Acute Pyelonephritis/Urosepsis

Background

  • The kidneys may become infected in a minority of patients with UTIs
  • As with UTI, pyelonephritis is more common in young women and the most common causative organisms are
    • E coli, Klebsiella pneumoniae, Proteus spp, Pseudomonas spp, Enterococcus spp

Risk factors

  • Structural renal abnormalities
  • Calculi
  • Urinary catheterisation
  • Stents or other urological procedures
  • Pregnancy
  • Diabetes
  • Primary Biliary Cirrhosis
  • Immunocompromise
  • Neuropathic bladder

Presentation

  • Classic triad of loin pain, fever and tenderness over the costophrenic angle (kidneys)
    • Onset is often acute
    • Suprapubic pain is also often present.  Other features of lower UTI may be present e.g. frequency, dysuria etc
    • Fever can often be high enough to cause rigors
    • Other systemic features may also be present e.g. nausea/vomiting, anorexia, malaise and occasionally diarrhoea

Investigations

  • Urinalysis for leucocytes and nitrites to confirm a UTI.  Urine microscopy and culture/sensitivities should also be sent
  • Blood tests
    • FBC (raised WCC); raised CRP and PV
    • Blood cultures
  • Imaging may be performed but isn’t necessary for management/diagnosis (may help in cases of uncertainty or if there is a chance of anatomical abnormality)

Management

  • Hospital
    • IV Amoxicillin and Gentamicin (Aztreonam can be an alternative to gentamicin)
      • IV Co-trimoxazole if penicillin allergic
      • Step down to oral co-trimoxazole
      • Total 14 days if pyelonephritis (28 days for urosepsis)
  • Community
    • Consider admission
    • Co-amoxiclav 625mg TDS or cotrimoxazole 960mg BD for 14 days

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