Complications

Dehydration is the most common acute complication of pyelonephritis. Intravenous (IV) fluid replacement is necessary in severe cases. Acute pyelonephritis may lead to renal abscess formation. Long-term complications include renal parenchyma scarring, hypertension, decreased renal function, and, in severe cases, renal failure. (See Prognosis.)

Etiology
UTIs are generally ascending in origin and caused by perineal contaminants, usually bowel flora. However, in neonates, infection is assumed to be hematogenous in origin rather than ascending. This feature may explain the nonspecific symptoms associated with UTI in these patients. After the neonatal period, bacteremia is generally not the source of infection; rather, UTI or pyelonephritis is the cause of the bacteremia. Bacterial pathogens are the most common cause of pyelonephritis. Bacterial sources of pyelonephritis include the following:

Escherichia coli - This is by far the most common organism, causing more than 90% of all cases of acute pyelonephritis Klebsiella oxytoca and species Proteus species Enterococcus faecalis and species Gram-positive organisms, including staphylococcal species and group BStreptococcusThese are rare causes of acute pyelonephritis

Definition of Pyelonephritis

Pyelonephritis is a serious bacterial infection of the kidney that can be acute or chronic.
Description of Pyelonephritis

One of the most common renal diseases, acute pyelonephritis is a sudden inflammation caused by bacteria. It primarily affects the interstitial area and the renal pelvis or, less often, the renal tubules. Chronic pyelonephritis is persistent kidney inflammation that can scar the kidneys and may lead to chronic renal failure. This disease is most common in patients who are predisposed to recurrent acute pyelonephritis, such as those with urinary obstructions or vesicoureteral reflux.

Definition
Pyelonephritis is an inflammation of the kidney and upper urinary tract that usually results from noncontagious bacterial infection of the bladder (cystitis)

Causes and symptoms

The most common cause of pyelonephritis is the backward flow (reflux) of infected urine from the bladder to the upper urinary tract. Bacterial infections also may be carried to one or both kidneys through the bloodstream or lymph glands from infection that began in the bladder. Kidney infection sometimes results from urine that becomes stagnant due to obstruction of free urinary flow. A blockage or abnormality of the urinary system, such as those caused by stones, tumors, congenital deformities, or loss of bladder function from nerve disease, increases a person's risk of pyelonephritis. Other risk factors include diabetes mellitus, pregnancy, chronic bladder infections, a history of analgesic abuse, paralysis from spinal cord injury, or tumors. Catheters, tubes, or surgical procedures may also trigger a kidney infection. The bacteria most likely to cause pyelonephritis are those that normally occur in the feces. Escherichia coli causes about 85% of acute bladder and kidney infections in patients with no obstruction or history of surgical procedures. Klebsiella, Enterobacter, Proteus, or Pseudomonas are other common causes of infection. Once these organisms enter the urinary tract, they cling to the tissues that line the tract and multiply in them. Symptoms of acute pyelonephritis typically include fever and chills, burning or frequent urination, aching pain on one or both sides of the lower back or abdomen, cloudy or bloody urine, and fatigue. The patient also may have nausea, vomiting, and diarrhea. The flank pain may be extreme. The symptoms of chronic pyelonephritis include weakness, loss of appetite, hypertension, anemia, and protein and blood in the urine.

Treatment
Treatment of acute pyelonephritis may require hospitalization if the patient is severely ill or has complications. Therapy most often involves a two- to three-week course of antibiotics, with the first few days of treatment given intravenously. The choice of antibiotic is based on laboratory sensitivity studies. The antibiotics used most often include ciprofloxacin (Cipro), ampicillin (Omnipen), or trimethoprim-sulfamethoxazole (Bactrim, Septra). Several advances in antibiotic therapy have been made in recent years. In 2003, the U.S. Food and Drug Administration (FDA) approved Cipro extended release tablets (Cipro XR) that could be taken once daily for acute uncomplicated pyelonephritis. A study in Europe also showed that a shorter course than that normally used in the United States could eradicate the bacteria that cause the disease. The primary objective of antimicrobial therapy is the permanent eradication of bacteria from the urinary tract. The early symptoms of pyelonephritis usually disappear within 48 to 72 hours of the start of antibacterial treatment. Repeat urine cultures are done in order to evaluate the effectiveness of the medication. Chronic pyelonephritis may require high doses of antibiotics for as long as six months to clear the infection. Other medications may be given to controlfever, nausea, and pain. Patients are encouraged to drink extra fluid to prevent dehydration and increase urine output. Surgery sometimes is necessary if the patient has complications caused by kidney stones or other obstructions, or to eradicate infection. Urine cultures are repeated as part of the follow-up of patients with chronic pyelonephritis. These repeat tests are necessary to evaluate the possibility that the patient's urinary tract is infected with a second organism as well as to assess the patient's response to the antibiotic. Some persons are highly susceptible to reinfection, and a second antibiotic may be necessary to treat the organism.

