eMedicine Specialties > Nephrology > Tubulointerstitial Diseases of the Kidney

Pyelonephritis, Acute: Follow-up

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

Follow-up

Further Inpatient Care

  • Continue supportive care.
  • Monitor urine and blood culture results.
  • Monitor comorbid conditions for deterioration.
  • Maintain hydration status with intravenous fluids until hydration can be maintained with oral intake.
  • Maintain intravenous antibiotics until defervescence and significant symptomatic improvement occur. Convert to an oral regimen guided by urine or blood culture results.

Further Outpatient Care

  • Continue supportive care by prescribing antiemetics, antipyretics, analgesics, and urinary tract analgesics as needed.
  • Complete a 14-day course of oral antibiotics. Recent evidence suggests that when treating a young, healthy female, the course of treatment can be shortened to 7 days from 14 days, if the antibiotic being used is a fluoroquinolone. Healthy young males should complete a 14-day course.
  • Obtain follow-up urine culture results in any patient with a complicated UTI (see Causes), a complicated course, or increased risk of infection.
  • Urine cultures are generally not indicated in healthy, nonpregnant women with resolved symptoms.
  • Rest is essential for recovery. Activity should be minimal. The patient should not return to work for 2 weeks in order to allow time for the infection to be eliminated and for the patient to recuperate physical strength. Temper this recommendation depending on the physical condition of the patient and the presence of comorbid conditions.
  • If the patient is not admitted at the time of diagnosis, follow-up reevaluation is important in 1-2 days to be sure the patient is progressing properly. A good rule based on common sense is that if the managing clinician is concerned that the patient may not respond well to outpatient management but still thinks the patient deserves a trial at home, then the initial follow-up visit should take place in 24 hours. If the clinician thinks that patient will do quite well with outpatient management, the initial follow-up visit can take place in 48 hours.
  • If the patient thinks that he or she is not progressing well or is getting worse, then the patient should be evaluated emergently for consideration for admission and intravenous antibiotics.
  • All patients with a complicated UTI (see Causes) should be considered for outpatient follow-up imaging of their urinary tract to evaluate for abnormalities that predispose to further infections.

Inpatient & Outpatient Medications

  • Antipyretics may be beneficial.
  • Use oral and parenteral antiemetics as needed. Early in the course of the illness, parenteral medication is often necessary to reduce morbidity from symptoms.
  • Use oral and parenteral analgesics as needed. Early in the course of the illness, parenteral medication is often necessary to reduce morbidity from symptoms. Nonsteroidal medications and narcotics are complementary and do not assume that one is better than the other.
  • Parenteral antibiotics are often initially administered at the time of diagnosis, regardless of whether the patient is admitted or discharged home. Continuing intravenous antibiotics for the admitted patient is essential until defervescence and improvement in the clinical condition warrants changing to oral antibiotics to complete the course. Once the patient is improved, due consideration can be given to discharge and close follow-up care in an outpatient setting.
  • Urinary tract analgesics may be beneficial if the patient has dysuria to such an extent that it disrupts the activities of daily living.

Transfer

  • When patients are treated in an inpatient setting, the facility to which they are admitted should be able to provide an appropriate level of care for pyelonephritis and any comorbid conditions. If the admitting facility is unable to provide an appropriate level of care, the patient should be transferred to a facility that is able to meet that patient's needs.

