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A - MSRA Renal and Urinary [17] > Pyelonephritis > Flashcards

Pyelonephritis Flashcards

1
Q

What is pyelonephritis?

A

Inflammation of the kidney parenchyma and renal pelvis

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2
Q

What typically causes pyelonephritis?

A

Bacterial infection

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3
Q

Who can acute pyelonephritis affect?

A

Patients of all ages

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4
Q

Who has the highest incidence of pyelonephritis?

A

Women aged 15-29

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5
Q

What can pyelonephritis be classified as?

A
  • Uncomplicated

- Complicated

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6
Q

What is uncomplicated pyelonephritis?

A

Present in structurally or functionally normal urinary tract in a non-immunocompromised host

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7
Q

Why are urinary tract infections in males complicated by definition?

A

Because they will be associated with abnormal urinary tracts

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8
Q

What does acute pyelonephritis result from?

A

Bacterial infection of the renal pelvis and parenchyma

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9
Q

How can bacteria reach the kidney?

A
  • Ascending from lower urinary tract
  • Directly from blood stream
  • Lymphatics
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10
Q

When is pyelonephritis caused by lymphatic spread seen?

A

In cases of retroperitoneal abscess

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11
Q

What happens once bacteria have infected the kidney?

A

Neutrophils infiltrate the tubules and interstitial and cause suppurative inflammation. These are often small renal cortical abscesses and streaks of pus in renal medulla

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12
Q

What is the most common causative organism of pyelonephritis?

A

E. coli

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13
Q

What other organisms can cause pyelonephritis?

A
  • Klebsiella
  • Proteus
  • Enteroccocus faecialis
  • Staphylococcus saprophyticus
  • Pseudomonas
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14
Q

Which of these bacteria cause pyelonephritis in catheterised patients?

A
  • S. aureus
  • E. faecalis
  • Pseudomonas
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15
Q

What can cause pyelonephritis in immunocompromised patients?

A
  • S. saprophytic
  • Mycobacterium spp.
  • Other fungi
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16
Q

What are the risk factors for pyelonephritis?

A
  • Factors reducing antegrade flow of urine
  • Factors promoting retrograde ascent of bacteria
  • Factors predisposing to infection or immunocompromisation
  • Factors promoting bacterial colonisation
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17
Q

What factors reduce the antegrade flow of urine?

A
  • Obstructed urinary tract, including BPH

- Spinal cord injury, resulting in neuropathic bladder

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18
Q

What factors promote the retrograde ascent of bacteria?

A
  • Female gender
  • Indwelling catheter or ureteric stents/nephrostomy tubes
  • Structural renal abnormalities, e.g. VUR
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19
Q

What factors predispose to infection or immunocompromise?

A
  • Diabetes mellitus
  • HIV
  • Corticosteroid use
  • Infection
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20
Q

What factors promote bacterial colonisation?

A
  • Renal calculi
  • Sexual intercourse
  • Oestrogen depletion
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21
Q

What is the classical triad of pyelonephritis?

A
  • Fever
  • Unilateral loin pain (or rarely bilateral)
  • Nausea and vomiting
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22
Q

Over what time frame does pyelonephritis develop?

A

24-48 hours

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23
Q

What other symptoms might be present in pyelonephritis?

A

Symptoms of co-existing lower urinary tract infection (frequency, urgency, dysuria), and haematuria

24
Q

What may be found on examination with pyelonephritis?

A

Patients often look unwell, often pyrexial and features of sepsis.
Will have unilateral or bilateral costovertebral angle tenderness, with or without suprapubic tenderness

25
Q

What should be assessed on examination in pyelonephritis?

A
  • Fluid status
  • Measure post-void residual volumes
  • Evidence of AAA
26
Q

What are the differentials for pyelonephritis?

A
  • Ruptured AAA
  • Renal calculi
  • Acute cholecystitis
  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Lower lobe pneumonia
  • Diverticulitis
27
Q

Who should ruptured AAA be considered in?

