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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.

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Presents with fever, chills, nausea, and flank pain

  • (+) CVA Tenderness
  • If symptoms are severe or the patient is unable to tolerate PO, they will need to be hospitalized

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
WBC cast in urine

White blood cell (WBC) cast in urine

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 14 days provided uropathogen known to be susceptible and ceftriaxone 1 g initial IV dose given

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
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Pyelonephritis interventions
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Question 1
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 1 Explanation: 
White cell casts are indicative of renal infection or inflammation as seen in pyelonephritis or interstitial nephritis.
Question 2
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:
See B for explanation.
B
Oral trimethoprim-sulfamethoxazole (Bactrim)
Hint:
The fluoroquinolones and trimethoprim-sulfamethoxazole are contraindicated in pregnancy.
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 2 Explanation: 
IV cephalosporins are first line treatment of pyelonephritis in a pregnant patient, followed by oral step-down therapy
Question 3
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:
See A for explanation.
C
Doxycycline
Hint:
See A for explanation.
D
Amoxicillin
Hint:
See A for explanation.
Question 3 Explanation: 
Treatment with a quinolone is first line treatment of pyelonephritis on an outpatient basis. If the patient were admitted then empiric treatment with Ampicillin and an aminoglycoside IV would be initiated until culture and sensitivity results were obtained.
Question 4
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 4 Explanation: 
Acute pyelonephritis presents with flank pain, fever, and generalized muscle tenderness. Urinalysis shows pyuria with leukocyte casts.
There are 4 questions to complete.
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References: Merck Manual · UpToDate

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