eMedicine Specialties > Nephrology > Tubulointerstitial Diseases of the Kidney

Pyelonephritis, Acute: Differential Diagnoses & Workup

Author: William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
Coauthor(s): Judith Green-McKenzie, MD, MPH, Associate Professor of Emergency Medicine, Director of Clinical Practice and Associate Director of Occupational Medicine, Department of Emergency Medicine, University of Pennsylvania School of Medicine, University Hospital; Christopher Edwards, MD, Staff Physician, Department of Emergency Medicine, University of Pennsylvania Medical School; Amy J Behrman, MD, Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine; Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine
Contributor Information and Disclosures

Updated: Jan 7, 2009

Differential Diagnoses

Abdominal Abscess
Proteus Infections
Abdominal Aortic Aneurysm
Pseudomonas Aeruginosa Infections
Acute Abdomen and Pregnancy
Pyelonephritis, Chronic
Acute Bacterial Prostatitis and Prostatic Abscess
Pyonephrosis
Appendicitis
Renal Corticomedullary Abscess
Bacterial Infections and Pregnancy
Renal Disease and Pregnancy
Cervicitis
Renal Vein Thrombosis
Chlamydial Genitourinary Infections
Salpingitis
Chronic Bacterial Prostatitis
Splenic Abscess
Diverticulitis
Splenic Infarct
Ectopic Pregnancy
Staphylococcal Infections
Endometritis
Streptococcus Group A Infections
Epididymitis
Streptococcus Group B Infections
Escherichia Coli Infections
Streptococcus Group D Infections
Gonococcal Infections
Struvite and Staghorn Calculi
Infective Endocarditis
Ureaplasma Infection
Interstitial Cystitis
Ureteropelvic Junction Obstruction
Klebsiella Infections
Urethritis
Nephritis, Interstitial
Urinary Tract Infection, Females
Nephrocalcinosis
Urinary Tract Infection, Males
Nephrolithiasis
Urinary Tract Infections in Pregnancy
Nephrolithiasis: Acute Renal Colic
Urinary Tract Obstruction
Nonbacterial Prostatitis
Urologic Imaging Without X-rays: Ultrasound, MRI, and Nuclear Medicine
Oophoritis
Vesicoureteral Reflux
Pancreatitis, Acute
Vesicovaginal and Ureterovaginal Fistula
Pancreatitis, Chronic
Vesicovaginal Fistula
Papillary Necrosis
Pelvic Inflammatory Disease
Prostatitis, Bacterial

