric, or nephrostomy catheters Calculus [3] More prone to get infections [1]
Immunosuppressed state [6] Reduced level of immunity has more chances of getting an infection. eg: Diabetes mellitus Sickle cell disease Transplantation Malignancy Chemoradiation HIV infections Corticosteroid use [1]
Gender : male [1] Males have more anatomic abnormalities in urinary tract, prostatic obstruction which has more chances of getting infections [1]
Obstruction Foreign body Calculi Bladder neck obstruction Posterior urethral valve Benign prostatic hypertrophy Neurogenic bladder [1] More prone for infections as stagnated urine is a good medium for bacterial growth [1]
Age [3] Infants,elderly (> 60 years of age) have poor immunity, thus more prone to get severe infections [1]
References
  1. RAMAKRISHNAN K, SCHEID DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician [online] 2005 Mar 1, 71(5):933-42 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15768623
  2. GUPTA K., HOOTON T. M., NABER K. G., WULLT B., COLGAN R., MILLER L. G., MORAN G. J., NICOLLE L. E., RAZ R., SCHAEFFER A. J., SOPER D. E.. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases [online] December, 52(5):e103-e120 [viewed 27 July 2014] Available from: doi:10.1093/cid/ciq257
  3. CHUNG VY, TAI CK, FAN CW, TANG CN. Severe acute pyelonephritis: a review of clinical outcome and risk factors for mortality. Hong Kong Med J [online] 2014 Mar 14 [viewed 27 July 2014] Available from: doi:10.12809/hkmj134061
  4. KUTWIN P, KONECKI T, JABÅ‚ONOWSKI Z. Emphysematous pyelonephritis in a diabetic patient with obstructed kidney. Cent European J Urol [online] 2014, 67(2):196-8 [viewed 02 October 2014] Available from: doi:10.5173/ceju.2014.02.art18
  5. TONG YQ, XIN B, SUN SQ. Pyelonephritis Caused Solely by Escherichia hermanii. Jundishapur J Microbiol [online] 2014 May, 7(5):e18138 [viewed 02 October 2014] Available from: doi:10.5812/jjm.18138
  6. VARMA PP, JAIRAM A, HOODA AK, BADWAL S. Renal outcome in biopsy proven cases of graft pyelonephritis. Indian J Nephrol [online] 2014 May, 24(3):161-5 [viewed 02 October 2014] Available from: doi:10.4103/0971-4065.132009
  7. LU YC, CHIANG BJ, PONG YH, HUANG KH, HSUEH PR, HUANG CY, PU YS. Predictors of failure of conservative treatment among patients with emphysematous pyelonephritis. BMC Infect Dis [online] 2014 Jul 29:418 [viewed 02 October 2014] Available from: doi:10.1186/1471-2334-14-418

Examination

Fact Explanation
Renal angle tenderness [1] Kidneys are retroperitoneal organs. The left kidney is approximately at the vertebral level T12 to L3 and the right slightly lower.Inflammation of these oragans give rise to renal angle tenderness [2]
Supra pubic pain [1] Pyelonephritis is an infection of the upper urinary tract, specifically the renal parenchyma and renal pelvis.Inflammatory process may cause irritation of the bladder [1]
Signs of shock : ill looking patient, hypotension, tachycardia, cold peripheries [2] Pyelonephritis can give rise to septicemia and shock [1]
Febrile patient [1] Inflammatory process give rise to fever due to inflammatory mediators [1]
References
  1. RAMAKRISHNAN K, SCHEID DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician [online] 2005 Mar 1, 71(5):933-42 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15768623
  2. GUPTA K., HOOTON T. M., NABER K. G., WULLT B., COLGAN R., MILLER L. G., MORAN G. J., NICOLLE L. E., RAZ R., SCHAEFFER A. J., SOPER D. E.. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases [online] December, 52(5):e103-e120 [viewed 27 July 2014] Available from: doi:10.1093/cid/ciq257

