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Acute Pyelonephritis Clinical Presentation

  • Author: Tibor Fulop, MD, FASN, FACP; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
 
Updated: Aug 11, 2015
 

History

The classic presentation in acute pyelonephritis is the triad of fever, costovertebral angle pain, and nausea and/or vomiting. These may not all be present, however, or they may not occur together temporally. Symptoms may be minimal to severe and usually develop over hours or over the course of a day. Infrequently, symptoms develop over several days and may even be present for a few weeks before the patient seeks medical care. Symptoms of cystitis may or may not be present to varying degrees. These may include urinary frequency, hesitancy, lower abdominal pain, and urgency.

Gross hematuria (hemorrhagic cystitis) is present in 30-40% of pyelonephritis cases in females, most often young women. Gross hematuria is unusual in males and should prompt consideration of a more serious cause.

Pain may be mild, moderate, or severe. Flank pain may be unilateral or sometimes bilateral. Discomfort or pain may be present in the back (lower or middle) and/or the suprapubic area. Patients may describe suprapubic symptoms as discomfort, heaviness, pain, or pressure. Upper abdominal pain is unusual, and radiation of pain to the groin is suggestive of a ureteral stone.

Fever is not always present. When present, it is not unusual for the temperature to exceed 103°F (39.4°C). The patient may demonstrate rigor, and chills may be present in the absence of demonstrated fever. Malaise and weakness may also be present.

Gastrointestinal symptoms vary. Anorexia is common. Nausea and vomiting vary in frequency and intensity from absent to severe. Diarrhea occurs infrequently.

The classic signs and symptoms observed in adults are often absent in children, particularly neonates and infants. In children 2 years of age and younger, the most common symptoms of urinary tract infection (UTI) are failure to thrive, feeding difficulty, fever, and vomiting. When fever is present, pyelonephritis should be in the differential diagnosis.

Elderly patients may present with typical manifestations of pyelonephritis, or they may experience fever, mental status change, decompensation in another organ system, or generalized deterioration.

Complicated pyelonephritis

A history of the following indicates an increased risk of complicated pyelonephritis:

  • Structural abnormalities of the urinary tract
  • Functional abnormalities of the urinary tract
  • Metabolic abnormalities predisposing to UTIs
  • Recent antibiotic use
  • Recent urinary tract instrumentation

The presence of any one of the above complicating factors should raise the clinician’s index of suspicion. In many instances, more than one complicating factor is involved. In addition, if the patient is male, elderly, or a child or has had symptoms for more than 7 days, the infection should be considered complicated until proven otherwise.

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Physical Examination

The patient may or may not have a fever. If fever is present, the temperature may be greater than 103°F (39.4°C); it may even be subnormal in patients with associated sepsis. Tachycardia may or may not be present, depending on associated fever, dehydration, and sepsis.

Blood pressure is usually within the reference range, unless the patient has underlying hypertension; in cases of underlying hypertension, the pressure may be elevated above the patient's baseline. A systolic blood pressure below 90 mm Hg suggests shock secondary to sepsis or perinephric abscess.

The patient's appearance is variable. Most commonly, the patient is uncomfortable or appears ill. Patients usually do not have a toxic appearance, unless there is an underlying problem, such as sepsis, perinephric abscess, or significant dehydration.

On abdominal examination, suprapubic tenderness usually ranges from mild to moderate without rebound. Abdominal tenderness other than in the suprapubic area suggests another diagnosis. Patients usually do not have rigidity or guarding, and bowel sounds are often normally active.

Flank or costovertebral angle (CVA) tenderness is most commonly unilateral over the involved kidney, although bilateral discomfort may be present. Discomfort varies from absent to severe. This finding is usually not subtle and may be elicited with mild or moderately firm palpation.

In women, a pelvic examination should be performed. Tenderness of the cervix, uterus, and adnexa should be absent. Any positive finding suggests an additional or alternative diagnosis. If any doubt remains as to the diagnosis, if any signs or symptoms of urethritis or vaginitis are present, or if a history of dyspareunia is present, a gynecologic cause of the symptoms should be pursued.

