Pyelonephritis

Question 1

A 46 year old woman presents with a 24 hour history of colicky high loin to groin pain. She has a temperature of 38.4. Her urinalysis reveals evidence of white cells and nitrates. How would you manage her?

Answer 1

Impression
Likely pyelonephritis given clinical picture of loin-to-groin pain and fever.

If complicated nephrolithiasis this is a urological emergency, requires surgical removal for definitive management.

Ddx
- other infective: cystitis, ureteritis, nephrolithiasis
- Gynaecological: ovarian torsion, ovarian cyst, ectopic
- GIT: appendicitis, colitis, volvulus, diverticulitis, etc

Goals
- Targeted Hx/Ex/Ix to rule out Ddx
- Confirm with Urine cultures, begin empirical therapy based on clinical severity

Question 2

Pyelonephritis - Assessment

Answer 2

Assessment
A -
B -
C - IVC access. Initial bloods: VBG, FBC, CRP/ESR, cultures. Rest of septic work-up. Fluid resus, start empirical IV ABx.
D

Question 3

Pyelonephritis - History

Answer 3

History
- sx: Pain (SOCRATES), associated: irritative LUTS, precceding illness
- Systemic: fevers, chills, rigors,
- O&G hx, STIs,
- RISKS for pyelo: recurrent UTI, anatomical , immunosuppression, pregnancy, AKI
- PMHx, Meds, allergies
- SNAP

Question 4

Pyelonephritis - Examination

Answer 4

Examination
- General obs + vitals
- Abdo exam: renal angle/loin to groin pain

Question 5

Pyelonephritis - Investigations

Answer 5

Investigations
Key/diagnostic
- Urine MCS, UA, rest of septic screen
- Renal tract U/S (usually not warranted to uncomplicated pyelonephritis)

• Bedside: UA + MCS
• Bloods: As per A to E.
• Imaging: Renal tract U/S/ KUB X-Ray

Question 6

Pyelonephritis - Management

Answer 6

Management

Disposition
- Inpatient vs outpatient based on clinical status and size of stone (if present)

Nephrolithiasis drainage
Blockage should be immediately decompressed
- Ureteroscopy +/- stenting (delayed)
- Percutaneous nephrostomy tube (IR placement)
-

Definitive
low-mod pyelonephritis
- Augmentin PO 14 days

Severe
- IV Gent + amp/amox
- then switch to directed therapy
- require hospital admission for treatment

Supportive
- analgesia, antipyretics
- fluids
- electrolytes
- optimise risk factors