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nephrology > 12 Pyelonephritis. Urinary tract infections > Flashcards

12 Pyelonephritis. Urinary tract infections Flashcards

1
Q

what is pyelonephritis ?

A

inflammation of the parenchyma and lining of the renal pelvis

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2
Q

what are the risk factors for pyelonephritis ?

A

hematogenous route :
septicemia
infective endocarditis
ureteral obstruction

ascending infection :
female - shorter urethera

catheterisation

obstruction of urine flow / incomplete bladder emptying

  • prostatic hypertrophy
  • renal calculi
  • tumor

loss of neurological control of bladder and sphincter - paraplegia and multiple sclerosis

vesicoureteral reflux

diabetes mellitus

not regular sanitisation / frequent sexual intercourse

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3
Q

what are the etiological agents of pyelonephritis ?

A 
usually enteric gram negative rods 
ecoli 
proteus mirabilis
citrobacter 
klebsiella 
eneterobacter
pseudomonad aeruginosa

gram positive
staph saprophytic

staph epidermidis enterococcus

corynebacteria

fungi - candida

protozoa - tichomonas vaginalis

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4
Q

what are the clinical features of pyelonephritis ?

A

acute
acute onset of pain

dysuria

Costovertebral angle tenderness: pain upon percussion of the flank (usually unilateral)

high fever - picket fence of 72hr

nausea

vomiting

cloudy urine , foul smelling

cystitis : increased frequency and urgency to pee
suprapubic pain
hematurea

======
chronic

perisitant flank or abdominal pain

=====
XG

recurrent fevers
painful kidney mass
loss of function of the affected kidney

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5
Q

what is the classification of pyelonephritis ?

A

acute
emphysematous pyelonephritis
complication

chronic = more often in children

  • chronic reflux associated - posterior urethras valve abnormality - and reflux
  • chronic obstructive - calculi or tumors

xanthogranulomatous pyelonephritis

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6
Q

diagnosis of pyelonephritis ?

A

non specific findings of the UTI

pyuria - positive esterase on dipstick test

leukocytouria

bacteria

positive nitrites on dipstick test = such as coli

hematurea

=======

urine ph more than 7 = urea splitting organism

WBC casts

======
urine culture

intravenous pyelogram - enlarged kidneys with poor flow of dye thriught the kidneys

====
blood culture - 2 sets

====
abc
leukocytosis
inflammatory markers

======

us not usually doe in patients with suspected acute uncomplicated pyelonephritis

US - abcess ,
edemtaous renal parenchyma
loss of corticomeduallry differentiation

ct

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7
Q

complication of acute pyelonephritis ?

A

papillary necrosis - DM , UT obstruction

pyonephrosis

perinephric abcess - extension through renal capsule

septics shock

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8
Q

where does acute pyelonephritis usually affect ?

A

exudative purulent localised inflammation of the renal pelvis
can go to the renal
the cortex - spares the glomerulus and vessels

purulent inflammation of the interstitialum and the the renal tubules

can cause tubular necrosis

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9
Q

what is the characteristic feature of chronic pyleoneprhits ?

A

chronic pyelonephritis by obstructive uropathy :
dilated pelvis
thin cortex
dilated calyces
thickened capsule
diffuse asymmetric scaring and fibrosis of the corticomedually junction

vesicouriteral reflex - irregular scarring on poles and thickened capsule there and thin cortex

blunted and dilated calyces - from recurrent urinary reflux
cortex is normal

histology - interstitial fibrosis
tubular atrophy
sclerosis of glomeruli
eosinophilic casts in tubules resembling thyroid tissue thyrioidisation of the kidney

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10
Q

what causes xanthogranulomatous pyelonephritis ?

A

chronic pyelonephritis characterized by chronic destructive granuloma formation, with lipid laden macrophages

Associated with Proteus mirabilis and Escherichia coli infections with chronic urinary obstruction

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11
Q

what are the causes for emphysematous pyelonephritis ?

A

exclusively in poorly controlled diabetic patients
production of gas in renal and perinephritisc tissue

bilateral papillary necrosis
rise in serum creatinin levels

Typically caused by E. coli or K. pneumoniae

Treatment includes IV antibiotics, percutaneous drainage, and, in some cases, nephrectomy.

