PANCE Blueprint Renal System (5%)

Home PANCE Blueprint Renal System (5%) Pyelonephritis (Lecture)

Pyelonephritis (Lecture)

PANCE Blueprint Renal System (5%)

Patient will present as → a 32-year-old female presents with fever, chills, nausea, and flank pain for 24 hours. She developed dysuria and urinary frequency 3 days prior and states that both have worsened. On physical exam, you note suprapubic abdominal pain and CVA tenderness. The urinalysis reveals white blood cell casts.

To watch this and all of Joe Gilboy PA-C's video lessons, you must be a member. Members can log in here or join now.

Presents with fever, chills, nausea, and flank pain

  • (+) CVA Tenderness (also a symptom of renal calculi)
  • If symptoms are severe or the patient is unable to tolerate PO, they will need to be hospitalized
  • Escherichia coli (E. coli) is by far the most common causative agent, responsible for approximately 70-80% of acute pyelonephritis cases

White blood cell casts in urine are pathognomonic for pyelonephritis

  • If complicated pyelonephritis - order a renal ultrasound as it may show hydronephrosis secondary to obstruction
White blood cell (WBC) cast in urine

White blood cell (WBC) cast in urine. Image: Ajay Kumar Chaurasiya, CC BY-SA 4.0, via Wikimedia Commons.

7 days of outpatient treatment is equivalent to longer treatment regimens

  • IV antibiotics are indicated for inpatients who are toxic or unable to tolerate oral antibiotics

An oral regimen is considered the best initial outpatient treatment

  • Ciprofloxacin: 500 mg BID for 7 days
  • Ciprofloxacin XR: 1,000 mg/day for 7 days
  • Levofloxacin: 750 mg/day for 5 days
  • Trimethoprim/sulfamethoxazole (TMP-SMX) (160/800 mg): 1 tab PO BID for 7 days provided uropathogen known to be susceptible and ceftriaxone 1 g initial IV dose given
  • Oral beta-lactam (cefpodoxime, cefuroxime, amoxicillin-clavulanate, cefadroxil) for 7 days if susceptible, after an initial IV ceftriaxone dose (IDSA 2025)

Management of acute pyelonephritis in pregnant women includes hospital admission for parenteral antibiotics

  • Empiric therapy includes IV/IM ceftriaxone
osmosis Osmosis
Picmonic
Pyelonephritis

Pyelonephritis is inflammation in an area of the kidney called the renal parenchyma. This condition is caused by a bacterial infection that begins in the lower urinary tract and travels upward and into the kidney(s). Patients with vesicoureteral reflux, urinary obstruction, or patients who are pregnant are at an increased risk of developing pyelonephritis. Presenting symptoms include fatigue, fever, chills, flank pain, nausea, vomiting, dysuria, and possible hematuria.

Pyelonephritis assessment
Play Video + Quiz
Pyelonephritis interventions
Play Video + Quiz

Question 1
A 26 year-old sexually active woman has a 3-day history of dysuria, frequency, and urgency. She has a fever of 102 degrees F orally with shaking chills and right-sided costovertebral angle tenderness. Urinalysis reveals 10-20 RBCs/HPF, 30 WBCs in clumps/HPF, 3-4 WBC casts and 3+ bacteria. Which of the following is the treatment of choice for outpatient management?
A
Ciprofloxacin
B
Erythromycin
Hint:
Erythromycin does not reliably cover the gram-negative organisms (E. coli) that cause pyelonephritis.
C
Doxycycline
Hint:
Doxycycline treats chlamydia and some STIs; it does not reach adequate kidney levels for pyelonephritis.
D
Amoxicillin
Hint:
Amoxicillin is not used empirically because E. coli resistance to it is high.
Question 1 Explanation: 
Treatment with a quinolone is first line treatment of pyelonephritis on an outpatient basis. Obtain a urine culture first. Outpatient options: ciprofloxacin 500 mg BID × 7 days or levofloxacin 750 mg daily × 5 days (if local fluoroquinolone resistance ≤10%); TMP-SMX or an oral beta-lactam × 7 days (after one IV ceftriaxone dose) if susceptible. If admitted: IV ceftriaxone, or pip-tazo/cefepime if MDR risk. Total course 5–7 days (IDSA 2025).
Question 2
A 25 year-old female presents with right lower quadrant pain, right flank pain, nausea, and vomiting. Her temperature is 39.6 degrees C. There is right CVA tenderness and RLQ tenderness. Pelvic exam is unremarkable. Urinalysis reveals pH 7.0, trace protein, negative glucose, negative ketones, positive blood, and positive nitrates. Specific gravity is 1.022. Microscopic shows 102 RBCs/HPF, 50-75 WBCs/HPF, rare epithelial cells, and WBC casts. The most likely diagnosis is
A
acute salpingitis
Hint:
Acute salpingitis would be suggested if pelvic exam abnormalities were present.
B
nephrolithiasis
Hint:
Nephrolithiasis does not usually present with fever or casts. Urinalysis will have RBCs present.
C
acute pyelonephritis
D
appendicitis
Hint:
This scenario is consistent with acute pyelonephritis, not acute appendicitis.
Question 2 Explanation: 
Acute pyelonephritis presents with flank pain, fever, and generalized muscle tenderness. Urinalysis shows pyuria with leukocyte casts.
Question 3
A 28-year-old female comes to the office with fever, flank pain, and dysuria for the past two days. Which of the following urinalysis results are suggestive of acute pyelonephritis?
A
Hyaline casts
Hint:
Hyaline casts may be found in concentrated urine and are not indicative of renal disease.
B
Red cell casts
Hint:
Red cell casts are indicative of glomerulonephritis.
C
White cell casts
D
Granular casts
Hint:
Granular casts are non-specific and may be seen in acute tubular necrosis
Question 3 Explanation: 
White cell casts are indicative of renal infection or inflammation as seen in pyelonephritis or interstitial nephritis.
Question 4
A 35 year-old pregnant patient presents with fever, chills, and left-sided flank pain. On physical examination left-sided CVA tenderness is noted. Urinalysis reveals numerous white blood cells and white blood cell casts. Which of the following is the most appropriate treatment?
A
Oral ciprofloxacin (Cipro)
Hint:
Fluoroquinolones are avoided in pregnancy, and pyelonephritis in pregnancy is treated with IV therapy in the hospital at first.
B
Oral trimethoprim-sulfamethoxazole (Bactrim)
Hint:
Pyelonephritis in pregnancy needs initial IV therapy; TMP-SMX is also avoided in the first trimester and near term.
C
IV gentamicin (Garamycin)
Hint:
Gentamicin is not indicated as first line therapy in the treatment of pyelonephritis in a pregnant patient
D
IV ceftriaxone (Rocephin)
Question 4 Explanation: 
IV cephalosporins are first line treatment of pyelonephritis in a pregnant patient, followed by oral step-down therapy
There are 4 questions to complete.
List
Return
Shaded items are complete.
1234
Return

References: Merck Manual · UpToDate

Nephrotic syndrome (ReelDx + Lecture) (Prev Lesson)
(Next Lesson) Acute kidney injury (ReelDx + Lecture)
Back to PANCE Blueprint Renal System (5%)

NCCPA™ CONTENT BLUEPRINT

🤖 NEW: Smarty PANCE now connects directly to your favorite AI tool. It builds custom exams from your weak areas, and it's included with your membership!

Connect your AI 👉
X