Workup

Laboratory Studies

  • In the outpatient setting, pyelonephritis is usually suggested based on the history and physical examination and is supported by urinalysis results, which should include microscopic analysis. Other lab studies are used to evaluate for complicating conditions and to assist in determining if the patient should be admitted.
  • Most easily diagnosed cases occur in women, both pregnant and nonpregnant. Men, patients at the extremes of age, patients harboring subclinical pyelonephritis, and patients who are hospitalized may present with an insidious onset. This section presents information relative to the perspective of pyelonephritis versus UTIs, in general.
  • Urinalysis
    • Gross hematuria occurs infrequently with pyelonephritis and is more common with lower UTI (hemorrhagic cystitis). When present, the differential should include calculi, cancer, glomerulonephritis, tuberculosis, trauma, and vasculitis.
    • Pyuria is defined as more than 5-10 WBCs per high-power field (hpf) on a specimen spun at 2000 rpm for 5 minutes. Almost all patients with pyelonephritis have significant pyuria (>20 WBCs/hpf), although the numbers may be smaller, particularly in those with subacute pyelonephritis.
    • The dipstick leukocyte esterase test (LET) helps screen for pyuria. LET results have a sensitivity of 75-96% and a specificity of 94-98% for detecting more than 10 WBC/hpf. The nitrite production test (NPT) for bacteriuria has 92-100% sensitivity and 35-85% specificity and may be falsely negative in the presence of diuretic use, low dietary nitrate, or organisms that do not produce nitrate reductase (eg, Enterococcus, Pseudomonas, Staphylococcus). Combined, the LET-NPT has a sensitivity of 79.2% and a specificity of 81%, which is too low for it to be used as the only screening study for bacteriuria.
    • Microscopic examination may reveal hematuria, but other causes should be considered, particularly calculi. This is especially true if the patient does not respond to therapy. White cell casts are suggestive of pyelonephritis; however, centrifuge speeds (>2000 rpm) used for urinalysis sediment preparation often fracture them and lead to their absence in the sediment.
    • Proteinuria is expected (up to 2 g/d). When it exceeds 3 g/d, glomerulonephritis should be considered.
    • The presence of a single bacterium in an unspun urine specimen by oil-immersion microscopic examination is equivalent to at least 105 organisms. Bacteria are identified much more easily on a stained versus an unstained specimen.
  • Urine culture
    • Urine culture is indicated in any patient with pyelonephritis, whether treated in an inpatient or an outpatient setting, because of the possibility of antibiotic resistance.
    • Specimens can be collected by clean catch, catheter, or suprapubic puncture (rarely performed or indicated).
  • Blood cultures
    • Blood cultures are indicated in any patient who is being admitted or who has already been admitted.
    • Approximately 12-20% are positive for infection. Bacteremia has not been associated with a poor outcome unless sepsis or another significant comorbidity is present.

Imaging Studies

  • Imaging studies are rarely indicated for the diagnosis of acute pyelonephritis in the adult who presents with typical signs and symptoms. Imaging may be warranted if the presentation is atypical or confusing. It is also warranted if the patient deteriorates or does not respond to therapy, as illustrated by the following scenarios, in which the important considerations are nephrolithiasis, obstructive uropathy, and perinephric abscess:
    • The patient has a fever or positive blood culture results that persist for longer than 48 hours.
    • The patient’s condition suddenly worsens.
    • Toxicity persists for longer than 72 hours.
    • The patient has a complicated UTI (see Causes).
  • The purpose is to evaluate immediately for an organ- or life-threatening complication. Contrast-enhanced helical/spiral computed tomography scan (CECT) is the imaging study of choice when there is suspicion for the development of a complication of acute pyelonephritis, both in adults and in children. A recent study demonstrated in an experimental model that CECT, magnetic resonance imaging (MRI), and dimercaptosuccinic acid 99m-technetium (99mTc-DMSA) scintigraphy were equivalent in their sensitivity and reliability to detect acute pyelonephritis. Clinical experience is still limited with MRI in this setting, and there are the issues of cost and availability. 99mTc-DMSA scintigraphy is used more often in children to image the urinary tract to lessen radiation exposure.
  • Imaging early in the presentation of acute pyelonephritis may be more useful than previously thought. In one recent study, 16% of cases admitted for acute pyelonephritis were found to have new and clinically significant abnormalities on renal imaging with ultrasound (US) or computed tomography (CT) at the time of admission. Independent of this observation, there are certain patients who warrant imaging at the time of admission, including those with AIDS, poorly controlled diabetes, an organ transplant (particularly renal), another immunocompromised state, sepsis syndrome, or septic shock, because of the increased risk of a complication.
  • The following studies have been used in the diagnosis of acute pyelonephritis:
    • As mentioned above, CECT is the imaging study of choice in adults. It is more sensitive than ultrasound and intravenous pyelogram (25% sensitivity), and it can more readily identify alterations in renal parenchymal perfusion, alterations in contrast excretion, perinephric fluid, and nonrenal disease.
    • Noncontrast helical/spiral CT findings may be normal in acute pyelonephritis with mild parenchymal involvement, but the findings are usually positive when the involvement is moderated or severe. It is the standard study for demonstrating gas-forming infections, hemorrhage, inflammatory masses, and obstruction. It also has 97% accuracy in identifying renal stones.
    • US can sometimes detect acute pyelonephritis, but a negative study does not exclude the possibility. Power Doppler US is superior to color Doppler US in the detection of pyelonephritis but remains inferior to CECT. It is useful in screening for urinary obstruction in children admitted for febrile illnesses. It can help differentiate solid and cystic structures, detect hydronephrosis and stones, and measure blood flow.
    • 99mTc-DMSA scintigraphy is almost as sensitive clinically as CECT in detecting focal renal abnormalities during acute pyelonephritis in adults. 99mTc-DMSA scintigraphy is not used much in adults because the focal abnormalities are not specific; rather, they are consistent with abscess, cyst, infarct, pyelonephritis, or tumor. Additionally, it is much less available in the acute setting than CECT. In children, it is the preferred study to lessen radiation exposure from CT scans. It is excellent for helping detect inflammation, scarring, and the distribution of renal function between kidneys. DMSA is a radiotracer that localizes to the renal cortex.
    • Experience with MRI in evaluating acute pyelonephritis is limited but growing. It is a suitable alternative in the patient with iodinated-dye allergy. It can evaluate the genitourinary system prenatally, renal infection/masses/vasculature, and urinary obstruction, using gadolinium-enhanced MRI, a nonnephrotoxic dye study.
  • CT urography and MR urography are evolving modalities that allow evaluation of the renal parenchyma and urothelium, according to one comprehensive study. Currently used in the evaluation of hematuria, these modalities will become more applicable to the study of other urological problems.
  • Imaging may be required to make the diagnosis in infants and children in whom pyelonephritis presents insidiously.
  • Imaging studies in conjunction with urological procedures, including cystoscopy and excretory urography, may be used during a follow-up examination to evaluate for urinary tract abnormalities that can predispose the patient to infection.
  • Patients with complicated UTIs should be considered for follow-up imaging to assess the urinary tract.

