Pathophysiology of

Pyelonephritis
Acute pyelonephritis, also known as acute infective tubulointerstitial nephritis, is a sudden inflammation caused
by bacteria that primarily affects the interstitial area and the renal pelvis or, less commonly, the renal tubules. It’s one
of the most common renal diseases and may affect one or both kidneys. With treatment and continued follow-up care,
the prognosis is good, and extensive permanent damage is rare.
Pyelonephritis is more common in females, probably because if the shorter female urethra and proximity of the
urinary meatus to vagina and the rectum. Both conditions allow bacteria to reach the bladder more easily. In males,
pyelonephritis may occur due to a lack of the antibacterial prostatic secretions normally produced in males.

HOW IT HAPPENS
Typically, the infection spreads from the bladder to the ureters, then to the kidneys, as in vesicoureteral reflux.
Vesicoureteral reflux may result from congenital weakness at the junction of the ureter and the bladder. Bacteria
refluxed to intrarenal tissues may create colonies of infection within 24 to 48 hours. Infection may also result from
instrumentation (such as catherterization, cystoscopy, or urologic surgery), from a hematogenic infection (as in
septicemia or endocarditis) or, possibly, from lymphatic infection.
Pyelonephritis may also result from an inability to empty bladder (for example, in patients with neurogenic
bladder), urinary stasis, or urinary obstruction due to tumors, structures, or benign prostatic hyperplasia.

RISK FACTORS
Incidence of pyelonephritis increases with age and is higher in the following groups:
 Sexually active women – intercourse increases the risk of bacterial contamination.
 Pregnant women – about 5% develop bacteriuria that produces no symptoms; if untreated, about 40% develop
pyelonephritis.
 People with diabetes – neurogenic bladder causes incomplete emptying and urinary stasis; glycosuria may
support bacterial growth in the urine.
 People with other renal diseases – compromised renal function aggravates susceptibility.
Clinical Manifestations of
Pyelonephritis
The clinical manifestations of acute uncomplicated pyelonephritis include flank pain, abdominal or
pelvic pain, nausea, vomiting, fever (≥37.8ºC), and/or costovertebral angle tenderness. Fever has been
strongly correlated with the diagnosis of acute pyelonephritis; thus, patients with clinical manifestations of
acute pyelonephritis in the absence of fever should be evaluated for alternative diagnoses. Symptoms of
cystitis may or may not be present. In some cases, the presentation may mimic pelvic inflammatory disease.
Rarely, patients with acute pyelonephritis present with sepsis, multiple organ system dysfunction, shock,
and/or acute renal failure.
In patients with complicated UTI’s, such as those with indwelling catherters, manifestations can range
from asymptomatic bacteriuria to a gram-negative sepsis with shock. Complicated UTI’s often are due o a
broader spectrum of organisms, have a lower response rate to treatment, and tend to recur. Many patients
with catheter-associated UTI’s are asymptomatic; however, any patients who suddenly develop signs and
symptoms of septic shock should be evaluated for urosepsis.

 Back pain or flank pain

 Chills with shaking
 Severe abdominal pain (occurs occasionally)
 Fatigue
 Fever
o Higher than 102 degrees Fahrenheit
o Persists for more than 2 days
 General ill feeling
 Chills with shaking
 Mental changes or confusion*
 Skin changes
o Flushed or reddened skin
o Moist skin (diaphoresis )
o Warm skin
 Urination problems
o Blood in the urine
o Cloudy or abnormal urine color
o Foul or strong urine odor
o Increased urinary frequency or urgency
o Need to urinate at night (nocturia)
o Painful urination
 Vomiting, nausea

* Mental changes or confusion may be the only signs of a urinary tract infection in the elderly.
Important Physical
Exams of Pyelonephritis
& Findings
A physical exam may show tenderness when the health care provider presses (palpates) the area of the
kidney.

 Blood culture may show an infection.

 Urinalysis commonly reveals white or red blood cells in the urine.
 Other urine tests may show bacteria in the urine.

An intravenous pyelogram (IVP) or CT scan of the abdomen may show swollen kidneys. These tests can also
help rule out underlying disorders.