A

Any patient with back pain and tachycardia and/or hypotension, especially if elderly or with sufficient risk factors

28
Q

What investigations are required in suspected pyelonephritis?

A
  • Urine
  • Bloods
  • Imaging
29
Q

What urine investigations are required in pyelonephritis?

A
  • Urinalysis, assessing for nitrates and leucocytes
  • Urinary beta-hCG (women of child-bearing age)
  • Urine culture
30
Q

What bloods should be done in pyelonephritis?

A
  • FBC
  • CRP
  • U&Es
31
Q

What imaging should be done in pyelonephritis?

A

Renal US scan

32
Q

Why should a renal US be done in pyelonephritis?

A

Look for evidence of obstruction (infected obstructed system is urological emergency)

33
Q

What should be done if an obstruction is suspected in pyelonephritis?

A

Non-contrast CT imaging of renal tract

34
Q

What will patients who are systemically unwell with pyelonephritis require for management?

A

A-E approach and appropriate resuscitation

35
Q

How should patients with pyelonephritis be initially managed?

A

Start empirical antibiotics based on local protocols and IV fluids as appropriate, also prescribing suitable analgesia and anti-emetics

36
Q

What should be done once bacterial sensitivities are available?

A

Tailor antibiotic therapy

37
Q

Where can many uncomplicated cases of pyelonephritis be treated?

A

In community

38
Q

When should admission be considered for pyelonephritis?

A
  • Clinically unstable
  • Significant dehydration
  • Co-morbidities such as diabetes mellitus, renal transplant graft, or immunocompromised
39
Q

What may be warranted in the management of severe or non-responding cases?

A

Catheterisation and high-dependency unit monitoring

40
Q

What should be considered in severe or non-responding cases of pyelonephritis?

A

Early CT imaging

41
Q

Why should early CT imaging be considered in severe or non-responding cases of pyelonephritis?

A

To check for obstruction and complications of pyelonephritis

42
Q

What are the complications of pyelonephritis?

A
  • Severe sepsis and multi-organ failure
  • Renal scarring leading to CKD
  • Pyonephrosis
  • Preterm labour in pregnant women
43
Q

What can repeated infections of pyelonephritis lead to?

A

Chronic pyelonephritis

44
Q

What can chronic pyelonephritis lead to?

A

Fibrosis and ultimately destruction of the kidney

45
Q

When is chronic pyelonephritis more common?

A

In obstructed systems resulting in urinary reflux

46
Q

What can cause urinary reflux?

A
  • UTIs
  • VUR
  • Anatomical abnormalities
47
Q

How is a diagnosis of chronic pyelonephritis made?

A

Radiologically, when evidence of small, scarred, shrunken kidney seen

48
Q

Who is chronic pyelonephritis most commonly seen in?

A

Children

49
Q

Why might chronic pyelonephritis be hard to diagnosis?

A

May be asymptomatic or first presentation of CKD

50
Q

What is the mainstay of management of chronic pyelonephritis?

A
  • Reverse underlying causes
  • Optimise renal function
  • Consider prophylactic antibiotics
51
Q

What is emphysematous pyelonephritis?

A

A rare and severe form of acute pyelonephritis caused by gas forming bacteria

52
Q

How does emphysematous pyelonephritis present?

A

Similar to acute, however typically fails to respond to empirical IV antibiotics

53
Q

What will CT show in emphysematous pyelonephritis?

A

Evidence of gas within and around the kidney

54
Q

Who is emphysematous pyelonephritis most common in?

A

Diabetic patients

55
Q

Why is emphysematous pyelonephritis most common in diabetic patients?

A

High glucose allows CO2 production from fermentation by enterobacteria

56
Q

How can mild cases of emphysematous pyelonephritis be treated?

A

Broad-spectrum anti-microbial cover

57
Q

How might severe cases of emphysematous pyelonephritis be treated?

A

Nephrostomy insertion or percutaneous drainage of any collections present

A - MSRA Renal and Urinary [17] (17 decks)

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