Deterrence/Prevention

  • Prevention of pyelonephritis involves identifying clinical situations that could lead to pyelonephritis and developing a strategy to decrease that likelihood. These strategies may include a change in contraceptive behavior, administration of prophylactic antibiotics, or early identification and treatment of UTIs. Several such strategies are elaborated below. Failure of these strategies to eliminate infection, recurrence of infection, or relapse (reinfection <14 d after completing an appropriate regimen) indicates the need to refer the patient for systematic evaluation for predispositional anatomic, functional, or structural abnormalities.
  • Children with recurrent UTIs or urinary tract structural abnormalities require prompt evaluation of urinary tract symptoms and appropriate treatment.
  • Premenopausal or postmenopausal women with recurrent, uncomplicated UTIs
    • In this population, recurrent UTIs may be defined as 2-2.6 UTIs per year, which occur in approximately 25% of women who develop acute uncomplicated UTIs.
    • Various behavioral and nutritional techniques have been recommended to decrease the recurrence of UTIs in young women. Daily cranberry juice intake has been suggested to be beneficial, but no conclusive evidence has been found. Behavioral techniques, such as postcoital voiding and front-to-back wiping after defecation, have been considered efficacious measures for lessening the risk of UTI; however, in a study of college-aged women, they accorded no benefit. Additionally, oral contraceptive use and tampon use were not associated with UTIs.
    • If the patient is using a diaphragm with spermicide for contraception, another method of contraception should be substituted so that spermicide-associated colonization of the vagina by uropathogens is avoided.
    • If the patient has 3 or more UTIs per year, postcoital or continuous antibiotic therapy is recommended for 6 months, followed by a reevaluation. Postcoital regimens include trimethoprim-sulfamethoxazole at 40 mg/200 mg, cephalexin at 125-250 mg, and nitrofurantoin at 50 mg (effective in pregnancy). Regimens for continuous dosing (daily or 3 times/wk) include trimethoprim-sulfamethoxazole at 40 mg/200 mg, trimethoprim at 100 mg, norfloxacin at 200 mg, nitrofurantoin at 200 mg, and cephalexin at 125-250 mg.
    • If the patient has fewer than 3 UTIs per year, patient-initiated therapy is recommended using standard regimens, such as single-dose therapy or 3-day therapy. Referral for urological evaluation is indicated if the patient is not responding, if the patient has any complicating condition, or if the patient has a relapse. Refer to Urinary Tract Infection, Females for more information.
  • Catheter-related infections or neurogenic bladder
    • Indwelling catheters have a cumulative incidence rate of bacteriuria of 3-10% per day. Two strategies for reducing bacteriuria and its sequelae are removal of the catheters as soon as possible and keeping the closed system closed. After the indwelling catheter is removed, alternative strategies for emptying the bladder that reduce but do not eliminate the risk of infection are condom catheters, intermittent catheterization (1-3% risk of bacteriuria per catheterization), intraurethral catheters, and suprapubic catheters.
    • Situations in which treatment of asymptomatic bacteriuria are indicated include culture of Serratia marcescens, clearance of an organism responsible for an infection cluster in an institution, and clearance of an organism in a high-risk patient (eg, neutropenic, posttransplantation, pregnant).
  • Chronic bacterial prostatitis
    • This condition produces recurrent bacteriuria interspersed with prolonged periods without bacteriuria.
    • Treatment involves 2-3 months of a fluoroquinolone that has good prostate penetration. The goal of therapy is to eradicate infection from the prostate.
  • Renal transplant recipients
    • The frequency of UTIs (35-79%) and the potential morbidity of transplant pyelonephritis are relatively high in this population.
    • Transplant recipients typically receive prophylaxis with trimethoprim-sulfamethoxazole for at least the first 6-12 months following transplantation.
    • The antibiotic chosen may be modified depending on local organism sensitivities.

Complications

  • Complications occur more often in patients with diabetes mellitus, chronic renal disease, sickle cell disease, renal transplant (particularly the first 3 mo), AIDS, and other immunocompromised states. Sometimes, determining if the entities listed below are occurring as a complication of pyelonephritis or presenting in the absence of pyelonephritis with signs and symptoms suggestive of pyelonephritis is difficult. The important point is to have a high index of suspicion because they are associated with markedly increased morbidity and mortality.
    • Abscess formation (see Surgical Care): This may include renal cortical abscess, renal corticomedullary abscess, or perinephric abscess.
    • Emphysematous formation (gas in tissues): This may occur (see Surgical Care), and recognizing it is critical. Treatment may include nephrectomy.
    • Emphysematous pyelitis (pneumopyonephrosis): This involves gas that is localized to the collecting system. Diabetes mellitus is present in 85-100% of patients. The left kidney is more affected than the right. Presentation is similar to 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 (see Medical Care). The mortality rate is 20%.
    • Emphysematous cystitis (cystitis emphysematosa): This 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 (see Medical Care) and relief of any outlet obstruction. This condition is not as serious as the other 2 previously described emphysematous conditions.
    • Acute renal failure (see Acute Renal Failure)
    • Chronic renal damage leading to hypertension and renal failure
    • Sepsis syndromes (see Sepsis, Bacterial)
    • Renal papillary necrosis (see Surgical Care)
    • Xanthogranulomatous pyelonephritis (see Surgical Care)