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12
Q

complication of chronic pyelonephritis ?

A

ESRD
papillary necrosis
focal glomerulosclerosis

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13
Q

treatment of pyelonephritis ?

A

Empiric antibiotic therapy for uncomplicated pyelonephritis
Most patients can be treated with an oral fluoroquinolone (e.g., ciprofloxacin, levofloxacin ) for 5–7 days

Alternatives
Amoxicillin-clavulanate for 10–14 days
or
Cefpodoxime for 10–14 days

Consider a single dose of a broad-spectrum parenteral antibiotic prior to the administration of oral antibiotics, especially when the local rates of drug-resistant E. coli are unknown or known to be > 10%.
Ceftriaxone
OR gentamicin

Supportive care
Encourage the patient to drink adequate amounts of fluids.

Analgesics as needed (see pain management)
Antiemetics as

=============

Patients with complicated acute pyelonephritis should be admitted to the hospital and started on parenteral empiric antibiotic therapy

Not severely ill and no risk factors for multidrug-resistant bacterial infection

A fluoroquinolone
Ciprofloxacin
or 
An extended-spectrum cephalosporin
Ceftriaxone

Consider adding an aminoglycoside until culture results are available.
Gentamicin

============

Severely ill (i.e., septic) and/or with risk factor(s) for multidrug-resistant gram-negative bacterial infection

A carbapenem
Meropenem
or 
An extended-spectrum penicillin with a β-lactamase inhibitor (e.g., piperacillin-tazobactam )
or 
An extended-spectrum cephalosporin 
Ceftriaxone

==========

Enterococcus or MRSA suspected
vancomycin
Daptomycin
Linezolid

If recurrence is caused by the same organism despite adequate treatment, then prolong the course of antibiotics for 6 weeks.

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14
Q

treatment for chronic pyelonephritis ?

A

Long-term antibiotics (e.g., oral trimethoprim-sulfamethoxazole or nitrofurantoin) may be necessary.

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15
Q

what are the main pathogens causing urinary tract infections ?

A

Infection ascends from the urethra to the bladder
Can ascend further to the ureters

Escherichia coli: leading cause of UTI (approx. 80%)

Staphylococcus saprophyticus: 2nd leading cause of UTI in sexually active women

Klebsiella pneumoniae: 3rd leading cause of UTI

Proteus mirabilis

(all of the above Produces ammonia, giving the urine a pungent or irritating smell
Associated with struvite stone formation)

candida - for immune compromised

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16
Q

what are the risk factors for urinary tract infections ?

SAME FOR PYELONEPHRITIS

A

Prevent bladder emptying and/or result in urinary stasis
Examples include:
Benign prostatic hyperplasia
Congenital malformations causing vesicoureteral reflux
Urinary bladder diverticulum
Neurogenic bladder
Urinary tract calculi

female:
urethra is shorter and the anal and genital regions are in close proximity
male - higher for uncirmbscribed

Pregnancy: hormonal changes during pregnancy → urinary stasis and vesicoureteral reflux → increased risk of UTIs

post menopause
Postmenopause: ↓ estrogen → ↓ vaginal lactobacilli → ↑ vaginal pH → ↑ colonization by E. coli

catheterisation

spermicide and diaphragm use
sexual intercourse

diabetes mellitus

17
Q

what i the classification of urinart tract infections ?

A

Upper UTI: upper urinary tract comprises kidneys and the ureters (pyelonephritis)

Lower UTI: lower urinary tract comprises the bladder (cystitis, the most common location of UTI), urethra (urethritis), and prostate in males (prostatitis)

18
Q

UTI and pylenephritis is divided into complicated and uncomplicated through what ?

A

Uncomplicated UTI: UTI in immunocompetent, premenopausal, nonpregnant women without conditions predisposing them to infection or therapy failure

Complicated UTI: UTIs in men, pregnant or postmenopausal women, children, and individuals with factors predisposing them to infection or therapy failure. Such factors include:
functional or anatomical abnormalities (e.g., BPH, obstruction, stricture)

UTI that spreads beyond the bladder (e.g., sepsis, prostatitis)

History of urological pathologies (e.g., neurogenic bladder, kidney cysts, stones)

History of impaired renal function or renal transplantation

Diabetes mellitus or other metabolic disorders

Immunocompromise (e.g., transplant recipients, HIV/AIDS)

Recent history of instrumentation (e.g., cystoscopy

19
Q

what is the definition of recurrent UTI ?

