Pyelonephritis: Clinical sciences

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A 36-year-old woman presents to the primary care clinic due to burning with urination for five days. This morning, the patient developed chills and pain in the right flank. The patient has not experienced nausea or vomiting, and review of systems is otherwise unremarkable. The patient has had three urinary tract infections in the last four years. The patient has no other significant medical history and takes no medications. Temperature is 38.2 ºC (100.8 ºF), pulse is 84/min, and blood pressure is 128/79 mmHg. On physical examination, the right costovertebral angle is tender to palpation. Pregnancy test is negative. Urine microscopy shows white blood cell casts and many bacteria. Serum white blood cell count is 14,000/mm3.  Serum basic metabolic panel shows no abnormalities. Which of the following is the most appropriate next step in management?  

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Acute pyelonephritis is an upper urinary tract infection that typically occurs when bacteria, most commonly E. Coli, make their way from the lower urinary tract, such as the urethra and bladder, up the ureters and kidneys. Now, based on the patient’s clinical features, acute pyelonephritis can be classified as complicated or uncomplicated. Complicated pyelonephritis occurs when the patient has functional or structural abnormalities, like neurogenic bladder, or like urinary obstruction due to nephrolithiasis. Complicated pyelonephritis also occurs when the patient has specific host risk factors, such as immunosuppression, advanced age, or male sex. On the other hand, a patient has uncomplicated pyelonephritis when there are no urinary tract abnormalities and no host specific risk factors.

Now, if you suspect acute pyelonephritis, you should first perform an ABCDE assessment to determine if they are stable or unstable. Unstable individuals might present with signs of sepsis or shock, like tachycardia and hypotension, so don’t forget to stabilize their airway, breathing, and circulation. Additionally, obtain IV access, administer supplemental oxygen, and put your patient on continuous vital sign monitoring.

Ok, let’s return to the ABCDE assessment. If the patient is stable or once you stabilize them, obtain a focused history and physical examination. Your patient will likely report fever, chills, malaise, flank pain, nausea and vomiting, and sometimes dysuria. On the other hand, physical exam may reveal elevated body temperature, hypotension, tachycardia, costovertebral angle and flank tenderness, and abdominal tenderness to palpation.

At this point you should suspect pyelonephritis, so your next step is to order labs, including CBC and CMP, as well as urinalysis and urine cultures.

Fuentes

  1. "Acute Pyelonephritis in Adults" New England Journal of Medicine (2018)
  2. "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" Clinical Infectious Diseases (2011)
  3. "Diagnosis and management of acute pyelonephritis in adults" Am Fam Physician. (2005 Dec 1)
  4. "EAU Guidelines on Urological Infections. " EAU Guidelines.
  5. "Edn. presented at the EAU Annual Congress Amsterdam, the Netherlands 2022. (pp. 19-24) " uroweb (March 2022.)
  6. "Acute Pyelonephritis in Adults" New England Journal of Medicine (2018)
  7. " I have a patient with dysuria. How do I determine the cause? Symptom to Diagnosis an Evidence Based Guide (4th ed., pp. 299 – 307)." Lange: McGraw Hill Education. (2020)
  8. "For regional Escherichia coli susceptibility data," CDC
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