Prognosis

  • In healthy, nonpregnant women with uncomplicated disease, the prognosis is excellent for full recovery and minimal damage to the kidney.
  • In healthy men without any known complicating conditions, the prognosis is good for full recovery; however, urologic evaluation is recommended to rule out an underlying complicating condition.
  • In children, the prognosis is good. Importantly, children should undergo a urological evaluation after the first episode to rule out structural abnormalities.
  • If the patient has a known complicating condition, urological evaluation is indicated to determine the status of the complicating condition and the status of the kidney (see Causes).

Patient Education

  • Patients must take antibiotics as directed and complete the course as prescribed. This minimizes the risk of recurrence and the development of resistant organisms.
  • Avoidance of dehydration is important for both patient well-being and kidney function. When under stress, men drink only enough liquid to replace two thirds of the loss. When ill, individuals drink less and predispose themselves to dehydration. Unavoidable daily water loss is 1.5 L, of which approximately 500 mL is replaced by the oxidation of carbohydrates. Because patients cannot measure urine specific gravity at home, they should drink enough water or other liquid to produce light-colored urine, almost like water.
  • For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Urinary Tract Infections and Blood in the Urine.

Miscellaneous

Medicolegal Pitfalls

  • Any poor outcome in a patient's illness could potentially raise a question of liability on the part of the physician managing that patient's case. Alternatively, in many instances good medical management decisions are made in a timely fashion but the outcome is still poor. Always keep in mind that the natural history of the disease may subvert even the best medical and surgical management possible.
  • The following are clinical issues in the management of pyelonephritis that are important considerations with the potential for liability, particularly if complications arise or the outcome is poor:
    • For patients with pyelonephritis who have an organ-threatening infection, the follow-up examination is important to be sure that the patient is progressing satisfactorily and that recovery is complete.
    • Patients with diabetes are at increased risk for complications related to pyelonephritis. Failure to diagnose these complications in a timely fashion could predispose the patient to a poor outcome.
    • Pregnant patients with pyelonephritis are at significant risk for premature labor. Timely diagnosis and management has a significant impact on the outcome.
    • Infants and children who have had pyelonephritis should be evaluated for urinary tract abnormalities.
    • Any patient with acute pyelonephritis who deteriorates suddenly or does not respond to conventional therapy may have a complication, resistant organism, or unrecognized comorbidity.

