​Kembara Xtra - Medicine - Pyelonephritis

​Kembara Xtra - Medicine - Pyelonephritis 
A syndrome brought on by an infection of the renal parenchyma and/or renal pelvis, frequently accompanied by localized flank/back pain as well as generalized symptoms including fever, chills, nausea, and vomiting; the illness can range in severity from moderate symptoms to septic shock.
The increasing inflammation of the renal interstitium and tubules that results from recurrent infection, vesicoureteral reflux, or both causes chronic pyelonephritis.
Pyelonephritis is regarded as uncomplicated if the infection is brought on by a typical pathogen in a patient with immunocompetence and normal renal and urinary architecture.
System(s) impacted: urologic and renal Upper urinary tract infection (UTI) (synonym) 

Aspects of Geriatrics

Alterations in mental status may be observed, and older people frequently have no temperature.
Older patients with diabetes and pyelonephritis are more likely to develop bacteremia, spend more time in the hospital, and die.
The use of urine dipsticks for UTI diagnosis in the elderly is less accurate due to the high prevalence of asymptomatic bacteriuria in this population.

pregnant women's issues
The most typical medical issue necessitating hospitalization. If asymptomatic bacteriuria (ABU) is not treated, pregnant women with ABU have a 20–30% chance of developing acute pyelonephritis.
1–2% of all pregnancies are affected. There is no difference in morbidity between trimesters.
1–2 weeks following therapy, do a urine culture to check for healing.
After receiving therapy for pregnancy-related pyelonephritis or recurrent cystitis, think about taking low-dose suppressive antibiotics for the balance of your pregnancy.

Child Safety Considerations
5% of patients with fever and no obvious source on the history and physical exam and age 2 months to 2 years are found to have UTI.
Treatment should be determined by the clinical scenario and patient toxicity, whether it is PO or IV; inpatient or outpatient.
EPIDEMIOLOGY
Incidence
3 to 4 occurrences of community-acquired acute pyelonephritis occur in every 10,000 men; 15 to 17 cases occur in every 10,000 women; 28 cases occur in every 10,000 women aged 18 to 49.
Prevalence
250,000 adult cases annually, including 200,000 hospital admissions


Pathophysiology and Etiology 
> 80% Escherichia coli Proteus, Klebsiella, Serratia, Clostridium, Pseudomonas, and Enterobacter spp. are additional gram-negative pathogens.
Staphylococcus: Staphylococcus epidermidis, Staphylococcus saprophyticus, and Staphylococcus aureus (number 2 cause in young women). Candida species.

Risk factors include the following: Underlying urinary tract abnormalities; Indwelling catheter/recent urinary tract instrumentation; Nephrolithiasis; Immunocompromised, including diabetes; Elderly, institutionalized patients (particularly women); Prostatic enlargement; stress incontinence; Childhood UTI; Acute pyelonephritis within the prior year; Recent sexual activity; use of spermicide; new sex partner within the prior year; Pregnancy

Benign prostatic hyperplasia and indwelling catheters are associated conditions.

Adult diagnoses include malaise, anorexia, and myalgia in addition to fever, flank pain, nausea, and vomiting.
- Urgency, frequency, and dysuria
- Achy suprapubic area
- Age-related changes in mental state
 GI symptoms in infants and children include fever, irritability, and poor eating.

clinical assessment 
Adults: 38 °C (100.4 °F) fever
- Tenderness at the costovertebral angle
- The presentation can be anything from septic shock to no physical symptoms.
Mental status changes are frequent in the elderly. Depending on the presentation, women should think about getting a pelvic exam to rule out pelvic inflammatory disease.
 In newborns and young children: Fatigue, fever, and inadequate skin perfusion
- Insufficient weight gain or loss - Jaundice, pallor, and gray skin tone


Differential Diagnosis Cholecystitis, acute pancreatitis, appendicitis, acute bacterial pneumonia (lower lobe), perforated viscus, aortic dissection, pelvic inflammatory disease, ectopic pregnancy, kidney stone, diverticulitis 

Initial test results from the laboratory and imaging
Leukocyte casts, hematuria, pyuria (>5 WBC/HPF), nitrites (sensitivity 35-85%; specificity 92-100%), and mild proteinuria are all detected in urine tests.  Positive urine leukocyte esterase (sensitivity: 74-96%; specificity: 94-98%)  Urine Gram stain; urine culture (over 100,000 CFU/mL or over 100 CFU/mL plus symptoms); and sensitivity  A pregnancy test (if necessary), complete blood count, blood urea nitrogen, creatinine, and glomerular filtration rate (GFR)  Serum albumin levels below 3.3 g/dL are also linked to an increased likelihood of hospital admission, and C-reactive protein levels are correlated with prolonged hospitalization and recurrence. Imaging is not required in most circumstances. Imaging is largely used to identify complications, such as renal abscess or emphysematous pyelonephritis.
Pediatrics: After the first febrile UTI between the ages of 2 and 24 months, guidelines advise renal/bladder US (rather than voiding cystourethrogram).

