Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Emphysematous Pyelonephritis (EPN) Medication

  • Author: Sugandh Shetty, MD, FRCS; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Dec 30, 2015
 

Medication Summary

As previously mentioned, prompt hydration, fluid resuscitation, and treatment with systemic antibiotics are the mainstays of management in emphysematous pyelonephritis (EPN). Initial antibiotic therapy consists of intravenous ampicillin, gentamicin, and metronidazole and is administered until the culture sensitivities are available. In patients with penicillin allergies, vancomycin is used in place of ampicillin. In patients with renal compromise, doses must be adjusted according to creatinine clearance.

Next

Isotonic Crystalloids

Class Summary

Isotonic sodium chloride (normal saline [NS]) and lactated Ringer (LR) are isotonic crystalloids, the standard intravenous (IV) fluids used for initial volume resuscitation. They expand the intravascular and interstitial fluid spaces. Typically, about 30% of administered isotonic fluid stays intravascular; therefore, large quantities may be required to maintain adequate circulating volume.

Both fluids are isotonic and have equivalent volume restorative properties. While some differences exist between metabolic changes observed with the administration of large quantities of either fluid, for practical purposes and in most situations, the differences are clinically irrelevant. No demonstrable difference in hemodynamic effect, morbidity, or mortality exists between resuscitation with either NS or LR.

Normal saline (NS, 0.9% NaCl)

 

NS restores interstitial and intravascular volume. It is used in initial volume resuscitation.

Lactated Ringer

 

LR restores interstitial and intravascular volume. It is used in initial volume resuscitation.

Previous
Next

Colloids

Class Summary

Colloids are used to provide oncotic expansion of plasma volume. They expand plasma volume to a greater degree than isotonic crystalloids and reduce the tendency of pulmonary and cerebral edema. About 50% of the administered colloid stays intravascular.

Albumin (Buminate, Albuminar)

 

Albumin is used for certain types of shock or impending shock. It is useful for plasma volume expansion and maintenance of cardiac output. A solution of NS and 5% albumin is available for volume resuscitation. Five percent solutions are indicated to expand plasma volume, whereas 25% solutions are indicated to raise oncotic pressure.

Previous
Next

Antibiotics

Class Summary

Antibiotic therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. The use of linezolid with or without rifampin should be considered for staphylococcal prosthetic joint infection.

Vancomycin (Vancocin)

 

Vancomycin is an anti-infective agent used against methicillin-sensitive S aureus (MSSA), methicillin-resistant coagulase-negative S aureus (CONS), and ampicillin-resistant enterococci in patients allergic to penicillin.

Ampicillin

 

Ampicillin is used for the treatment of systemic illness warranting hospitalization. It is a broad-spectrum penicillin that interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. It can be used as an alternative to amoxicillin when unable to take medication orally.

Until recently, the HACEK bacteria were uniformly susceptible to ampicillin. Recently, however, beta-lactamase–producing strains of HACEK have been identified.

Gentamicin

 

Gentamicin is used for the treatment of systemic illness warranting hospitalization. It is an aminoglycoside antibiotic for gram-negative coverage bacteria including g Pseudomonas species. It is synergistic with beta-lactamse against enterococci. This agent interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.

Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution, as well as body space into which agent needs to distribute. Dose of gentamicin may be given IV/IM. Each regimen must be followed by at least trough level drawn on third or fourth dose, 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion.

Metronidazole (Flagyl)

 

Metronidazole is a nitroimidazole that, once concentrated within the organism, is reduced by intracellular electron transport proteins. The formation of free radicals causes disruption of cellular elements and subsequent death of the organism. It is the most commonly prescribed antibiotic for giardiasis. The recommended adult dose is 250 mg PO tid for 5-7 days.

Previous
 
Contributor Information and Disclosures
Author

Sugandh Shetty, MD, FRCS Associate Professor of Urology, Oakland University William Beaumont School of Medicine; Attending Physician, Department of Urology, William Beaumont Hospital

Sugandh Shetty, MD, FRCS is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ajay K Singh, MB, MRCP, MBA Associate Professor of Medicine, Harvard Medical School; Director of Dialysis, Renal Division, Brigham and Women's Hospital; Director, Brigham/Falkner Dialysis Unit, Faulkner Hospital

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

References
  1. Kelly HA, MacCullum WG. Pneumaturia. JAMA. 1898. 31:375-81.

  2. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000 Mar 27. 160(6):797-805. [Medline].

  3. Tang HJ, Li CM, Yen MY, et al. Clinical characteristics of emphysematous pyelonephritis. J Microbiol Immunol Infect. 2001 Jun. 34(2):125-30. [Medline].

  4. Wan YL, Lo SK, Bullard MJ, Chang PL, Lee TY. Predictors of outcome in emphysematous pyelonephritis. J Urol. 1998 Feb. 159(2):369-73. [Medline].

