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Acute Pyelonephritis Differential Diagnoses

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

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  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.

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  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 coli70-9521-54
Proteus mirabilis1-21-10
Klebsiella spp1-22-17
Citrobacter spp< 15
Enterobacter spp< 12-10
Pseudomonas aeruginosa< 12-19
Other< 16-20
Gram positive  
Coagulase-negative staphylococci5-10*1-4
Enterococci1-21-23
Group B streptococci< 11-4
Staphylococcus aureus< 11-23
Other< 12
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 (%)11.5-31.5-31.2
Female-to-male ratio1:1.510:110:130:1
Route of infectionBloodAscendingAscendingAscending
Signs and symptomsFailure to thrive, fever, hypothermia, irritability, jaundice, poor feeding, sepsis, vomitingDiarrhea, failure to thrive, fever, irritability, poor feeding, strong-smelling urine, vomitingAbdominal pain, dysuria, enuresis, fever, gross hematuria, meningismus, strong-smelling urine, urinary urgency, urinary frequency, vomitingDysuria, enuresis, fever, flank pain or tenderness, urinary urgency, urinary frequency
Predominant organismKlebsiella speciesE coliE coli, Proteus species in older boysE coli
ManagementAdmit for intravenous ampicillin and gentamicin and further evaluationAdmit for intravenous ampicillin and gentamicin and further evaluationFollow adult guidelines, but avoid fluoroquinolones, which are theoretically contraindicated due to potential effects on the musculoskeletal systemFollow adult guidelines, but avoid fluoroquinolones, which are theoretically contraindicated due to potential effects on the musculoskeletal system
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