Tests in the Future & Special Considerations
Children who are not toilet trained should undergo catheterization or a suprapubic aspiration to obtain samples. If hospitalized, blood cultures should be performed if the diagnosis is unclear or there is a possibility of immunosuppression. Lab results could be affected by recent antibiotic use.
Consider a CT scan of the abdomen and pelvis with contrast if the patient's condition does not improve within 72 hours, if obstruction or anatomic abnormality is suspected, in patients with immunosuppression or multiple comorbidities, and/or if certain lab abnormalities are present (urine pH >7, GFR 40, 50% decline in renal function). Children and adults with acute pyelonephritis often receive contrast-enhanced computed tomography (CECT) as the image of choice.
US of the kidneys, ureter, and bladder is less sensitive than CT but is more affordable and accessible.
- Ureteral catheterization and cystoscopy

Acute: creation of an abscess with a neutrophil response; chronic: fibrosis with shrinkage of renal tissue

In individuals (including those with bacteremia) without urogenital anomalies, a treatment regimen of 7 days is similar to longer regimens.
 Intravenous antibiotics (IV) for hospitalized patients who appear toxic or are unable to take oral medications


Broad-spectrum antibiotics are first used to treat illnesses based on their severity, current health, and risk factors for resistant microorganisms; they are then tailored depending on the findings of culture and sensitivity tests.
- Risk factors for germs or illnesses that are multidrug resistant (MDR) if they have appeared within the previous three months:  Urinary MDR pathogen history
 A stay as an inpatient at a medical facility (a hospital, a nursing home, etc.) Use of broad-spectrum -lactams, trimethoprim-sulfamethoxazole (TMP-SMX), or fluoroquinolone Travel to areas with a high prevalence of MDR infections, such as India, the Middle East, and Central America  Antipyretics and analgesics
For dysuria, take into account urinary analgesics (such as phenazopyridine 200 mg q8h).

Medication: A fluoroquinolone is suggested for oral empiric treatment. A single first IV dosage of a long-acting antibiotic, such as ceftriaxone 1 g, is advised if fluoroquinolone resistance is greater than 10% or the patient is experiencing nausea or vomiting.
Fluoroquinolones, aminoglycosides with or without ampicillin, extended-spectrum cephalosporins with or without -lactamase inhibitors, extended-spectrum penicillins with or without aminoglycosides, and carbapenem are suggested for parenteral therapy.
Fluoroquinolones are not advised for use in children, adolescents, or pregnant women unless no other options are available, which is a contraindication.
- For the treatment of pyelonephritis, nitrofurantoin does not reach reliable tissue levels.
 Safety measures
- When treating individuals with renal impairment, alter antibiotic dosages.
- Track renal function and aminoglycoside concentrations.
- If a Gram stain indicates that Enterococcus is present, ampicillin, gentamicin, or piperacillin-tazobactam are appropriate first-line options; if the patient is allergic to penicillin, use vancomycin instead. Add amoxicillin to the fluoroquinolone if the patient is an outpatient, pending culture results and sensitivity. For suspected or confirmed enterococcal infections, a third-generation cephalosporin should not be used.
- In community-acquired infections, more than 20% of E. coli strains are resistant to ampicillin and TMPSMX.
- Extended-spectrum beta-lactamase (ESBL)-producing strains should be treated with ceftolozane-tazobactam, plazomicin, or a carbapenem beta-lactamase inhibitor.


