[55] Pyelonephritis

Question 1

What is pyelonephritis?

Answer 1

Inflammation of the kidney typically due to bacterial infection

Question 2

Acute pyelonephritis is the underlying cause of the majority of what presentations?

Answer 2

Febrile urinary tract infections in infants and young children

Question 3

What usually causes pyelonephritis?

Answer 3

Ascension of perineal contaminants via the urinary tract to colonise the kidneys

Question 4

Where do the perineal contaminants usually come from?

Answer 4

Bowel flora

Question 5

What is the assumed origin of pyelonephritis in neonates?

Answer 5

Haematogenous

Question 6

What bacteria accounts for 90% of all pyelonephritis cases?

Answer 6

E. coli

Question 7

What other bacteria can cause pyelonephritis?

Answer 7

• Klebsiella
• Proteus
• Enterococcus faecalis
• Gram +ve organisms e.g. staph and Group B Strep

Question 8

What are the risk factors for developing pyelonephritis?

Answer 8

• High-grade VUR
• Congenital or acquired renal abnormalities
• Delayed or incomplete voiding
• Constipation
• Catheterisation
• Sexual activity

Question 9

What are the potential causes of delayed or incomplete voiding?

Answer 9

• Neurogenic bladder
• Obstruction
• Dysfunctional voiding

Question 10

What are the signs and symptoms of pyelonephritis in neonates?

Answer 10

• Jaundice
• Hypothermia or fever
• Poor feeding
• Vomiting
• Failure to thrive

Question 11

What are the signs and symptoms of pyelonephritis in infants and young children?

Answer 11

• Fever (longer than 48 hours)
• Poor feeding
• Vomiting
• Diarrhoea
• Foul urine
• Haematuria

Question 12

What are the signs and symptoms of pyelonephritis in pre-school and school-age children?

Answer 12

• Fever
• Abdominal pain or flank pain
• Vomiting, diarrhoea and anorexia
• Foul urine
• Haematuria
• Voiding related symptoms e.g. enuresis, dysuria, urgency and frequency

Question 13

What are the signs and symptoms of pyelonephritis in adolescents?

Answer 13

• Fever, often with chills and rigors
• Flank pain
• Abdominal and suprapubic pain
• Voiding related symptoms
• Foul urine
• Haematuria

Question 14

What investigations can be used in pyelonephritis?

Answer 14

• Urinalysis
• Urine culture
• U&E’s
• ESR
• Imaging

Question 15

What are the signs of a UTI on urinalysis?

Answer 15

• Nitrites
• Leukocytes
• Blood

Question 16

Does a normal urinalysis result exclude pyelonephritis?

Answer 16

No

Question 17

What urine culture result is diagnostic of a UTI?

Answer 17

Clean catch sample with more than 100,000 CFU’s of a single organism

Question 18

Why might U&E’s be abnormal in pyelonephritis?

Answer 18

Due to diarrhoea and vomiting

Question 19

What ESR result is indicative of pyelonephritis in the picture of a febrile UTI?

Answer 19

30mm/h

Question 20

What imaging can be useful in assessing pyelonephritis?

Answer 20

• USS

- Voiding cystourethrography

Question 21

What are the differentials for pyelonephritis?

Answer 21

• Bacteraemia
• Kawasaki disease
• UTI
• Appendicits
• Urolithiasis

Question 22

How is the antibiotic of choice determined in pyelonephritis?

Answer 22

Based on urine cultures

Question 23

How should pyelonephritis be treated prior to culture results?

Answer 23

Empirically based on local E. coli sensitivity

Question 24

How long should IV antibiotics be given for?

Answer 24

3-4 days

Question 25

How long should oral antibiotics be given post IV antibiotics?

Answer 25

10-14 days

Question 26

When is hospitalisation for pyelonephritis necessary?

Answer 26

- Toxicity or sepsis - Signs of obstruction or underlying disease - Inability to tolerate oral fluids or medication - Infants younger than 2

Question 27

What should happen to patients managed as outpatients after 48 hours?

Answer 27

Re-assessment of hydration and response to therapy

Question 28

What are the potential complications of pyelonephritis?

Answer 28

- Dehydration - Renal parenchymal scarring - Hypertension - Decreased renal function - Renal failure