Acute Pyelonephritis Differential Diagnoses

Author: Tibor Fulop, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN more...

Updated: Feb 29, 2012

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Contributor Information and Disclosures

Author

Tibor Fulop, MD Associate Professor of Medicine, Medical Director, Outpatient Dialysis Services, Department of Medicine, Division of Nephrology, University of Mississippi Medical Center

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

Disclosure: Nothing to disclose.

Coauthor(s)

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

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.

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.

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, 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.

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.

Additional Contributors

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.

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

Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis. Aug 1 2007;45(3):273-80. [Medline].
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.
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. Mar 1 2010;63(3):252-62. [Medline].
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. Nov 2009;57(11):2125-8. [Medline].
Lumbiganon P, Laopaiboon M, Thinkhamrop J. Screening and treating asymptomatic bacteriuria in pregnancy. Curr Opin Obstet Gynecol. Apr 2010;22(2):95-9. [Medline].
Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. Mar 2008;22(1):73-87, vi. [Medline].
Martina MC, Campanino PP, Caraffo F, et al. Dynamic magnetic resonance imaging in acute pyelonephritis. Radiol Med. Mar 2010;115(2):287-300. [Medline].
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. Feb 2009;250(2):309-23. [Medline].
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. Mar 22-29 2000;283(12):1583-90. [Medline].
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. Mar 1 2011;52(5):e103-20. [Medline].
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.
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. Feb 2010;60(2):114-21. [Medline].
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. Mar 2008;31(3):287-9. [Medline].
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. Jan 2008;71(1):17-22. [Medline].
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. Dec 2008;24(12):3423-34. [Medline].
Harwood-Nuss AL, Etheredge W, McKenna I. Urological Emergencies. In: Harwood-Nuss A, Wolfson AB, eds. The Clinical Practice of Emergency Medicine. 3^rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001:2227-61.
Hansson S, Martinell J, Stokland E, Jodal U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am. Sep 1997;11(3):499-512. [Medline].

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.

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: 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

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:

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

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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