Acute Pyelonephritis: Treatment

Acute pyelonephritis (1/3): definition, causes and pathology
Acute pyelonephritis (2/3): symptoms and diagnostic work-up
Acute pyelonephritis (3/3): treatment

Review literature: (Fihn, 2003) (Nickel, 2001) (Roberts, 1999) (DGU S3-Guideline urinary tract infections).

Treatment of Acute Pyelonephritis

Symptomatic Treatment of pyelonephritis:

Bed rest
Analgesics with antipyretic effect, e.g. metamizol, for children paracetamol
Increased fluid intake

Antibiotics for Pyelonephritis:

Appropriate antibiotics are fluoroquinolones, aminopenicillin in combination with beta-lactamase inhibitor and cephalosporins. In children, cephalosporins are preferred. Because of high resistance rates up to 40%, ampicillin or cotrimoxazole alone are inadequate.

Antibiotic Treatment in Adults:

Duration of treatment: 7–14 days depending on severity and improvement
Ciprofloxacin 500 mg p.o. 1-0-1 or 400 mg 1-0-1 i.v. Since the oral bioavailability is high, intravenous administration is necessary only in case of vomiting.
Amoxicillin and clavulanic acid 2.2 g 1-1-1 i.v.
Third or fourth generation cephalosporin, e.g. ceftriaxone 1–2 g every 24 h or cefotaxime 1–2 g every 12 h i.v.
In severe disease, an antibiotic combination may be appropriate: e.g. cephalosporin or amoxicillin/clavulanic acid combined with gentamicin 3 mg/kg 1-0-0 i.v.
Antibiotic treatment may have to be switched depending on the results of the urine culture

Antibiotic Treatment in Children:

Treatment is started intravenously, after defervescence treatment is possible with an oral cephalosporin. Mild uncomplicated pyelonephritis may be treated with oral cephalosporins alone.

Ceftriaxon 50 mg/kg i.v. once a day
Cefepime 50 mg/kg every 8–12 h i.v.
Dosage of oral cephalosporins: e.g. ceftibuten 9 mg/kg 1–0–0 or cefixim 4–8 mg/kg 1–0–1.

Treatment of Fungal Pyelonephritis:

Antifungal treatment is possible with fluconazole 5–10 mg/kg p.o. 1-0-0 or amphotericin B 0.6 mg/kg i.v. 1-0-0. Important is the exclusion of fungal balls with intravenous urography, CT or retrograde pyelography. Fungal pyelonephritis with upper tract obstruction should be treated with percutaneous nephrostomy, which enables antegrade nephrostomy irrigation with amphotericin or fluconazole. Nephrectomy is necessary in a non-functioning kidney with fungal infection.

Management of Infected Hydronephrosis:

Infected hydronephrosis is a potentially life-threatening emergency and requires immediate drainage of the urinary tract. Possible techniques are the insertion of a ureteral stent (MJ or DJ catheter) or percutaneous nephrostomy.

Lack of Clinical Improvement

If the patient does not improve within 48–72 hours, an abdominal CT should be done to search for a renal abscess, hydronephrosis or other possible diseases (see differential diagnosis). Repeat urine culture and check for the results of antibiotic testing.

Relapsing pyelonephritis after antibiotic treatment (10%) makes another antibiotic treatment for 14 days necessary. In some cases, long term antibiotic treatment is sound.

Nephrectomy

Nephrectomy should be kept in mind, if urosepsis cannot be stabilized with the help of intensive medical care. Nephrectomy is necessary without delay especially in poor organ function or emphysematous pyelonephritis. Lumbar nephrectomy may be technically demanding due to adhesions to neighbouring organs. Transperitoneal nephrectomy with removal of Gerota's fascia or subcapsular nephrectomy are technical alternatives.

Pyelonephritis symptoms

Index

Chronic pyelonephritis

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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References

DGU S-3 Guideline Urinary tract infections: Epidemiologie, Diagnostik, Therapie und Management unkomplizierter bakterieller ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten
AWMF, 2010, Register-Nr. 043/044
Dalla-Palma und Pozzi-Mucelli 2000 DALLA-PALMA, L. ; POZZI-MUCELLI, F.:: [The imaging of chronic renal infections].
In: Radiologe
40 (2000), Nr. 6, S. 537–46
Fihn 2003 FIHN, S. D.:: Clinical practice. Acute uncomplicated urinary tract infection in women.
In: N Engl J Med
349 (2003), Nr. 3, S. 259–66
Kawashima u.a. 2000 KAWASHIMA, A. ; SANDLER, C. M. ; GOLDMAN, S. M.:: Imaging in acute renal infection.
In: BJU Int
86 Suppl 1 (2000), S. 70–9
Nickel 2001 NICKEL, J. C.:: The management of acute pyelonephritis in adults.
In: Can J Urol
8 Suppl 1 (2001), S. 29–38
Roberts 1999 ROBERTS, J. A.:: Management of pyelonephritis and upper urinary tract infections.
In: Urol Clin North Am
26 (1999), Nr. 4, S. 753–63

Deutsche Version: Therapie der Pyelonephritis

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