Special Concerns

  • Pregnancy issues
    • Physiological changes in the urinary tract predispose pregnant women to an increased risk of UTI and pyelonephritis, which may lead to preterm labor and kidney damage.
    • Hydroureter of pregnancy develops around the seventh week and progresses throughout the remainder of pregnancy; it resolves by 8 weeks postpartum. The ureters may dilate sufficiently to contain 200 mL of urine or more. In addition, the kidneys enlarge and bladder capacity may double. The left kidney is more affected than the right. The prevalence rate of bacteriuria in pregnancy is 2-25%, depending on the study criteria.
    • Symptomatic UTI (1-3% of all pregnancies) leads to premature labor in 20-50% of cases. The recommendation is that all pregnant women have a screening urine culture at 16 weeks' gestation. If the results are negative for a UTI, no additional cultures are indicated. If the patient has a history of recurrent UTIs, further cultures and other screening techniques (eg, nitrite dipstick or urine Gram stain) may be needed to detect the development of asymptomatic bacteriuria.
    • Accepted regimens for treating asymptomatic bacteriuria include amoxicillin (250 mg tid for 3 d or 7 d; 3-g single dose), cephalexin (2- or 3-g single dose), and nitrofurantoin (200-mg single dose; 100 mg qid for 3 d or 7 d). Successfully treated bacteriuria prevents pyelonephritis.
    • Presentation of pyelonephritis is similar in pregnant and nonpregnant females. The antibiotic regimen of choice is intravenous ampicillin and gentamicin. This is followed by an oral regimen to complete a 14-day course guided by results from susceptibility studies. Obtain an additional urine culture 1-2 weeks after the completion of therapy to verify eradication of the infection, and obtain monthly urine cultures until delivery to monitor the urine for recurrent infection.
    • Postcoital therapy with cephalexin or nitrofurantoin is recommended for prophylaxis against recurrent infection.
    • If the initial infection requires a second agent for clearing the infection or a recurrent infection occurs, suppressive therapy until delivery is indicated with nitrofurantoin (50 mg or 100 mg qhs).
    • Recurrent infection or persistent bacteriuria is an indication for urological evaluation 3-6 months after delivery.
  • Geriatric issues
    • After age 65 years, at least 20% of women and 10% of men have bacteriuria. Several factors appear to account for this level of bacterial presence in the urinary tracts of elderly persons, as follows:
      • Obstructive uropathy (eg, urinary stones, prostatic hypertrophy, uterine prolapse, cystocele)
      • Decreased bactericidal activity in prostatic secretions
      • Perineal soiling with fecal matter in women with dementia
      • Neuromuscular disease
      • Increased instrumentation of urinary tract
      • Urinary catheters
      • Reduced Tamm-Horsfall protein secretion in the urine
      • Increased uropathogens in the postmenopausal vagina and introitus
    • The single most important factor predisposing the urinary tract to infection is obstruction in any form.
    • Elderly patients may present with pyelonephritis manifesting as abnormal urine coupled with fever, mental status change, decompensation in another organ system, or generalized deterioration. Alternatively, the presentation may include previously described signs and symptoms (see Clinical). If sepsis is suggested, refer to Sepsis, Bacterial. If an underlying condition is decompensating as a result of pyelonephritis, refer to the appropriate eMedicine article for management of the condition. Management principles remain the same as outlined above. The important issue is to consider the diagnosis in any elderly patient who presents with an acute medical condition.
  • Pediatric issues
    • The manifestation of symptomatic UTI and pyelonephritis varies in the pediatric population depending on the age of the patient. The classic signs and symptoms observed in adults are often absent in children, particularly neonates and infants. When fever is present, pyelonephritis should be in the differential diagnosis.
    • Indications for immediate urological referral during acute pyelonephritis are abnormal electrolyte values associated with acidosis, elevated blood urea nitrogen level, hypertension, a palpable bladder, and voiding difficulty (dribbling, poor stream, straining).
    • Aside from the effects of acute infection, the overriding concern is progressive renal deterioration of an already compromised kidney (hypoplastic or dysplastic) secondary to scarring from recurrent pyelonephritis with or without associated obstruction.
    • The groups at greatest risk are infants and preschool-aged children. Initial management varies with patient age and presentation.
    • Close follow-up examination, regardless of whether the patient is initially admitted, is essential to ensure recovery. Immediate reevaluation is encouraged for any recurrence of symptoms because treatment of asymptomatic bacteriuria and long-term suppressive therapy have not been found to be efficacious.
    • Urological evaluation is necessary to establish the presence of any urological abnormality. The preferred imaging study for the diagnosis of acute pyelonephritis is DMSA scintigraphy. Ultrasonography is the imaging study of choice for the diagnosis of urinary tract structural abnormalities.
    • Age-related data adapted from Harwood-Nuss and colleagues and Hansson and colleagues are presented in Table 5.6,7
Table 5. Pediatric Urinary Tract Infections

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Table
NeonatesInfants Aged 6 Weeks to 3 YearsChildren Aged 3-6 YearsChildren Aged 6-11 Years
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 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.
NeonatesInfants Aged 6 Weeks to 3 YearsChildren Aged 3-6 YearsChildren Aged 6-11 Years
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 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.
 


More on Pyelonephritis, Acute

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Differential Diagnoses & Workup: Pyelonephritis, Acute
Treatment & Medication: Pyelonephritis, Acute
Follow-up: Pyelonephritis, Acute
References
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Further Reading

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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

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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.

 
 
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