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Complications

Complications occur more often in patients with diabetes mellitus, chronic renal disease, sickle cell disease, renal transplant (particularly during the first 3 months), AIDS, and other immunocompromised states. It can sometimes be difficult to determine whether the entities listed below are occurring as a complication of pyelonephritis or are occurring in the absence of pyelonephritis but with signs and symptoms suggestive of pyelonephritis. The important point is to have a high index of suspicion for these complications.

Complications may involve any of the following:

Abscesses

Abscesses may include renal cortical abscess, renal corticomedullary abscess, or perinephric abscess. Older adults have a higher incidence of renal corticomedullary abscesses, which affect men and women equally.

Corticomedullary abscess

Patients with renal corticomedullary abscesses often present with chills, fever, and flank or abdominal pain, and patients may have dysuria and/or nausea and vomiting. Leukocytosis may be present. Bacteriuria, pyuria, hematuria, or proteinuria may be present, as the intrarenal abscesses drain in the collecting system, but the urinalysis results may be normal in as many as 30% of patients. Bacteremia may be observed in acute focal or multifocal bacterial nephritis.

Corticomedullary abscess is usually associated with a urinary tract abnormality, such as vesicoureteral reflux or obstruction. It is commonly caused by Enterobacteriaceae.

The pathology represents a spectrum of disease, as follows:

  • Acute focal bacterial nephritis (eg, acute lobar nephroma, focal pyelonephritis) that affects a single renal lobe, with interstitial inflammation represented by marked polymorphonuclear leukocytes
  • Acute multifocal bacterial nephritis, with a similar process throughout the kidney that produces liquefaction and abscess formation
  • Xanthogranulomatous pyelonephritis, with chronic parenchymal infection, granulomatous tissue, and perirenal fibrosis
  • Emphysematous pyelonephritis, with severe, necrotizing infection

Perinephric abscess

The suppurative material of the abscess is located between the renal capsule and the surrounding renal fascia. The material is secondary to chronic or recurrent pyelonephritis; rupture or extension of a suppurative process from within the kidney; or dissemination (blood, lymph) or direct extension from other sites of infection. Although it is usually confined to the perinephric space, it may extend to the colon, flank, groin, lung (empyema, nephrobronchial fistula), paracervical area, peritoneal cavity, psoas muscle, skin surface, or subphrenic space.

Development is insidious. Presentation may include the following:

  • Fever
  • Chills
  • Unilateral flank pain (70%)
  • Dysuria (40%)
  • Nausea
  • Vomiting
  • Weight loss (25%)
  • Flank tenderness
  • Costovertebral angle tenderness
  • Abdominal tenderness (60%)
  • Referred pain (ie, hip, thigh, or knee)
  • Flank or abdominal mass (< 50%)
  • Pyuria (70%)
  • Sterile urine (40%)
  • Bacteremia (40%)
  • Curvature of the spine away from the involved kidney

One third of patients are diagnosed upon admission; another third are diagnosed at autopsy. Perinephric abscess is not usually readily apparent; a high index of clinical awareness is necessary.

Renal cortical abscess

Renal cortical abscess (renal carbuncle) is an uncommon condition that is usually caused by the hematogenous spread of S aureus. It occurs 3 times more commonly in men than in women. Microabscesses develop in the cortex and coalesce to form a circumscribed abscess that may or may not communicate with the collecting system. This process takes days to months.

Patients with renal cortical abscess may present with chills, fever, and flank or abdominal pain. A flank mass or a bulge in the lumbar region may be evident. Some patients have abnormal results on lung examination of the affected side (dullness to percussion, rales). Blood and urine culture results usually are negative, but the white blood cell (WBC) count is often elevated.

Emphysematous pyelonephritis, pyelitis, and cystitis

Emphysematous pyelonephritis, which most commonly occurs in patients with diabetes, is a severe, necrotizing form of acute multifocal bacterial nephritis with extension of the infection through the renal capsule. This leads to the presence of gas within the kidney substance and in the perinephric space. Persons with diabetes (with or without obstruction) account for 85-100% of cases, although some cases have occurred in patients without diabetes who had obstruction.  Females outnumber males (2-6:1).

