Acute Pyelonephritis
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Upper urinary tract infection involving one or both kidneys (but not usually involving the glomeruli)
Cause
- Bacterial infection, g. Escherichia coli, usually due to ascending infection (faecal-perineal-urethral progression of bacteria)
Risk Factors
- Bladder outlet obstruction
- Malformations of urinary tract
- Pregnancy
- HIV, old age, diabetes
Clinical features
- Loin pain, tenderness in one or both kidney areas (renal angle)
- Fever, rigors (generalised body tremors)
- Vomiting
- If associated cystitis: dysuria, urgency, frequency
- Diarrhoea and convulsions (common in children)
- In infants and elderly: may simply present as fever and poor feeding/disorientation without other signs
Differential diagnosis
- Appendicitis
- Infection of the fallopian tubes (salpingitis)
- Infection of the gall bladder (cholecystitis)
Investigations
- Urine: Microscopy for pus cells and organisms, C&S of mid-stream urine
- Specimen should reach the lab within 2 hours of collection or be refrigerated at 4°C for not >24 hours
- Blood: Full count, C&S, urea, electrolytes
- Ultrasound kidneys/prostate
ManagementTreatment
- Ensure adequate intake of fluid (oral or IV) to irrigate bladder and dilute bacterial concentrations
- Give paracetamol 1 g every 6-8 hours for pain and fever
If outpatient (only adults):
- Ciprofloxacin 500 mg every 12 hours for 10-14 days (only adults)
In severe cases, all children or if no response to above in 48 hours:
- Ceftriaxone 1 g IV once a day
- Child: 50-80 mg/kg IV once a day
Following initial response to parenteral therapy
- Consider changing to:
- Ciprofloxacin 750 mg every 12 hours to complete 10 days (adults only)
- Or cefixime 200 mg every 12 hours to complete 10 days of treatment
- Child: 16 mg/kg the first day then 8 mg/kg to complete 10 days
Alternative regimen
- Gentamicin 5-7 mg/kg IV in one or divided doses with or without ampicillin 2 g IV every 6 hours
- Child : gentamicin 2.5 mg/kg every 8 hours (or 7.5 mg/kg once daily on outpatient basis) with or without ampicillin 25 mg/kg every 6 hours
- Consider referral if there is no response in 72 hours and for children with recurrent infections (to exclude urinary tract malformations)
Prevention
- Ensure perianal hygiene
- Ensure regular complete emptying of the bladder and/or double voiding (additional attempt to empty bladder after initial urine flow ceases)