Procedures

  • Urine specimens obtained for examination and culture should approximate the urine contained in the bladder as closely as possible. The 3 procedures for collecting such a urine specimen are clean catch, urethral catheterization, and suprapubic needle aspiration.
    • Clean catch
      • When properly collected, a clean-catch specimen adequately reflects the microbiology of the urine in the bladder.
      • This technique can be performed by ambulatory females aged 6 years and older who do not have any limiting physical handicap. The presence of a large number of epithelial cells after microscopic examination suggests that the specimen is not a true clean catch and is rendered unreliable for culture because of contamination with vaginal contents. Importantly, the patient should wash only the area where urine is passed, wash front to back, hold the cup by the outside, and keep the labia spread while collecting the urine. This is to ensure that the urine goes into the cup without touching the labia.
      • This technique can also be performed by ambulatory males aged 6 years and older who do not have any limiting physical handicap. Specimens are usually reliable. Importantly, the patient should clean the head of the penis, retract the foreskin (in uncircumcised males), maintain a good stream, and hold the cup by the outside. In the presence of epispadias or hypospadias, care must be taken to maintain a good stream while collecting the specimen.
    • Urethral catheterization
      • This engenders a small risk of introducing bacteria into the sterile bladder environment.
      • Several indications justify this risk when a urine culture is necessary, including (1) inability or difficulty voiding urine even with hydration, (2) marked obesity or redundant labia in females, (3) ill patients who cannot reliably perform the procedure, (4) performance of a urological procedure during which a specimen can be collected, and (5) children aged 2-6 years (unless a clinician-assisted clean-catch specimen cannot be collected).
    • Suprapubic needle aspiration
      • This technique is rarely used.
      • It is indicated when (1) another alternative is lacking, (2) the need exists to exclude contamination from other methods of collection, (3) the need exists to verify the presence of an infecting organism that is otherwise considered a contaminant, and (4) the need exists to verify infection in infants who have a positive culture result from a specimen obtained from a strap-on device.