Differential Diagnoses

Fact Explanation
Vaginitis [1] In women with dysuria, the presence of vaginal discharge or odor, pruritus, dyspareunia, and absence of urinary frequency or urgency should prompt consideration of vaginitis. Causes of vaginitis include yeast infection, trichomoniasis, and bacterial vaginosis [1]
Pelvic inflammatory disease [1] Lower abdominal or pelvic pain and fever are the most common clinical findings in patients with pelvic inflammatory disease (PID), although dysuria may also be present. The findings of mucopurulent endocervical discharge or cervical motion tenderness on pelvic examination are strongly suggestive of PID [1]
Nephrolithiasis [1] The majority of patients with symptomatic nephrolithiasis have flank pain/renal colic in addition to gross or microscopic hematuria. In the absence of infection, fever is unusual in patients with nephrolithiasis [1]
References
  1. COLGAN R, WILLIAMS M, JOHNSON JR. Diagnosis and treatment of acute pyelonephritis in women. Am Fam Physician [online] 2011 Sep 1, 84(5):519-26 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21888302

Investigations - for Diagnosis

Fact Explanation
Urine full report [1] Pus cells will be present in urine due to the infection. > 5 WBCs/HPF Sensitivity (%) : 72 to 95 Specificity (%) : 48 to 82 Red blood cells may also be present as the cells in the urinary tract can get damage and bleed due to the inflammatory process. Protein may also be positive in urine as proteins may be excreted during an infection of the urinary tract [1]
Leukocyte esterase test [1] Leukocyte esterase is a screening test used to detect a substance that suggests there are white blood cells in the urine.This will be positive in pyelonephritis as pus cells are present in urine due to the infection. Sensitivity (%) : 74 to 96 Specificity (%) : 94 to 98 [1]
Nitrite test [1] A nitrite test is a chemical test used to determine the presence of nitrite ion in solution. A positive nitrite test indicates that the cause of the urinary tract infection ( UTI ) is a gram negative organism, most commonly Escherichia coli. The reason for nitrites' existence in the presence of a UTI is due to a bacterial conversion of endogenous nitrates to nitrites. Sensitivity (%) : 35 to 85 Specificity (%) : 92 to 100 [1]
Urine culture and antibiotic sensitivity testing [1] To detect the causative organism and sensitive antibiotics. Urine cultures are positive in 90 percent of patients with acute pyelonephritis, and culture specimens should be obtained before initiation of antibiotic therapy. The consensus definition of pyelonephritis established by the Infectious Diseases Society of America (IDSA) is a urine culture showing at least 10,000 colony-forming units (CFU) per mm3 and symptoms compatible with the diagnosis. Most common organisms are : Escherichia coli , Staphylococcus saprophyticus , Proteus , Klebsiella , Enterococci [1]
References
  1. RAMAKRISHNAN K, SCHEID DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician [online] 2005 Mar 1, 71(5):933-42 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15768623

Investigations - Fitness for Management

Fact Explanation
Full blood count [1] Will show neutrophilic leukocytosis due to the infection [1]
Serum creatinine [2] Infection can damage the kidneys thus it is important to assess the renal functions [2]
References
  1. RAMAKRISHNAN K, SCHEID DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician [online] 2005 Mar 1, 71(5):933-42 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15768623
  2. GUPTA K., HOOTON T. M., NABER K. G., WULLT B., COLGAN R., MILLER L. G., MORAN G. J., NICOLLE L. E., RAZ R., SCHAEFFER A. J., SOPER D. E.. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases [online] December, 52(5):e103-e120 [viewed 27 July 2014] Available from: doi:10.1093/cid/ciq257