Emphysematous pyelonephritis occurs in the left kidney in approximately two thirds of cases. The etiology is usually Enterobacteriaceae (E coli, 60%), with some reported cases of Streptococcus species and Candida species. A triad of diabetes, obstruction, and remote or recent pyelonephritis should raise clinical suspicion. Patient presentation includes fever, chills, abdominal pain, nausea, vomiting, flank pain, flank mass (50%), crepitation (over thigh or flank), urinary symptoms, and pyuria.

Emphysematous pyelitis (pneumopyonephrosis) involves gas that is localized to the collecting system. Diabetes mellitus is present in 85-100% of patients. The left kidney is more frequently affected than the right. Presentation is similar to that of pyelonephritis. On plain radiographs, the gas pattern is noted in the renal pelvis and may be seen in the ureter. The patient should be admitted and treated with intravenous antibiotics. The mortality rate is 20%.

Emphysematous cystitis (cystitis emphysematosa) involves gas that is localized to the bladder secondary to a bladder infection. Gas in the bladder is more frequently related to a fistula between the bladder and the colon or vagina than to a gas-producing infection. As many as 80% of patients are diabetic.

Patient presentation is similar to that for pyelonephritis. Plain radiographs may demonstrate gas in the bladder wall or lumen, an air-fluid level in the bladder, or a cobblestone appearance to the bladder wall. CT scan is the study of choice to help localize the gas to the proper organ. Treatment involves intravenous antibiotics and relief of any outlet obstruction. This condition is not as serious as the other two previously described emphysematous conditions.

Xanthogranulomatous pyelonephritis

Xanthogranulomatous pyelonephritis is a rare form of pyelonephritis that is almost always associated with chronic obstruction (eg, from staghorn calculus [75% of cases], other calculus, stricture, or tumor). In adults, the female-to-male ratio is 3:1; in children, it is 1.1:1. It is a chronic infection that finally manifests acutely with fever and flank pain or tenderness, and it may be complicated by a flank mass, cutaneous fistula, septic arthritis, or hematochezia if extension has occurred beyond the renal capsule. Kidney function is absent (71%) or poor (25%) in almost all cases. Diagnosis is difficult preoperatively.

Tuberculosis

Tuberculosis (TB) of the kidney results from hematogenous spread but is relatively rare in developing countries. Unlike most other extrapulmonary manifestations of the disease, TB of the kidney does not become manifest until 5-15 years after the primary infection. Constitutional symptoms are uncommon, and most patients present with symptoms of bladder irritation.

Initially, pyuria is observed, and with progression of the disease, proteinuria and blood may be observed as well. Repeated urine samples should be sent for mycobacterial culture. A loss of calyceal architecture and ureteric obstruction may be observed on imaging studies.

Concurrent pulmonary disease is present in 5% of patients, and the tuberculin test rarely is helpful. Antituberculous medicines should be administered for 6 months. If the ureter is obstructed, corticosteroids have been advocated; if obstruction persists, surgical intervention is necessary.

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Contributor Information and Disclosures
Author

Tibor Fulop, MD, FASN, FACP Professor of Medicine, Department of Medicine, Division of Nephrology, University of Mississippi Medical Center

Tibor Fulop, MD, FASN, FACP is a member of the following medical societies: American College of Physicians, American Society of Diagnostic and Interventional Nephrology, American Society of Hypertension, American Society of Nephrology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Fresenius Medical Care, Hungary.

Specialty Editor Board

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, International Society of Nephrology, American Society for Biochemistry and Molecular Biology, American Federation for Medical Research, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, Kentucky Medical Association, National Kidney Foundation, Phi Beta Kappa

Disclosure: Received grant/research funds from Dept of Veterans Affairs for research; Received salary from American Society of Nephrology for asn council position; Received salary from University of Louisville for employment; Received salary from University of Louisville Physicians for employment; Received contract payment from American Physician Institute for Advanced Professional Studies, LLC for independent contractor; Received contract payment from Healthcare Quality Strategies, Inc for independent cont.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology

Disclosure: Nothing to disclose.