Histologic Findings

Features of acute pyelonephritis include suppurative necrosis or abscess formation within the renal substance. Features of chronic pyelonephritis (chronic interstitial nephritis) include papillary atrophy and blunting, interstitial fibrosis with inflammatory infiltrate (ie, lymphocytes, plasma cells, neutrophils [occasional]), tubules (ie, dilated with possible colloid casts, contracted with atrophy of epithelium), and concentric fibrosis about the parietal layer of the Bowman capsule.

More on Pyelonephritis, Acute

Overview: Pyelonephritis, Acute
Differential Diagnoses & Workup: Pyelonephritis, Acute
Treatment & Medication: Pyelonephritis, Acute
Follow-up: Pyelonephritis, Acute
References
[ CLOSE WINDOW ]

References

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

  2. Peterson J, Kaul S, Khashab M, et al. 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. Jan 2008;71(1):17-22. [Medline].

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

  4. Warren JW, Abrutyn E, Hebel JR, et al. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA). Clin Infect Dis. Oct 1999;29(4):745-58. [Medline].

  5. 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.

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

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

  8. Andrews WW, Goldenberg RL, Hauth JC. Preterm labor: emerging role of genital tract infections. Infect Agents Dis. Dec 1995;4(4):196-211. [Medline].

  9. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. Jul 2001;29(7):1303-10. [Medline].

  10. Angus DC, Wax RS. Epidemiology of sepsis: an update. Crit Care Med. Jul 2001;29(7 Suppl):S109-16. [Medline].

  11. Bauer R, Kogan BA. New developments in the diagnosis and management of pediatric UTIs. Urol Clin North Am. Feb 2008;35(1):47-58; vi. [Medline].

  12. Chuang CK, Lai MK, Chang PL, et al. Xanthogranulomatous pyelonephritis: experience in 36 cases. J Urol. Feb 1992;147(2):333-6. [Medline].

  13. Cole DE, Taylor TL, McCullough DM, et al. Acute respiratory distress syndrome in pregnancy. Crit Care Med. Oct 2005;33(10 Suppl):S269-78.

  14. Cunningham FG, Lucas MJ, Hankins GD. Pulmonary injury complicating antepartum pyelonephritis. Am J Obstet Gynecol. Apr 1987;156(4):797-807. [Medline].

  15. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med. Apr 2004;30(4):536-55. [Medline].

  16. Dembry LM, Andriole VT. Renal and perirenal abscesses. Infect Dis Clin North Am. Sep 1997;11(3):663-80. [Medline].

  17. Efstathiou SP, Pefanis AV, Tsioulos DI, et al. Acute pyelonephritis in adults: prediction of mortality and failure of treatment. Arch Intern Med. May 26 2003;163(10):1206-12. [Medline].

  18. Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. May 27 2004;350(22):2247-56. [Medline].

  19. Forbes C, Jepson R, Martin-Hirsch P. Interventions targeted at women to encourage the uptake of cervical screening. Cochrane Database Syst Rev. 2002;CD002834. [Medline].

  20. Foxman B, Frerichs RR. Epidemiology of urinary tract infection: I. Diaphragm use and sexual intercourse. Am J Public Health. Nov 1985;75(11):1308-13. [Medline].

  21. Foxman B, Klemstine KL, Brown PD. Acute pyelonephritis in US hospitals in 1997: hospitalization and in-hospital mortality. Ann Epidemiol. Feb 2003;13(2):144-50. [Medline].

  22. Gargan RA, Hamilton-Miller JM, Brumfitt W. Effect of pH and osmolality on in vitro phagocytosis and killing by neutrophils in urine. Infect Immun. Jan 1993;61(1):8-12. [Medline].

  23. Gonzalez R. Urologic disorders in infants. In: Nelson WE, Behrman RE, Kliegman RM, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders; 1996:1528-34.

