eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Emphysematous Pyelonephritis: Treatment

Author: Sugandh Shetty, MD, Consulting Staff, Department of Urology, William Beaumont Hospital
Contributor Information and Disclosures

Updated: May 1, 2008

Treatment

Medical Therapy

Prompt hydration, fluid resuscitation, and treatment with systemic antibiotics are the mainstays of management. A monitored-care facility may be needed for patients in shock. Control of diabetes and maintenance of adequate fluid balance should be achieved quickly. Initial antibiotic therapy consists of intravenous ampicillin, gentamicin, and metronidazole and is administered until the culture sensitivities are available. In patients with penicillin allergies, vancomycin is used in place of ampicillin. In patients with renal compromise, doses must be adjusted according to creatinine clearance.

Start imaging studies immediately. Any obstruction found should be relieved with either percutaneous drainage or stent placement. The decision regarding the percutaneous drainage versus a double-J stent probably depends on the patient's condition (see Surgical Therapy). Placement of a stent requires mild sedation or general anesthesia, whereas a percutaneous procedure can be performed with only a local anesthetic. In cases of bilateral emphysematous pyelonephritis (EPN) or in cases of EPN in a solitary kidney, percutaneous drainage has been useful. EPN with gas in the collecting system alone or gas and fluid in the perinephric space may respond well to percutaneous drainage.

Patients with EPN are extremely ill and need resuscitative measures in the intensive care unit. Surgical intervention should be performed only after stabilization of the cardiorespiratory status.

Patients with stones and EPN deserve special mention. The presence of a stone often leads to obstruction, which must be urgently relieved with percutaneous drainage or stenting. Definitive treatment for stones should be deferred until later.

Huang et al reported an overall EPN mortality rate of 19%.1 They reported significant success with percutaneous drainage and antibiotics (66%).

Wan et al reported a mortality rate of 40%.3 Furthermore, Wan et al reported a high risk of death in patients with serum creatinine levels greater than 1.4 mg/dL and platelet count of less than 60,000/μL. Huang et al analyzed 46 cases and concluded that class 1 and class 2 EPN could be managed with percutaneous drainage and antibiotics.1 In class 3 and class 4 EPN, the presence of fewer than 2 risk factors (eg, thrombocytopenia, elevated serum creatinine levels, altered sensorium, shock) indicated that percutaneous drainage and antibiotics could also be used. However, in the presence of more than 2 risk factors, nephrectomy yielded better results.

Surgical Therapy

Nephrectomy is the treatment of choice in most patients with EPN. 

A retroperitoneal flank incision is the preferred approach to avoid peritoneal contamination. Nephrectomy may be associated with significant bleeding and injury to surrounding structures. The initial procedure should often be conservative with care to drain the abscess. Patients may require intensive-care management. In a series in which nephrectomy was the exclusive treatment after stabilization, the mortality rate was low, suggesting that an aggressive surgical option should be chosen. However, less-invasive options, such as percutaneous drainage, have also been used with success.16

Surgical intervention should be performed only after stabilization of the cardiorespiratory status.

Gas in the renal parenchyma or dry-type EPN should be treated immediately with nephrectomy. Bilateral nephrectomy may be necessary in patients with bilateral EPN. Mortality rates were 15-20% in 2 series in which nephrectomy was the treatment of choice.5,4

Huang et al analyzed 46 cases and concluded that class 1 and class 2 EPN could be managed with percutaneous drainage and antibiotics.1 In class 3 and class 4 EPN, the presence of fewer than 2 risk factors (eg, thrombocytopenia, elevated serum creatinine levels, altered sensorium, shock) indicated that percutaneous drainage and antibiotics could also be used. However, in the presence of more than 2 risk factors, nephrectomy yielded better results.

In a recent review, Aswathaman et al (2008) reported on 41 patients with EPN; 80% of those patients were successfully treated with antibiotics and percutaneous drainage without requiring nephrectomy.17

Follow-up

For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Urinary Tract Infections.

Complications

Untreated cases of emphysematous pyelonephritis (EPN) result in death. Medical treatment of EPN may lead to uncontrollable sepsis that requires surgical intervention. Perinephric abscess and renal failure are other complications. Nephrectomy complications include injury to the colon, duodenum, and great vessels. Postoperative wound infection is common because wound healing in these patients is compromised.

More on Emphysematous Pyelonephritis

Overview: Emphysematous Pyelonephritis
Workup: Emphysematous Pyelonephritis
Treatment: Emphysematous Pyelonephritis
Follow-up: Emphysematous Pyelonephritis
Multimedia: Emphysematous Pyelonephritis
References
Further Reading
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References

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

  2. Tang HJ, Li CM, Yen MY, Chen YS, Wann SR, Lin HH, et al. Clinical characteristics of emphysematous pyelonephritis. J Microbiol Immunol Infect. Jun 2001;34(2):125-30. [Medline].