Acknowledgements

Amy J Behrman, MD Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine

Amy J Behrman, MD is a member of the following medical societies: American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Christopher Edwards, MD Resident Physician, Department of Emergency Medicine, University of Pennsylvania School of Medicine

Christopher Edwards, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Judith Green-McKenzie, MD, MPH Associate Professor, Director of Clinical Practice, Occupational Medicine Residency Director, University of Pennsylvania School of Medicine

Judith Green-McKenzie, MD, MPH is a member of the following medical societies: American College of Occupational and Environmental Medicine, American College of Physicians, American College of Preventive Medicine, National Medical Association, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Eleanor Lederer, MD Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Dept of Veterans Affairs Grant/research funds Research

Chike Magnus Nzerue, MD Associate Dean for Clinical Affairs, Vice-Chairman of Internal Medicine, Meharry Medical College

Chike Magnus Nzerue, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Society of Nephrology, and National Kidney Foundation

Disclosure: Nothing to disclose.

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM Associate Professor, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

William H Shoff, MD, DTM&H Director, PENN Travel Medicine; Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Glaxo Smith Kline None None; Glaxo Smith Kline Honoraria Speaking and teaching

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

Disclosure: Medscape Salary Employment

References
  1. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1. 52(5):e103-20. [Medline].

  2. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis. 2007 Aug 1. 45(3):273-80. [Medline].

  3. National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC). Kidney and Urologic Diseases Statistics for the United States. Available at http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/#urologic. Accessed: October 31, 2011.

  4. Mazaki-Tovi S, Vaisbuch E, Romero R, et al. Maternal plasma concentration of the pro-inflammatory adipokine pre-B-cell-enhancing factor (PBEF)/visfatin is elevated in pregnant patients with acute pyelonephritis. Am J Reprod Immunol. 2010 Mar 1. 63(3):252-62. [Medline].

  5. Kofteridis DP, Papadimitraki E, Mantadakis E, et al. Effect of diabetes mellitus on the clinical and microbiological features of hospitalized elderly patients with acute pyelonephritis. J Am Geriatr Soc. 2009 Nov. 57(11):2125-8. [Medline].

  6. Lumbiganon P, Laopaiboon M, Thinkhamrop J. Screening and treating asymptomatic bacteriuria in pregnancy. Curr Opin Obstet Gynecol. 2010 Apr. 22(2):95-9. [Medline].

  7. Arambašić J, Mandić S, Debeljak Ž, Mandić D, Horvat V, Šerić V. Differentiation of acute pyelonephritis from other febrile states in children using urinary neutrophil gelatinase-associated lipocalin (uNGAL). Clin Chem Lab Med. 2015 Jun 6. [Medline].

  8. Rafiei A, Mohammadjafari H, Bazi S, Mirabi AM. Urinary neutrophil gelatinase-associated lipocalin (NGAL) might be an independent marker for anticipating scar formation in children with acute pyelonephritis. J Renal Inj Prev. 2015. 4 (2):39-44. [Medline].

  9. Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008 Mar. 22(1):73-87, vi. [Medline].

  10. Martina MC, Campanino PP, Caraffo F, et al. Dynamic magnetic resonance imaging in acute pyelonephritis. Radiol Med. 2010 Mar. 115(2):287-300. [Medline].

  11. Silverman SG, Leyendecker JR, Amis ES Jr. What is the current role of CT urography and MR urography in the evaluation of the urinary tract?. Radiology. 2009 Feb. 250(2):309-23. [Medline].

  12. Talan DA, Stamm WE, Hooton TM, et al. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis pyelonephritis in women: a randomized trial. JAMA. 2000 Mar 22-29. 283(12):1583-90. [Medline].

  13. Sandberg T, Skoog G, Hermansson AB, Kahlmeter G, Kuylenstierna N, Lannergård A, et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012 Aug 4. 380(9840):484-90. [Medline].

  14. Pohl A. Modes of administration of antibiotics for symptomatic severe urinary tract infections (Review) [database online]. www.thecochranelibrary.com: The Cochrane Collaboration. 2008, Issue 3.

  15. van Nieuwkoop C, van't Wout JW, Spelt IC, et al. Prospective cohort study of acute pyelonephritis in adults: safety of triage towards home based oral antimicrobial treatment. J Infect. 2010 Feb. 60(2):114-21. [Medline].