  24. Griebling TL. Urologic diseases in america project: trends in resource use for urinary tract infections in men. J Urol. Apr 2005;173(4):1288-94. [Medline].

  25. Griebling TL. Urologic diseases in America project: trends in resource use for urinary tract infections in women. J Urol. Apr 2005;173(4):1281-7. [Medline].

  26. Hardman JG, Limbird LE [Eds]. '. Goodman and Gilman's The Pharmocological Basis of Therapeutics, 9th Ed. 1996.

  27. Harjai K, Mittal R, Chhibber S, et al. Contribution of Tamm-Horsfall protein to virulence of Pseudomonas aeruginosa in urinary tract infection. Microbes Infect. Jan 2005;7(1):132-7. [Medline].

  28. Hill JB, Sheffield JS, McIntire DD, et al. Acute pyelonephritis in pregnancy. Obstet Gynecol. Jan 2005;105(1):18-23. [Medline].

  29. Hoberman A, Chao HP, Keller DM, et al. Prevalence of urinary tract infection in febrile infants. J Pediatr. Jul 1993;123(1):17-23. [Medline].

  30. Hooton TM. The current management strategies for community-acquired urinary tract infection. Infect Dis Clin North Am. Jun 2003;17(2):303-32. [Medline].

  31. Hooton TM, Scholes D, Hughes JP, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med. Aug 15 1996;335(7):468-74. [Medline].

  32. Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am. Sep 1997;11(3):551-81. [Medline].

  33. Hotchkiss RS, Karl IE. The pathophysiology and treatment of sepsis. N Engl J Med. Jan 9 2003;348(2):138-50. [Medline].

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

  35. Israel RS, Lowenstein SR, Marx JA, et al. Management of acute pyelonephritis in an emergency department observation unit. Ann Emerg Med. Mar 1991;20(3):253-7. [Medline].

  36. Jacobson SH, Eklof O, Eriksson CG, et al. Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up. BMJ. Sep 16 1989;299(6701):703-6. [Medline].

  37. Jennette JC [Ed]. '. 5th Ed. Hepinstall's Pathology of the Kidney; 1998.

  38. Johnson JR. Microbial virulence determinants and the pathogenesis of urinary tract infection. Infect Dis Clin North Am. Jun 2003;17(2):261-78, viii. [Medline].

  39. Johnson JR, Stamm WE. Urinary tract infections in women: diagnosis and treatment. Ann Intern Med. Dec 1 1989;111(11):906-17. [Medline].

  40. Kaplan DM, Rosenfield AT, Smith RC. Advances in the imaging of renal infection. Helical CT and modern coordinated imaging. Infect Dis Clin North Am. Sep 1997;11(3):681-705. [Medline].

  41. Kawashima A, Glockner JF, King BF Jr. CT urography and MR urography. Radiol Clin North Am. Sep 2003;41(5):945-61. [Medline].

  42. Kawashima A, LeRoy AJ. Radiologic evaluation of patients with renal infections. Infect Dis Clin North Am. Jun 2003;17(2):433-56. [Medline].

  43. Kontiokari T, Sundqvist K, Nuutinen M, et al. Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women. BMJ. Jun 30 2001;322(7302):1571. [Medline].

  44. Kooman JP, Barendregt JN, van der Sande FM, et al. Acute pyelonephritis: a cause of acute renal failure?. Neth J Med. Nov 2000;57(5):185-9. [Medline].

  45. Kunin CM. The natural history of recurrent bacteriuria in schoolgirls. N Engl J Med. Jun 25 1970;282(26):1443-8. [Medline].

  46. Lee B, Bhuta T, Craig J, et al. Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev. 2002;CD003265. [Medline].

  47. Majd M, Nussbaum Blask AR, Markle BM, et al. Acute pyelonephritis: comparison of diagnosis with 99mTc-DMSA, SPECT, spiral CT, MR imaging, and power Doppler US in an experimental pig model. Radiology. Jan 2001;218(1):101-8. [Medline].