  3. Wan YL, Lo SK, Bullard MJ, Chang PL, Lee TY. Predictors of outcome in emphysematous pyelonephritis. J Urol. Feb 1998;159(2):369-73. [Medline].

  4. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology. Mar 1997;49(3):343-6. [Medline].

  5. Pontin AR, Barnes RD, Joffe J, Kahn D. Emphysematous pyelonephritis in diabetic patients. Br J Urol. Jan 1995;75(1):71-4. [Medline].

  6. Kelly HA, MacCullum WG. Pneumaturia. JAMA. 1898;31:375-81.

  7. Cheng YT, Wang HP, Hsieh HH. Emphysematous pyelonephritis in a renal allograft: successful treatment with percutaneous drainage and nephrostomy. Clin Transplant. Oct 2001;15(5):364-7. [Medline].

  8. Schainuck LI, Fouty R, Cutler RE. Emphysematous pyelonephritis. A new case and review of previous observations. Am J Med. Jan 1968;44(1):134-9. [Medline].

  9. Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection. J Urol. Jul 1991;146(1):148-51. [Medline].

  10. Yang WH, Shen NC. Gas-forming infection of the urinary tract: an investigation of fermentation as a mechanism. J Urol. May 1990;143(5):960-4. [Medline].

  11. Wang YC, Wang JM, Chow YC, Chiu AW, Yang S. Pneumomediastinum and subcutaneous emphysema as the manifestation of emphysematous pyelonephritis. Int J Urol. Oct 2004;11(10):909-11. [Medline].

  12. Gaither K, Ardite A, Mason TC. Pregnancy complicated by emphysematous pyonephrosis. J Natl Med Assoc. Oct 2005;97(10):1411-3. [Medline].

  13. Langston CS, Pfister RC. Renal emphysema. A case report and review of the literature. Am J Roentgenol Radium Ther Nucl Med. Dec 1970;110(4):778-86. [Medline].

  14. Michaeli J, Mogle P, Perlberg S, Heiman S, Caine M. Emphysematous pyelonephritis. J Urol. Feb 1984;131(2):203-8. [Medline].

  15. Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology. Feb 1996;198(2):433-8. [Medline].

  16. Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. J Urol. May 1997;157(5):1569-73. [Medline].

  17. Aswathaman K, Gopalakrishnan G, Gnanaraj L, Chacko NK, Kekre NS, Devasia A. Emphysematous Pyelonephritis: Outcome of Conservative Management. Urology. Mar 25 2008;[Medline].

  18. Ahlering TE, Boyd SD, Hamilton CL, Bragin SD, Chandrasoma PT, Lieskovsky G, et al. Emphysematous pyelonephritis: a 5-year experience with 13 patients. J Urol. Dec 1985;134(6):1086-8. [Medline].

  19. Ahmad M. Emphysematous pyelonephritis due to Aspergillus fumigatus: a case report. J Nephrol. May-Jun 2004;17(3):446-8. [Medline].

  20. George J, Chakravarthy S, John GT, Jacob CK. Bilateral emphysematous pyelonephritis responding to nonsurgical management. Am J Nephrol. 1995;15(2):172-4. [Medline].

  21. Guvel S, Kilinc F, Kayaselcuk F, Tuncer I, Ozkardes H. Emphysematous pyelonephritis and renal amoebiasis in a patient with diabetes mellitus. Int J Urol. Jul 2003;10(7):404-6. [Medline].

  22. Roy C, Pfleger DD, Tuchmann CM, Lang HH, Saussine CC, Jacqmin D. Emphysematous pyelitis: findings in five patients. Radiology. Mar 2001;218(3):647-50. [Medline].

  23. Wheeler LD. Cystitis emphysematosa: case report. J Urol. Jan 1954;71(1):43-8. [Medline].

  24. Wu VC, Fang CC, Li WY, Hsueh PR, Chu TS. Candida tropicalis-associated bilateral renal papillary necrosis and emphysematous pyelonephritis. Clin Nephrol. Dec 2004;62(6):473-5. [Medline].

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Further Reading

For additional information, visit Medscape’s Diabetic Microvascular Complications Resource Center and Stone Disease Resource Center.

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Keywords

emphysematous pyelonephritis, emphysematous pyelitis, gas-forming infection of the urinary tract, EPN, renal parenchyma infection, urinary tract infection, UTI, pneumaturia, renal emphysema, pneumo-nephritis, pneumonephritis, diabetes, xanthogranulomatous pyelonephritis

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Contributor Information and Disclosures

Author

Sugandh Shetty, MD, Consulting Staff, Department of Urology, William Beaumont Hospital
Sugandh Shetty, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ajay K Singh, MB, MRCP, MBA, Associate Professor of Medicine, Harvard Medical School; Clinical Chief, Renal Division, Director of Dialysis, Brigham and Women's Hospital; Consulting Staff, Faulkner Hospital
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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