Additional tests and procedures that may be done include:

 Kidney biopsy
 Kidney scan
 Kidney ultrasound
 Voiding cystourethrogram

Pathology
 BX/Renal Abnormal
 BX/Renal Cortex tubulointerstitial nephritis/acute

Isotope Scan
 Isotope/DMAS Kidney Scan Abnormal
 Isotope/Renal Scan Abnormal

CT Scan
 CT Scan/Abdomen Small kidneys
 CT Scan/Renal/No contrast/Small kidneys

X-RAY
 Xray/Small kidneys/KUB
 Xray/Unilateral absence of renal outline/KUB

X-RAY With contrast

 IVP/Abnormal (intravenous pyelogram)
 IVP/Bulge of renal outline
 IVP/Decreased dye visualization/bilateral
 IVP/Renal margin/outline depressions
 IVP/Small kidneys bilateral
 IVP/Unilateral small kidney/KUB (Xray)

Ultrasound
 Ultrasound/Renal Small kidneys/bilateral
 Ultrasound/Renal/Unequal kidney size
Differential
Diagnosis for
Pyelonephritis
Doctors may rely on various tests to diagnose pyelonephritis:
 History
Telling the story of your illness and specific symptoms helps a doctor make the diagnosis of pyelonephritis.

 Physical Examination
A doctor notes a person's general appearance, vital signs, and presses over the kidneys to check for tenderness.

 Urinalysis
In pyelonephritis, microscopic analysis of the urine virtually always shows signs of infection. This can include an
excess of white blood cells and bacteria.
 Urine culture
Within days, bacteria in urine may grow on a culture dish, allowing the best antibiotic to be chosen.
 Blood cultures
If pyelonephritis has spread to the blood, blood cultures can detect this and guide treatment.
 Computed tomography (CT scan)
A scanner takes a rapid series of X-rays, and a computer creates detailed images of the abdomen and
kidneys. A CT scan is not necessary to diagnose pyelonephritis, but sometimes helps.
 Kidney ultrasound
A probe directs high-frequency sound waves through the skin, creating images of the kidneys and
ureters. Ultrasound can help identify abscesses, stones, and blockages.

In addition to diagnosing pyelonephritis itself, doctors look for any conditions that make pyelonephritis more
likely. For example, kidney stones or birth defects of the urinary tract are potentially correctable, reducing the
chances of future kidney infections.

Treatment of
Pyelonephritis
The goals of treatment are to:

 Control the infection

 Relieve symptoms

Due to the high death rate in the elderly population and the risk of complications, prompt treatment is
recommended. Sudden (acute) symptoms usually go away within 48 to 72 hours after appropriate treatment.
Your doctor will select the appropriate antibiotics after a urine culture identifies the bacteria that is causing
the infection. In acute cases, you may receive a 10- to 14-day course of antibiotics.
If you have a severe infection or cannot take antibiotics by mouth, you may be given antibiotics through a vein
(intravenously) at first.

Chronic pyelonephritis may require long-term antibiotic therapy. It is very important that you finish all the
medicine.

Commonly used antibiotics include the following:

 Amoxicillin
 Cephalosporin
 Levofloxacin and ciprofloxacin
 Sulfa drugs such as sulfisoxazole/trimethoprim

Antimicrobial Agents Used in the Treatment of Acute Pyelonephritis

Dosing Oral dose

Agent schedule (mg) IV dose Comments
Penicillins
Amoxicillin Every 8 to 12 500 — None
hours
Amoxicillin-clavulanate Every 8 to 12 500/125 — GI side effects*
potassium hours

Agent
Cephalosporins
Cefotaxime (Claforan)
Ceftriaxone (Rocephin)
Cephalexin (Keflex)
Fluoroquinolones
Levofloxacin (Levaquin)
Aminoglycosides
Amikacin (Amikin)
Gentamicin (Garamycin)
Tobramycin (Nebcin)
Other antibiotics
TMP-SMX (Bactrim; Septra)
Dosing Oral dose
schedule (mg) IV dose Comments
Every 8 to 12 — 1 to 2 g Thrombophlebitis
hours
Once in 24 — 1 to 2 g Leukopenia; elevated BUN and liver enzyme
hours levels
Every 6 hours 500 — GI side effects*
Every 24 hours 250 to 750 250 to 750 mg ECG QT prolongation; pregnancy category C
Every 12 hours — 7.5 mg per kg Ototoxicity; nephrotoxicity
Every 24 hours — 5 to 7 mg per kg Ototoxicity; nephrotoxicity
Every 24 hours — 5 to 7 mg per kg Ototoxicity; nephrotoxicity
Every 12 hours 160/800 8 to 10 mg per kg G6PD deficiency; sulfa allergy; do not use in
(TMP) third trimester

In rare cases, pyelonephritis may progress to form a pocket of infection (abscess). Abscesses are difficult or
impossible to cure with antibiotics alone and must be drained. Most often, this is done with a tube inserted
through the skin on the back into the kidney abscess (a procedure called a nephrostomy).