  48. Marriott HL. Water and salt depletion. Springfield, Ill: Charles C. Thomas; 1950.

  49. Martinell J, Hansson S, Claesson I, et al. Detection of urographic scars in girls with pyelonephritis followed for 13-38 years. Pediatr Nephrol. Sep 2000;14(10-11):1006-10. [Medline].

  50. Millar LK, Wing DA, Paul RH, et al. Outpatient treatment of pyelonephritis in pregnancy: a randomized controlled trial. Obstet Gynecol. Oct 1995;86(4 Pt 1):560-4. [Medline].

  51. Miller O, Hemphill RR. Urinary tract infection and pyelonephritis. Emerg Med Clin North Am. Aug 2001;19(3):655-74. [Medline].

  52. Mittal P, Wing DA. Urinary tract infections in pregnancy. Clin Perinatol. Sep 2005;32(3):749-64. [Medline].

  53. Mombelli G, Pezzoli R, Pinoja-Lutz G, et al. Oral vs intravenous ciprofloxacin in the initial empirical management of severe pyelonephritis or complicated urinary tract infections: a prospective randomized clinical trial. Arch Intern Med. Jan 11 1999;159(1):53-8. [Medline].

  54. Nahar A, Akom M, Hanes D, et al. Pyelonephritis and acute renal failure. Am J Med Sci. Aug 2004;328(2):121-3. [Medline].

  55. Nicolle LE. Asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am. Sep 1997;11(3):647-62. [Medline].

  56. Nicolle LE. Asymptomatic bacteriuria: when to screen and when to treat. Infect Dis Clin North Am. Jun 2003;17(2):367-94. [Medline].

  57. Nicolle LE. Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis. Urol Clin North Am. Feb 2008;35(1):1-12, v. [Medline].

  58. Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetes. Infect Dis Clin North Am. Sep 1997;11(3):735-50. [Medline].

  59. Patterson LT, Strife CF. Acquired versus congenital renal scarring after childhood urinary tract infection. J Pediatr. Jan 2000;136(1):2-4. [Medline].

  60. Patterson TF, Andriole VT. Detection, significance, and therapy of bacteriuria in pregnancy. Update in the managed health care era. Infect Dis Clin North Am. Sep 1997;11(3):593-608. [Medline].

  61. Pewitt EB, Schaeffer AJ. Urinary tract infection in urology, including acute and chronic prostatitis. Infect Dis Clin North Am. Sep 1997;11(3):623-46. [Medline].

  62. Pfaller MA, Koontz FP. Laboratory evaluation of leukocyte esterase and nitrite tests for the detection of bacteriuria. J Clin Microbiol. 1985;21:840-42.

  63. Pinson AG, Philbrick JT, Lindbeck GH, et al. ED management of acute pyelonephritis in women: a cohort study. Am J Emerg Med. May 1994;12(3):271-8. [Medline].

  64. Pinson AG, Philbrick JT, Lindbeck GH, et al. Oral antibiotic therapy for acute pyelonephritis: a methodologic review of the literature. J Gen Intern Med. Sep-Oct 1992;7(5):544-53. [Medline].

  65. Pitts GC, Johnson RE, Consolazio FC. Work in the heat as affected by intake of water, salt, and glucose. Med Sci Sports Exerc. 1944;142:253.

  66. Quinn FM, Dick AC, Corbally MT, et al. Xanthogranulomatous pyelonephritis in childhood. Arch Dis Child. Dec 1999;81(6):483-6. [Medline].

  67. Ramakrishnan K, Scheid DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician. Mar 1 2005;71(5):933-42. [Medline].

  68. Raz R, Sakran W, Chazan B, et al. Long-term follow-up of women hospitalized for acute pyelonephritis. Clin Infect Dis. Oct 15 2003;37(8):1014-20. [Medline].