A

≥ 3 infections in one year or ≥ 2 infections in 6 months

20
Q

what are the clinical features of UTI ?

A 
Lower urinary tract infection :
Hematuria 
Increased urinary frequency
Urinary urgency
Suprapubic tenderness
Dysuria

UUTI:
same as pyelonephritis

21
Q

diagnosis of UTI ?

A

Pseudomonas aeruginosa: blue-green pigment

Urinalysis

Urinalysis collection method:
Clean-catch midstream : necessary to avoid contamination with vaginal or skin flora

Diagnostic criteria for UTI:
> Pyuria: ≥ 5–10 WBC/HPF
> Bacteriuria: abnormal number of bacteria present in urine sample

Findings indicative of UTI :
Positive leukocyte esterase: an enzyme produced by WBC that indicates pyuria

Positive nitrites: indicates presence of bacteria that convert nitrates to nitrites, which are most commonly gram-negative bacteria (e.g., E.coli)

Positive urease: indicates presence of urease-producing organisms (e.g., Proteus, Klebsiella, S. saprophyticus), which cause the urine to become more alkaline (pH > 7)

Other findings
Leukocyte casts will likely be absent with lower UTIs.

URINE CULTURE
Significant bacteriuria: defined as ≥ 10^5 CFU/mL; confirms the diagnosis

Typical colony findings
E. coli: intensely pink on MacConkey agar

Klebsiella pneumoniae: viscous colonies

Proteus mirabilis: target or branching appearance on agar

Diagnostic imaging

Indications
> Persistent symptoms (after > 48–72 hours of appropriate antibiotic therapy)

> Recurrent symptoms (within a few weeks of appropriate treatment)

> Suspected urinary tract obstruction

> Severe illness (e.g., septic shock)

CT scan without contrast
First choice
Assessment of urinary stones, obstruction, tumors, cysts, trauma

Ultrasound
potential urinary obstruction
Can help diagnose pyelonephritis

22
Q

treatmnet of UTI ?

A

uncomplicated UTI

increased fluid intake
empiric treatmnet
LOCAL RESIATNCE PATTERN SHOULD GUIDE THE CHOICE OF EMPERIC THERAPY
Phenazopyridine, a urinary analgesic

First-line treatment
Fosfomycin (single dose): should be avoided in suspected pyelonephritis

Nitrofurantoin for 5–7 days: should be avoided in patients with renal insufficiency or in suspected pyelonephritis
Trimethoprim-

sulfamethoxazole (TMP-SMX) for 3 days: should be avoided in areas with high resistance (> 20%)

SECOND LINE Fluoroquinolones (e.g., ciprofloxacin, levofloxacin)
Oral cephalosporins (e.g., cefpodoxime, cefdinir)
Penicillins (e.g., amoxicillin-clavulanate)

23
Q

what is the antibiotic therapy for complicated UTI?

A

Treatment is generally given for 7–14 days in complicated UTIs.
Antibiotics of choice
Fluoroquinolones (e.g., ciprofloxacin, levofloxacin)
TMP-SMX [34]

Considerations for treatment in men
Fosfomycin and nitrofurantoin are not treatment options, as they do not penetrate prostatic tissue and prostatitis is a common issue with UTI since its close to he bladder

24
Q

antibiotic therapy for recurrent infections ?

A

restarted on the same treatment for 2 additional weeks and a urine culture should be obtained.

Chemoprophylaxis :
Postcoital prophylaxis
Nitrofurantoin or a single dose of TMP-SMX
esp in women trying to conceive

Continuous prophylaxis with low-dose TMP-SMX for up to 6 months

25
Q

prevent UTI and pyelonephritis ?

A

Increased fluid intake
Timely bladder voiding
Postcoital voiding
Adequate genital hygiene

Intermittent straight catheterization
Indicated for individuals with neurogenic bladder

nephrology (16 decks)

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