Signs and symptoms

This section requires expansion.

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.[1] Chronic pyelonephritis causes persistent flank or abdominal pain, signs of infection (fever, unintentional weight loss, malaise, decreased appetite), lower urinary tract symptoms andblood in the urine.[2] Chronic pyelonephritis can in addition cause fever of unknown origin. Furthermore, inflammation-related proteins can accumulate in organs and cause the conditionAA amyloidosis.[3] Physical examination may reveal fever and tenderness at the costovertebral angle on the affected side.[4] [edit]Causes

Antimicrobial Agents Used in the Treatment of Acute Pyelonephritis

Agent Penicillins Amoxicillin Amoxicillin-clavulanate potassium (Augmentin) Ampicillin-sulbactam (Unasyn) Aztreonam (Azactam) Imipenem (Primaxin I.V.) Piperacillin (Pipracil) Piperacillin-tazobactam (Zosyn) Ticarcillin-clavulanate (Timentin) Cephalosporins Cefotaxime (Claforan) Ceftriaxone (Rocephin) Dosing schedule Every 8 to 12 hours Every 8 to 12 hours Every 4 to 6 hours Every 6 to 8 hours Every 6 hours Every 6 hours Every 6 to 8 hours Every 4 to 6 hours Every 8 to 12 hours Once in 24 Oral dose (mg) IV dose 500 500/125 150 to 200 mg per kg per day 1 to 2 g 0.5 g 3g Comments None GI side effects* GI side effects*

Phlebitis; GI side effects* None GI side effects*; phlebitis

3.375 g/4.5 g GI side effects*; rash; headaches; insomnia 3.1 g GI side effects*; rash; phlebitis

1 to 2 g 1 to 2 g

Thrombophlebitis Leukopenia; elevated BUN

Agent Cephalexin (Keflex) Fluoroquinolones Ciprofloxacin (Cipro)

Dosing schedule hours Every 6 hours Every 12 hours Every 24 hours Every 24 hours Every 24 hours Every 24 hours Every 12 hours Every 12 hours Every 12 hours Every 24 hours Every 24 hours Every 12 hours

Oral dose (mg) IV dose 500

Comments and liver enzyme levels GI side effects*

500

400 mg

Enoxacin (Penetrex) Gatifloxacin (Tequin) Levofloxacin (Levaquin) Lomefloxacin (Maxaquin) Norfloxacin (Noroxin) Ofloxacin (Floxin) Aminoglycosides Amikacin (Amikin) Gentamicin (Garamycin) Tobramycin (Nebcin) Other antibiotics TMP-SMX (Bactrim; Septra)

400 250 to 750 400 400 200 to 400

400 mg 250 to 750 mg 400 mg

Nausea; headache; photosensitivity; pregnancy category C Pregnancy category C Pregnancy category C ECG QT prolongation; pregnancy category C Pregnancy category C Pregnancy category C Pregnancy category C

7.5 mg per Ototoxicity; nephrotoxicity kg 5 to 7 mg per Ototoxicity; nephrotoxicity kg 5 to 7 mg per Ototoxicity; nephrotoxicity kg 8 to 10 mg G6PD deficiency; sulfa per kg (TMP) allergy; do not use in third trimester

160/800

IV = intravenous; GI = gastrointestinal; BUN = blood urea nitrogen; ECG = electrocardiogram; TMP-SMX = trimethoprim-sulfamethoxazole; G6PD = glucose-6-phosphate dehydrogenase. *GI side effects include nausea, vomiting, and diarrhea.

Symptoms of Pyelonephritis

No matter what the underlying cause, the symptoms of acute bacterial pyelonephritis are often the same. The first indications are usually shaking chills, accompanied by a high fever and pain in the joints and muscles including flank pain. Attention may not be drawn to the kidneys at all. The situation may be especially confusing in children, when high temperature may suddenly bring on a seizure or a change in mental state, or in the aged, where fever may bring confusion, or the infection may be masked by generalized aches and pains. There may be irritative voiding symptoms (burning when urinating, a sense of urgency, or increased frequency of urination). In acute infections, the symptoms develop rapidly, the fever noted first, followed by possible changes in the color of the urine, and then tenderness in the flank. As the kidney becomes more inflamed, pain, loss of appetite, headache, and all the general effects of infection develop. This type of kidney pain differs from renal colic pain of kidney stones in that it is continuous and does not come in waves, stays in one spot, and may be worse by moving around. While patients with chronic pyelonephritis may have acute infections, sometimes there are no symptoms, or the symptoms may be so mild that they go unnoticed. This carries the risk that the infectious inflammatory disease may progress slowly undetected over many years until there is enough deterioration to produce kidney failure. Thus, hypertension (high blood pressure) or anemia or symptoms related to renal insufficiency may be the first indication of trouble. Unfortunately, irreversible damage may have already taken place.