  69. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med. Sep 9 1993;329(11):753-6. [Medline].

  70. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. Nov 8 2001;345(19):1368-77. [Medline].

  71. Rivers EP, McIntyre L, Morro DC, et al. Early and innovative interventions for severe sepsis and septic shock: taking advantage of a window of opportunity. CMAJ. Oct 25 2005;173(9):1054-65. [Medline].

  72. Ronald AR, Harding GK. Complicated urinary tract infections. Infect Dis Clin North Am. Sep 1997;11(3):583-92. [Medline].

  73. Rubenstein JN, Schaeffer AJ. Managing complicated urinary tract infections: the urologic view. Infect Dis Clin North Am. Jun 2003;17(2):333-51. [Medline].

  74. Rusinek H, Kaur M, Lee VS. Renal magnetic resonance imaging. Curr Opin Nephrol Hypertens. Nov 2004;13(6):667-73. [Medline].

  75. Safrin S, Siegel D, Black D. Pyelonephritis in adult women: inpatient versus outpatient therapy. Am J Med. Dec 1988;85(6):793-8. [Medline].

  76. Saint S, Chenoweth CE. Biofilms and catheter-associated urinary tract infections. Infect Dis Clin North Am. Jun 2003;17(2):411-32. [Medline].

  77. Schlager TA. Urinary tract infections in infants and children. Infect Dis Clin North Am. Jun 2003;17(2):353-65, ix. [Medline].

  78. Scholes D, Hooton TM, Roberts PL, et al. Risk factors associated with acute pyelonephritis in healthy women. Ann Intern Med. Jan 4 2005;142(1):20-7. [Medline].

  79. Segura JW, Preminger GM, Assimos DG, et al. Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. The American Urological Association Nephrolithiasis Clinical Guidelines Panel. J Urol. Jun 1994;151(6):1648-51. [Medline].

  80. Sheehan GJ, Harding GK, Haase DA, et al. Double-blind, randomized comparison of 24 weeks of norfloxacin and 12 weeks of norfloxacin followed by 12 weeks of placebo in the therapy of complicated urinary tract infection. Antimicrob Agents Chemother. Aug 1988;32(8):1292-3. [Medline].

  81. Shen Y, Brown MA. Renal imaging in pyelonephritis. Nephrology (Carlton). Feb 2004;9(1):22-5. [Medline].

  82. Smaill F. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev. 2000;(2):CD000490. [Medline].

  83. Smellie JM, Prescod NP, Shaw PJ, et al. Childhood reflux and urinary infection: a follow-up of 10-41 years in 226 adults. Pediatr Nephrol. Nov 1998;12(9):727-36. [Medline].

  84. Sobel JD. Pathogenesis of urinary tract infection. Role of host defenses. Infect Dis Clin North Am. Sep 1997;11(3):531-49. [Medline].

  85. Sobel JD, Kaye D. Urinary tract infections. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 5th ed. Philadelphia. Pa: Churchill Livingstone; 2000:773-805.

  86. Stamm WE, Hooton TM. Management of urinary tract infections in adults. N Engl J Med. Oct 28 1993;329(18):1328-34. [Medline].

  87. Stapleton A. Prevention of recurrent urinary-tract infections in women. Lancet. Jan 2 1999;353(9146):7-8. [Medline].

  88. Stapleton A, Stamm WE. Prevention of urinary tract infection. Infect Dis Clin North Am. Sep 1997;11(3):719-33. [Medline].

  89. Strom BL, Collins M, West SL, et al. Sexual activity, contraceptive use, and other risk factors for symptomatic and asymptomatic bacteriuria. A case-control study. Ann Intern Med. Dec 1987;107(6):816-23. [Medline].

  90. Talan DA, Naber KG, Palou J, et al. Extended-release ciprofloxacin (Cipro XR) for treatment of urinary tract infections. Int J Antimicrob Agents. Mar 2004;23 Suppl 1:S54-66. [Medline].

