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Subject: Pyelonephritis
Date: Sat, 20 Sep 2003 12:02:52 +0300
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<H2>7.02 Upper Urinary Tract Infection (Pyelonephritis) </H2>
<HR>

<H4>Presentation</H4>The patient has some combination of urinary =
frequency,=20
urgency, dysuria, flank pain, nausea, fever, and chills. On physical=20
examination, there is tenderness elicited by percussing the =
costovertebral angle=20
over the kidneys. The urinalysis may help establish the diagnosis with =
tubular=20
casts of white cells.=20
<H4>What to do:</H4>
<UL>
  <LI>Examine urine for presence of gram-positive cocci (presumptively=20
  enterococci) or the more usual gram- negative rods, and send for =
culture and=20
  sensitivity.=20
  <LI>If the patient appears toxic, with a high fever or white count, =
nausea or=20
  vomiting to prevent adequate oral medicatication and hydration, or if =
the=20
  patient is pregnant or there is any sign of urinary obstruction or =
developing=20
  sepsis, he or she should be admitted to the hospital for intravenous=20
  antibiotics.=20
  <LI>For stable, otherwise healthy patients, start with a first dose of =

  intravenous antibiotics in the ED (ampicillin 1000mg plus gentamicin =
80mg,=20
  ceftriaxone 1000-2000mg, ofloxacin 200-400mg or ciprofloxacin =
200-400mg), then=20
  discharge home on oral hydration and two weeks of oral antibiotics=20
  (trimethoprim 160mg plus sulfamethoxazole 800mg bid, ciprofloxacin =
500mg bid,=20
  norfloxacin 400mg bid or ofloxacin 400mg bid x 14d).=20
  <LI>Instruct the patient to return to the ED for re-evaluation in =
24-48 hours,=20
  and sooner if symptoms worsen. Most patients improve on this regimen, =
but the=20
  others will require hospital admission if they are not improving in =
two days.=20
  </LI></UL>
<H4>What not to do:</H4>
<UL>
  <LI>Do not lose the patient to followup. Although lower UTIs often =
resolve=20
  without treatment, upper UTIs inadequately treated can lead to renal =
damage or=20
  sepsis.=20
  <LI>Do not miss an infection above a ureteral stone or obstruction. =
Crampy,=20
  colicky pain or hematuria with the symptoms above calls for an =
excretory=20
  urogram (IVP). Antibiotics and hydration alone may not cure an =
infected=20
  obstruction. </LI></UL>
<H4>Discussion</H4>Although oral antibiotics are usually sufficient =
treatment=20
for upper UTIs, there is a significant incidence of renal damage and =
sepsis as=20
sequelae, mandating good followup or admission when necessary. By the =
same=20
token, lower UTIs can ascend into upper UTIs, or it can be difficult to =
decide=20
the level of a given UTI, in which case it should be treated as an upper =
UTI.
<P>Studies have shown tat a 14 day course of oral therapy is highly =
effective=20
for the woman with clinical evidence of pyelonephritis without sepsis, =
nausea or=20
vomiting. Quinolones such as ofloxacin (Floxin), ciprofloxacin (Cipro) =
and=20
norfloxacin (Noroxin) are highly effective and probably the drugs of =
choice in=20
this setting, except for pregnant women, for whom they are =
contraindicated.=20
Trimethoprim-sulfamethoxazole (Bactrim, Septra) could also be used, =
although=20
resistance of 5% to 15% of pathogens may be a more important factor in =
the=20
selection of therapy for pyelonephritis than for cyctitis.=20
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 from Buttaravoli &amp; Stair: COMMON SIMPLE EMERGENCIES =A9 =
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          <TD><FONT face=3Dverdana,arial,helvetica color=3D#000000 =
size=3D1><B>Craig=20
            Feied, MD<BR>Mark Smith, MD<BR>Jon Handler, MD<BR>Michael =
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------=_NextPart_000_0005_01C37F6F.1E72C000--