Initial Line
Adults: Oral (first-line outpatient therapy)
Levofloxacin: 750 mg/day for 5 days; Ciprofloxacin: 1,000 mg/day; Ciprofloxacin XR: 500 mg q12h for 7 days.
Ceftriaxone 1 g first IM/IV dose - IV (initial inpatient treatment for individuals with no risk factors for MDR organisms) TMP-SMX (160/800 mg): 1 tablet q12h for 14 days given uropathogen known to be sensitive Levofloxacin: 750 mg/day Ciprofloxacin: 400 mg every 12 hours
Ceftriaxone: 1 to 2 g/day Cefotaxime: 1 to 2 g q12h Cefepime: 1 to 2 g q8-12h
Gentamicin for Enterococcus - IV (first inpatient treatment for patients with at least one risk factor for MDR organisms): 5 to 7 mg/kg body weight daily; Piperacillin-tazobactam: 3.375 g q6-8h; Ampicillin: 2 g q6; Carbapenem antipseudomonal
Add vancomycin for methicillin-resistant S. aureus (MRSA) or daptomycin or linezolid for vancomycin-resistant Enterococcus (VRE). Meropenem: 1 g q8h; Imipenem: 500 mg q6h; Doripenem: 500 mg q8h.
- Severe illness: tolerating PO intake and IV therapy till afebrile for 24 to 48 hours. To finish a course of up to two weeks, switch to oral medications.
Children: Cefdinir, 14 mg/kg/day for 10-14 days; Ceftibuten, 9 mg/kg/day for 10–14 days; Cefixime, 8 mg/kg/day for 10–14 days – IV (Age 2 months or clinical concern in other ages is a general indication for IV treatment.) Ceftriaxone 75 mg/kg/day (acceptable for IM usage in an outpatient setting) Cefotaxime: 150 mg/kg/day split into three to four doses
 Gentamicin 7.5 mg/kg/day divided into three doses in addition to ampicillin 100 mg/kg/day

Second-line grownups
● Oral
- When using oral -lactams, exercise caution; if necessary, administer an initial IV dose of ceftriaxone or a combined 24-hour dosage of an aminoglycoside; lengthier treatment durations (10 to 14 days); recommended Targeted therapy for MDR pathogens - Cefpodoxime (Proxetil): 200 mg every 12 hours - Amoxicillin-clavulanate: 875/125 mg every 12 hours or 500/125 mg every 8 hours - IV
 Meropenem-vaborbactam: 4 g q8h Ertapenem: 1 g q24h Ceftazidime-avibactam: 2.5 g q8h Ceftolozane-tazobactam: 1.5 g q8h (3)[A]
15 mg/kg/day of plazomicin (4)[A]
Cefiderocol: 2 g every 8 hours (5)[A]
Child Safety Considerations
Children under the age of two and children with fever or recurrent UTI should be treated for 10 to 14 days.
E. coli should be covered with the initial empiric antibiotic of choice. If Enterococcus is suspected, add ampicillin.
- Ceftibuten, cefixime, and amoxicillin/clavulanic acid may be taken orally alone. - IV antibiotics (single daily dose if an aminoglycoside is used) for 2–4 days may also be utilized, then oral antibiotics for a total of 10–14 days may be taken. Complete the whole course of outpatient antibiotics.

Referral Chronic pyelonephritis, aberrant urogenital anatomy Acute pyelonephritis that is not responding to treatment

Surgical Techniques 

Surgical drainage may be necessary for perinephric abscess.


Admission 
Inpatient treatment for severe sickness, risk factors for complex pyelonephritis, pregnancy, or extreme ages (e.g., high fevers, intense pain, notable debility, intractable vomiting, inability to accept oral intake, potential sepsis).  IV fluids for dehydration; blood cultures for patients admitted with pyelonephritis; discharge on oral medication once patient is afebrile 24 to 48 hours to complete up to 2 weeks of therapy; outpatient therapy if mild to moderate illness, uncomplicated course, and tolerating oral intake.

Take Action 
Routine follow-up cultures are not advised for women unless symptoms return after two weeks, in which case a urologic assessment is required. Men, kids, teenagers, people with recurring infections, and people with risk factors urologic assessment following the first episode of pyelonephritis and with recurrences; repeat cultures 1–2 weeks after the end of therapy patient observation
If there is no reaction after 48 hours (5% of patients),
Review cultures, CT scans, or US scans again; modify therapy as necessary; visit a urologist or an infectious disease specialist. A resistant organism and nephrolithiasis are the two most frequent reasons why an organism fails to respond.
 Collaborate with parents to keep an eye on kids' reactions.
DIET
Encourage drinking of water.

Prognosis 
Within 48 hours, 95% of treated patients show improvement.

Acute or chronic renal failure, septic shock, and mortality can all result from complications, including: renal abscess, perinephric abscess, metastatic infection of the skeletal system, endocardium, eye, and meningitis with subsequent convulsions.

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