Investigations - Followup

Fact Explanation
Ultra sound scan - abdomen [1] Ultrasound examination identifies acute bacterial nephritis, abscesses, ureteral obstruction, and hydronephrosis [1]
Serum creatinine [1] Infection can damage the kidneys thus it is important to assess the renal functions [2]
Computed tomographic (CT) scan; magnetic resonance imaging; and intravenous pyelography [1] May identify complicating factors such as anatomic abnormalities, obstruction, acute bacterial nephritis (localized, non liquefied interstitial inflammation) [1]
References
  1. RAMAKRISHNAN K, SCHEID DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician [online] 2005 Mar 1, 71(5):933-42 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15768623
  2. GUPTA K., HOOTON T. M., NABER K. G., WULLT B., COLGAN R., MILLER L. G., MORAN G. J., NICOLLE L. E., RAZ R., SCHAEFFER A. J., SOPER D. E.. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases [online] December, 52(5):e103-e120 [viewed 27 July 2014] Available from: doi:10.1093/cid/ciq257

Investigations - Screening/Staging

Fact Explanation
Ultra sound scan -abdomen [1] Ultrasound examination identifies acute bacterial nephritis, abscesses, ureteral obstruction, and hydronephrosis [1]
Serum creatinine [2] Infection can damage the kidneys thus it is important to assess the renal functions [2]
Computed tomographic (CT) scan [3]; magnetic resonance imaging; and intravenous pyelography [1] May identify complicating factors such as anatomic abnormalities, obstruction, acute bacterial nephritis (localized, nonliquified interstitial inflammation) [1]
Full blood count [1] Will show neutrophilic lueukocytosis due to the infection [1]
References
  1. RAMAKRISHNAN K, SCHEID DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician [online] 2005 Mar 1, 71(5):933-42 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15768623
  2. GUPTA K., HOOTON T. M., NABER K. G., WULLT B., COLGAN R., MILLER L. G., MORAN G. J., NICOLLE L. E., RAZ R., SCHAEFFER A. J., SOPER D. E.. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases [online] December, 52(5):e103-e120 [viewed 27 July 2014] Available from: doi:10.1093/cid/ciq257
  3. KIM JS, LEE S, LEE KW, KIM JM, KIM YH, KIM ME. Relationship between uncommon computed tomography findings and clinical aspects in patients with acute pyelonephritis. Korean J Urol [online] 2014 Jul, 55(7):482-6 [viewed 02 October 2014] Available from: doi:10.4111/kju.2014.55.7.482

Management - General Measures

Fact Explanation
Increase fluid intake [1] More urine will be passed with more fluid intake and there will be a good urine flow without stagnation of urine [1]
Catheter care [1] Sterile insertion and care of the catheter, minimizing the duration of catheterization, intermittent catheterization, closed drainage systems [1]
References
  1. GUPTA K., HOOTON T. M., NABER K. G., WULLT B., COLGAN R., MILLER L. G., MORAN G. J., NICOLLE L. E., RAZ R., SCHAEFFER A. J., SOPER D. E.. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases [online] December, 52(5):e103-e120 [viewed 27 July 2014] Available from: doi:10.1093/cid/ciq257

Management - Specific Treatments

Fact Explanation
Antibiotics [1] Indications for Hospitalization in Patients with Acute Pyelonephritis: Persistent vomiting Progression of uncomplicated UTI Suspected sepsis Uncertain diagnosis Urinary tract obstruction Oral ciprofloxacin for 7 days, (with or without an initial intravenous dose) is an appropriate choice for therapy in patients not requiring hospitalization. Patients who requiring hospitalization should be initially treated with an intravenous antimicrobial regimen, such as a fluoroquinolone; an aminoglycoside, with or without ampicillin; an extended-spectrum cephalosporin or extended-spectrum penicillin, with or without an aminoglycoside; or a carbapenem. [1]
References
  1. GUPTA K., HOOTON T. M., NABER K. G., WULLT B., COLGAN R., MILLER L. G., MORAN G. J., NICOLLE L. E., RAZ R., SCHAEFFER A. J., SOPER D. E.. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases [online] December, 52(5):e103-e120 [viewed 27 July 2014] Available from: doi:10.1093/cid/ciq257