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PyelonephritisPyelonephritis

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Definition

• It is Bacterial infection of the renal pelvis, tubules and interstitial tissue of one or both kidneys

Pathophysiology and aetiology

• Infection usually ascends from the urethra most bacterial causes eg Ecoli

• Haematogenous spread is rare eg Staph aureus

• Frequently due to ureterovesical reflux

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Other causes are : -

urinary tract obstruction by

• bladder tumours

• urethral strictures

• benign prostatic hyperplasia

• urinary stones

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Pyelonephritis may be acute or chronicPathology

• Kidneys enlarge• Interstitial infiltration of inflammatory cells• Abscesses on the capsule and at

corticomedullary junction• Result in destruction of tubules and the

glomeruli• When chronic, kidneys become scarred,

contracted and nonfunctioning

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Clinical Manifestations of acute pyelonephritis

• Acutely ill• Chills • Fever• Flank pain and• Renal angle tenderness• Leukocytosis• Pyuria• BacteriuriaIn addition symptoms of lower tract

involvement • Dysuria• Frequency

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Investigations

• CT scan

• IVP=intra venous pyelogram

• Radionucleotide imaging with gallium citrate and indium-111-labeled WBCs

• Urine culture and sensitivity

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Micturiting cystourethrogram (MCW showing bilateral VUR, grade IV on right and grade III on left-side. There is bilateral ureteral and pelvic dilation with blunting of fornices in the right kidney.

See the next picture also

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Bilateral reflux Bilateral reflux extending into the extending into the

pelvicalyceal pelvicalyceal systems of the systems of the kidney without kidney without dilatation of the dilatation of the

calyces or ureters. calyces or ureters. (Note catheter in (Note catheter in

bladder)bladder)

To go to any slide type the number and press enter during slide show only

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Medical Management

• Treated as outpatients if there is no nausea, vomiting or dehydration and other signs and symptoms of sepsis

• Very ill patients and all pregnant women are hospitalized at least for 2 to 3 days for parenteral therapy

• 2 weeks course• Bactrim• Ciprofloxacin• Gentamicin with or without amoxicillin

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Problem Problem

• Chronic or recurring symptomless infection persisting for months or years

• Another 6 weeks course if relapse

• Follow up urine culture 2 weeks after completion of therapy

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Chronic PyelonephritisChronic PyelonephritisRepeated bouts of acute pyelonephritis may lead

to chronic pyelonephritisClinical manifestations• No symptoms of infection unless an acute

exacerbation occurs• Fatigue• Head ache• Poor appetite• Polyuria• Excessive thirst• Weight lossProgressive scarring renal failure

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Assessment and diagnostic findings • IVP• Serum creatinine • Blood urea• Culture and sensitivity

Complications

ESRD=end stage renal disease

Hypertension

Kidney stonesMedical management• According to C&S result• Drugs carefully titrated if renal function is impaired

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Nursing management

• Fluid balance – I / O chart• Fluids encouraged unless contraindicated• 4th hourly temp• Antibiotics• Bed rest• Teach how to prevent recurrent infections :

adequate fluids, emptying the bladder regularly and performing recommended perineal hygiene taking antibiotics as prescribed

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Scarred and contorted kidneysScarred and contorted kidneys

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Destruction of approximately 70% of the kidney. Numerous dilated Destruction of approximately 70% of the kidney. Numerous dilated calyces with yellow-brown calculi. The central necrotic areas are calyces with yellow-brown calculi. The central necrotic areas are surrounded by dense fibrosis.surrounded by dense fibrosis.

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Organism causing pyelonephritisOrganism causing pyelonephritis

1. Ascending pathway or vesicoureteric refluxa. Mainly – E. coli- Klebsiella aerogenes (causes renal stone)- Enterobacter- Pseudomonas- Enterococcus faecalis- Staphylococcus saprophyticusb. Haematogenous pathogensa. Staphylococcus aureus from infection elsewhere.b. Mycobacterium tuberculosisc. Salmonella typhid. Brucella melitensise. Candida albicans

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Laboratory diagnosis of Laboratory diagnosis of PyelonephritisPyelonephritis

A. Urine examination a. Microscopy Pyuria : Presence of pus cell 10 pus cells/cmm unspun urine b. Gram stain one drop of urine 1 organism indicate 10⁵ significant bacteriuria c. Urine biochemical test 1. nitrate reduction to Nitrate by enterobacteriaceae e.g. E. coli 2. Leukocyte esterase indicate presence of pus cells.

B. Blood Culture : As acute Pyelonephritis is most accompanied by fever and Bacterimia.

C. Radiological Studies: These indicate Kidneys and urinary tract abnormalities in chronic

Pyelonephritis

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Treatment of Pyelonephritis by Treatment of Pyelonephritis by Antimicrobial agentsAntimicrobial agents

Most of the antibiotics used for cytitis can be used in treatment of Pyelonephritis as far as they are distributed in Blood stream examples are:a.ampicillin /amoxicillin/ clavulanic acidb.Cephosporinsc.Ciprosfloxacind.Gentamicin

Other Anti-microbial which cannot be used in treatment of Pyelonephritis include:a.Nitrofurantoinb.Nalidixic acid