  5. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology. 1997 Mar. 49(3):343-6. [Medline].

  6. Pontin AR, Barnes RD, Joffe J, Kahn D. Emphysematous pyelonephritis in diabetic patients. Br J Urol. 1995 Jan. 75(1):71-4. [Medline].

  7. Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. J Urol. 1997 May. 157(5):1569-73. [Medline].

  8. Schainuck LI, Fouty R, Cutler RE. Emphysematous pyelonephritis. A new case and review of previous observations. Am J Med. 1968 Jan. 44(1):134-9. [Medline].

  9. Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection. J Urol. 1991 Jul. 146(1):148-51. [Medline].

  10. Yang WH, Shen NC. Gas-forming infection of the urinary tract: an investigation of fermentation as a mechanism. J Urol. 1990 May. 143(5):960-4. [Medline].

  11. Cheng YT, Wang HP, Hsieh HH. Emphysematous pyelonephritis in a renal allograft: successful treatment with percutaneous drainage and nephrostomy. Clin Transplant. 2001 Oct. 15(5):364-7. [Medline].

  12. Wang YC, Wang JM, Chow YC, Chiu AW, Yang S. Pneumomediastinum and subcutaneous emphysema as the manifestation of emphysematous pyelonephritis. Int J Urol. 2004 Oct. 11(10):909-11. [Medline].

  13. Tsu JH, Chan CK, Chu RW, Law IC, Kong CK, Liu PL, et al. Emphysematous pyelonephritis: an 8-year retrospective review across four acute hospitals. Asian J Surg. 2013 Jul. 36(3):121-5. [Medline].

  14. Fatima R, Jha R, Muthukrishnan J, Gude D, Nath V, Shekhar S, et al. Emphysematous pyelonephritis: A single center study. Indian J Nephrol. 2013 Mar. 23(2):119-24. [Medline]. [Full Text].

  15. Langston CS, Pfister RC. Renal emphysema. A case report and review of the literature. Am J Roentgenol Radium Ther Nucl Med. 1970 Dec. 110(4):778-86. [Medline].

  16. Michaeli J, Mogle P, Perlberg S, Heiman S, Caine M. Emphysematous pyelonephritis. J Urol. 1984 Feb. 131(2):203-8. [Medline].

  17. Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology. 1996 Feb. 198(2):433-8. [Medline].

  18. Uruc F, Yuksel OH, Sahin A, Urkmez A, Yildirim C, Verit A. Emphysematous pyelonephritis: Our experience in managing these cases. Can Urol Assoc J. 2015 Jul-Aug. 9 (7-8):E480-3. [Medline].

  19. Aboumarzouk OM, Hughes O, Narahari K, Coulthard R, Kynaston H, Chlosta P, et al. Emphysematous pyelonephritis: Time for a management plan with an evidence-based approach. Arab J Urol. 2014 Jun. 12 (2):106-15. [Medline].

  20. Nana GR, Brodie A, Akhter W, Karim O, Motiwala H. Nephroureterectomy for emphysematous pyelonephritis: An aggressive approach is sometimes necessary. A case report and literature review. Int J Surg Case Rep. 2015. 10:179-82. [Medline].

  21. Aswathaman K, Gopalakrishnan G, Gnanaraj L, Chacko NK, Kekre NS, Devasia A. Emphysematous pyelonephritis: outcome of conservative management. Urology. 2008 Jun. 71(6):1007-9. [Medline].

  22. Sharma PK, Sharma R, Vijay MK, Tiwari P, Goel A, Kundu AK. Emphysematous pyelonephritis: Our experience with conservative management in 14 cases. Urol Ann. 2013 Jul. 5(3):157-62. [Medline]. [Full Text].

  23. Gaither K, Ardite A, Mason TC. Pregnancy complicated by emphysematous pyonephrosis. J Natl Med Assoc. 2005 Oct. 97(10):1411-3. [Medline]. [Full Text].

 
Previous
Next
 
Kidneys, ureter, and bladder imaging showing a streaky gas pattern over the entire right kidney in a patient with emphysematous pyelonephritis.
Emphysematous pyelonephritis. Kidneys, ureter, and bladder imaging showing gas over the region of the right kidney. White arrows outline the area. The faint outline of a staghorn calculus can be seen in the right kidney.
Emphysematous pyelonephritis. Renal sonogram showing hyperechoic shadows suggestive of gas along the lower pole of the kidney.
Emphysematous pyelonephritis. CT scan showing gas in the left kidney, with stones and xanthogranulomatous pyelonephritis.
CT scan showing right renal and perinephric gas in a patient with emphysematous pyelonephritis.
CT scan showing gas in both kidneys and the inferior vena cava in a patient with bilateral emphysematous pyelonephritis.
Algorithm for the management of emphysematous pyelonephritis.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.