  16. Nicolle L, Duckworth H, Sitar D, Bryski L, Harding G, Zhanel G. Pharmacokinetics/pharmacodynamics of levofloxacin 750 mg once daily in young women with acute uncomplicated pyelonephritis. Int J Antimicrob Agents. 2008 Mar. 31(3):287-9. [Medline].

  17. Peterson J, Kaul S, Khashab M, Fisher AC, Kahn JB. A double-blind, randomized comparison of levofloxacin 750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for the treatment of complicated urinary tract infections and acute pyelonephritis. Urology. 2008 Jan. 71(1):17-22. [Medline].

  18. Vouloumanou EK, Rafailidis PI, Kazantzi MS, Athanasiou S, Falagas ME. Early switch to oral versus intravenous antimicrobial treatment for hospitalized patients with acute pyelonephritis: a systematic review of randomized controlled trials. Curr Med Res Opin. 2008 Dec. 24(12):3423-34. [Medline].

  19. Harwood-Nuss AL, Etheredge W, McKenna I. Urological Emergencies. Harwood-Nuss A, Wolfson AB, eds. The Clinical Practice of Emergency Medicine. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001. 2227-61.

  20. Hansson S, Martinell J, Stokland E, Jodal U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am. 1997 Sep. 11(3):499-512. [Medline].

  21. Juliano TM, Stephany HA, Clayton DB, Thomas JC, Pope JC 4th, Adams MC, et al. Incidence of Abnormal Imaging and Recurrent Pyelonephritis After First Febrile Urinary Tract Infection in Children 2-24 Months. J Urol. 2013 Jan 22. [Medline].

 
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Nonobstructing distal left ureteral calculus 2 X 1 X 2 cm.
Multiple abscesses, upper pole of left kidney.
Bilateral hydronephrosis.
Table 1. Bacterial Etiology of Urinary Tract Infections
Bacteria % Uncomplicated % Complicated
Gram negative    
Escherichia coli 70-95 21-54
Proteus mirabilis 1-2 1-10
Klebsiella spp 1-2 2-17
Citrobacter spp < 1 5
Enterobacter spp < 1 2-10
Pseudomonas aeruginosa < 1 2-19
Other < 1 6-20
Gram positive    
Coagulase-negative staphylococci 5-10* 1-4
Enterococci 1-2 1-23
Group B streptococci < 1 1-4
Staphylococcus aureus < 1 1-23
Other < 1 2
Adapted from Hooton TM. The current management strategies for community-acquired urinary tract infection. Infect Dis Clin North Am. Jun 2003;17(2):303-32. [Medline].



* S saprophyticus



Table 2. Outpatient Treatment for Pyelonephritis
First-line therapy
  • ciprofloxacin (Cipro) 500 mg PO BID for 7d or
  • ciprofloxacin extended-release (Cipro XR) 1000 mg PO daily for 7d or
  • levofloxacin (Levaquin) 750 mg PO daily for 5d
  • If fluoroquinolone resistance is thought to be >10%, administer a single dose of ceftriaxone (Rocephin) 1g IV or  a consolidated 24-hour dose of an aminoglycoside (gentamicin 7 mg/kg IV or  tobramycin 7 mg/kg IV or amikacin 20 mg/kg IV)
Second-line therapy
  • trimethoprim/sulfamethoxazole* 160 mg/800 mg (Bactrim DS, Septra DS) 1 tablet PO BID for 14d
  • If trimethoprim/sulfamethoxazole is used when the susceptibility is not known, an initial single IV dose of the following may also be given: ceftriaxone (Rocephin) 1 g IV or  a consolidated 24-h dose of an aminoglycoside (gentamicin 7 mg/kg IV or  tobramycin 7 mg/kg IV or amikacin 20 mg/kg IV)
Alternative therapy
  • Oral beta-lactams are not as effective for treating pyelonephritis; however, if they are used, administer with a single dose of ceftriaxone (Rocephin) 1 g IV or  a consolidated 24-h dose of an aminoglycoside (gentamicin 7 mg/kg IV or  tobramycin 7 mg/kg IV or amikacin 20 mg/kg IV)
  • amoxicillin-clavulanate (Augmentin) 500 mg/125 mg PO BID for 14d or
  • amoxicillin-clavulanate (Augmentin) 250 mg/125 mg PO TID for 3-7d or
  • cefaclor 500 mg PO TID for 7d
*Should generally be avoided in elderly patients because of the risk of affecting renal function.
Table 3. Inpatient Treatment for Acute Pyelonephritis
First-line therapy
  • ciprofloxacin (Cipro) 400 mg IV q12h for 10-14d or
  • levofloxacin (Levaquin) 250 mg IV q24h for 10d or
  • levofloxacin (Levaquin) 750 mg IV q24h for 5d
Second-line therapy
Extended-spectrum cephalosporins or penicillins:



  • ampicillin 500 mg IM/IV q6h or
  • ampicillin-sulbactam (Unasyn) 1.5 g IV q6h or
  • piperacillin-tazobactam (Zosyn) 3.375 g IV q6h or
  • ticarcillin-clavulanate (Timentin) 3.1 g IV 4-6h or
  • cefotaxime (Claforan) 1-2 g IV q8h or
  • ceftriaxone (Rocephin) 1 g IV q24h or
  • ceftazidime (Fortaz, Tazicef) 2 g IV q8h
  • All of the above can be administered with or without an aminoglycoside (except in pregnant patients); see Aminoglycosides, below
Carbapenems:



  • meropenem (Merrem) 500 mg IV q8h or
  • ertapenem (Invanz) 1 g IV q24h or
  • doripenem (Doribax) 500 mg IV q8h
Monobactam (penicillin allergy):



  • aztreonam (Azactam) 1 g IV q8-12h
Alternative therapy
Aminoglycosides (because of their potential nephrotoxicity, aminoglycoside antibiotics should be reserved for patients with serious and potentially life-threatening infections, and their dosage and blood levels should be carefully monitored to minimize the risk of nephrotoxicity):
  • gentamicin 3 mg/kg/day IV/IM in 3 divided doses or 7 mg/kg/day pulsed dosing or
  • tobramycin 3 mg/kg/day IV/IM in 3 divided doses or 7 mg/kg/day pulsed dosing or
  • amikacin 10 mg/kg/day IV/IM in 3 divided doses or 20 mg/kg/day pulsed dosing
Table 4. Treatment of Pyelonephritis During Pregnancy
Mild to moderate pyelonephritis
  • ceftriaxone (Rocephin) 1 g IV q24h or
  • cefepime (Maxipime) 1 g IV q12h or
  • cefotaxime (Claforan) 1-2 g IV q8h or
  • ceftazidime (Fortaz, Tazicef) 2 g IV q8h or
  • ampicillin 1-2 g IV q6h plus  gentamicin IV 1.5 mg/kg q8h
Severe pyelonephritis
If patient is immunocompromised and/or has incomplete urinary drainage:
  • ticarcillin-clavulanate (Timentin) 3.1 g IV q6h or
  • ampicillin-sulbactam (Unasyn) 1.5 g IV q6h or
  • piperacillin-tazobactam (Zosyn) 3.375 g IV q6h
Table 5. Pediatric Urinary Tract Infections
  Neonates Infants 6 weeks to 3 years of age Children 3-6 years of age Children 6-11 years of age
UTI frequency (%) 1 1.5-3 1.5-3 1.2
Female-to-male ratio 1:1.5 10:1 10:1 30:1
Route of infection Blood Ascending Ascending Ascending
Signs and symptoms Failure to thrive, fever, hypothermia, irritability, jaundice, poor feeding, sepsis, vomiting Diarrhea, failure to thrive, fever, irritability, poor feeding, strong-smelling urine, vomiting Abdominal pain, dysuria, enuresis, fever, gross hematuria, meningismus, strong-smelling urine, urinary urgency, urinary frequency, vomiting Dysuria, enuresis, fever, flank pain or tenderness, urinary urgency, urinary frequency
Predominant organism Klebsiella species E coli E coli, Proteus species in older boys E coli
Management Admit for intravenous ampicillin and gentamicin and further evaluation Admit for intravenous ampicillin and gentamicin and further evaluation Follow adult guidelines, but avoid fluoroquinolones, which are theoretically contraindicated due to potential effects on the musculoskeletal system Follow adult guidelines, but avoid fluoroquinolones, which are theoretically contraindicated due to potential effects on the musculoskeletal system
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