  91. Talner L, Vaughan M. Nonobstructive renal causes of flank pain: findings on noncontrast helical CT (CT KUB). Abdom Imaging. Mar-Apr 2003;28(2):210-6. [Medline].

  92. Taskinen S, Ronnholm K. Post-pyelonephritic renal scars are not associated with vesicoureteral reflux in children. J Urol. Apr 2005;173(4):1345-8. [Medline].

  93. Teichman JM, Long RD, Hulbert JC. Long-term renal fate and prognosis after staghorn calculus management. J Urol. May 1995;153(5):1403-7. [Medline].

  94. Tolkoff-Rubin NE, Rubin RH. Urinary tract infection in the immunocompromised host. Lessons from kidney transplantation and the AIDS epidemic. Infect Dis Clin North Am. Sep 1997;11(3):707-17. [Medline].

  95. Vargas AD, Bragin SD, Mendez R. Staghorn calculis: its clinical presentation, complications and management. J Urol. May 1982;127(5):860-2. [Medline].

  96. Vazquez JC, Villar J. Treatments for symptomatic urinary tract infections during pregnancy. Cochrane Database Syst Rev. 2000;(3):CD002256. [Medline].

  97. Wagenlehner FM, Weidner W, Naber KG. Pharmacokinetic characteristics of antimicrobials and optimal treatment of urosepsis. Clin Pharmacokinet. 2007;46(4):291-305. [Medline].

  98. Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am. Sep 1997;11(3):609-22. [Medline].

  99. Wennerström M, Hansson S, Jodal U, et al. Primary and acquired renal scarring in boys and girls with urinary tract infection. J Pediatr. Jan 2000;136(1):30-4. [Medline].

  100. Wing DA. Pyelonephritis. Clin Obstet Gynecol. Sep 1998;41(3):515-26. [Medline].

  101. Wullt B, Bergsten G, Fischer H, et al. The host response to urinary tract infection. Infect Dis Clin North Am. Jun 2003;17(2):279-301. [Medline].

  102. Yadav V, Harjai K, Kaur R, et al. Urovirulence of Pseudomonas aeruginosa: planktonic cells vs. biofilm cells. Folia Microbiol (Praha). 2004;49(4):465-70. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

infectious tubulointerstitial nephritis, kidney infection, renal infection, upper urinary tract infection, upper UTI, Escherichia coli, E coli, bacterial infection, gram-positive infection, uropathogens, urovirulent organisms, urinary obstruction, prostatic infection, calculi, urinary diversion procedure, infected cysts, urinary catheter, nephrostomy tubes, vesicoureteral reflux, neurogenic bladder, bladder abscess, renal abscess, perinephric abscess, diabetes mellitus, pregnancy complications, renal impairment, xanthogranulomatous pyelonephritis, XGP, malakoplakia, primary biliary cirrhosis, transplantation, neutropenia, AIDS, immunodeficiency, emphysematous pyelonephritis, sepsis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
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 Consulting fee Consulting; Glaxo Smith Kline Honoraria Speaking and teaching

Coauthor(s)

Judith Green-McKenzie, MD, MPH, Associate Professor of Emergency Medicine, Director of Clinical Practice and Associate Director of Occupational Medicine, Department of Emergency Medicine, University of Pennsylvania School of Medicine, University Hospital
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.

Christopher Edwards, MD, Staff Physician, Department of Emergency Medicine, University of Pennsylvania Medical School
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.

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.

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, 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.

Medical Editor

Chike Magnus Nzerue, MD, Associate Dean for Clinical Affairs, 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eleanor Lederer, MD, Consulting Staff, Louisville VA Hospital; Professor of Medicine, Director of Nephrology Training Program, Kidney Disease Program, University of Louisville School of Medicine; Director, Metabolic Stone Clinic
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: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Roche Honoraria Consulting

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, 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, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.