پیلونفریت

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Upper urinary track infection PYELONEPHRITIS 

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* Pyelonephritis is a disease with inflammation & infection involving the calyx and pelvis of the kidney. * Pyelonephritis may be acute and chronic forms according to clinical course. * One or both kidney may be involved in the disease. 

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¢ Results are : * deformation of underlining calyx and pelvis ٠ pyelonephritic fibrosis & scar 

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Pathogenesis of pyelonephritis OHematogenous pathway QO urogenous pathway( 85% ) Ascending infection 

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Acute pyelonephritis O occurring in the setting of renal or ureteric stones, strictures, prostatic obstruction (hypertrophy or malignancy), vesicoureteric reflux, neurogenic bladder, catheters, DM, polycystic kidney disease, immunosuppression, and post-renal transplant 

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Etiology O usually ascending microorganisms, most often bacteria O in females with pyelonephritis usually E. coli O causative microorganisms are usually E. coli, Klebsiella, Proteus, Serratia, Pseudomonas, Enterococcus, and S. aureus O if S. aureus is found, suspect bacteremic spread from a distant focus (e.g. septic emboli in infective endocarditis or nerinenhric aheccecc) 

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Clinical Presentation U0 rapid onset (hours to a day) Ofever, tachycardia, chills O lethargic and unwell QO nausea and vomiting XO) marked CVA or flank tenderness; possible abdominal pain on deep palpation XO symptoms of lower UTI may be (urgency, frequency, dysuria) OO may have symptoms of sepsis 

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Note O) Patients (especially the elderly) with acute pyelonephritis & sepsis may present initially with only back pain, abdominal pain, symptoms of disturbed GI function, or mental status changes 

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Investigations Oi urine dipstick: leukocytes and nitrites, possible hematuria >5 WBC urine, bacteria O culture: Gram stain: Gram negative or Gram positive O CBC and differential: leukocytosis, high % neutrophils O blood cultures: may be positive in 20% of cases, especially in S. aureus infection ۳ KUB , IVP, abdo /pelvis Sono, CT, cystoscopy 

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prognosis * may be in Recovery ¢ Transformation in chronic pyelonephritis 

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Complications End Stage Renal Disease Hypertension Kidney stones Urosepsis 

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Treatment + Treatment of the cause * Medical treatment * Surgical treatment: — Removal of obstruction — Repair of vesicoureteric reflux 

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Treatment QO uncomplicated pyelonephritis with mild symptoms * 14 day course of (trimethoprim-sulfamethoxazole) or third generation cephalosporin * start with IV for several days and then switch to PO (can then be treated as outpatient) QO» start broad spectrum IV antibiotics until cultures return (imipenem or emropenem or piperacillin /tazobactam or ampicillin+ gentamicin) and treat 2-3 weeks ۰ follow-up cultures 2-4 weeks after stopping treatment O if no improvement in 48-72 hr, need to continue on IV antibiotics, assess for complicated pyelonephritis or possible renal or perinephric abscess 

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Nursing care * Bed rest + Analgesic * Antipyretic * Intake fluid * Follow up 

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CHRONIC PYELONEPHRITIS | 

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Chronic pyelonephritis * Persistent presence of bacteria in the kidney Oa form of chronic tubulointerstitial nephritis of bacterial origin O cortical scarring, tubulointerstitial damage, and calyceal deformities seen UO may be active (persistent infection) or inactive (persistent focal sterile scars post- infection) @) active chronic pyelonephritis may respond 

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Clinical Manifestations: + Usually no symptom (bacteriuria) ¢ , Upper UTIs: a. Chills, fever. b. Malaise. c. Pain below the ribs. d. Nausea, Vomiting. 

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Diagnostic tests: * 1. Urine analysis. 2. Urine culture. 3.CBC 

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Prognosis & treatment The condition is life threatening, with a mortality rate of 40% to 80%. treatment with IV antibiotics . Obstruction requires drainage either percutaneously or by stent placement. Operative treatment, including nephrectomy and drainage along with antibiotics, decreases the mortality rate to less than 20%. 

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Clinical features ٠ Gradual onset of renalinsufficiency * Development of hypertension * Possible bacteriuria ٠ Latent devlopment of glomerulosclerosis [] proteinuria * €ventually[|chronic renal failure