7.02 Upper Urinary Tract Infection (Pyelonephritis)

agk’s Library of Common Simple Emergencies

Presentation

The patient has some combination of urinary frequency, urgency, dysuria, flank pain, nausea, fever, and chills. On physical examination, there is tenderness elicited by percussing the costovertebral angle over the kidneys. The urinalysis may help establish the diagnosis with tubular casts of white cells.

What to do:

• Examine urine for presence of gram-positive cocci (presumptively enterococci) or the more usual gram- negative rods, and send for culture and sensitivity.
• If the patient appears toxic, with a high fever or white count, nausea or vomiting to prevent adequate oral medicatication and hydration, or if the patient is pregnant or there is any sign of urinary obstruction or developing sepsis, he or she should be admitted to the hospital for intravenous antibiotics.
• For stable, otherwise healthy patients, start with a first dose of intravenous antibiotics in the ED (ampicillin 1000mg plus gentamicin 80mg, ceftriaxone 1000-2000mg, ofloxacin 200-400mg or ciprofloxacin 200-400mg), then discharge home on oral hydration and two weeks of oral antibiotics (trimethoprim 160mg plus sulfamethoxazole 800mg bid, ciprofloxacin 500mg bid, norfloxacin 400mg bid or ofloxacin 400mg bid x 14d).
• Instruct the patient to return to the ED for re-evaluation in 24-48 hours, and sooner if symptoms worsen. Most patients improve on this regimen, but the others will require hospital admission if they are not improving in two days.

What not to do:

• Do not lose the patient to followup. Although lower UTIs often resolve without treatment, upper UTIs inadequately treated can lead to renal damage or sepsis.
• Do not miss an infection above a ureteral stone or obstruction. Crampy, colicky pain or hematuria with the symptoms above calls for an excretory urogram (IVP). Antibiotics and hydration alone may not cure an infected obstruction.

Discussion

Although oral antibiotics are usually sufficient treatment for upper UTIs, there is a significant incidence of renal damage and sepsis as sequelae, mandating good followup or admission when necessary. By the same token, lower UTIs can ascend into upper UTIs, or it can be difficult to decide the level of a given UTI, in which case it should be treated as an upper UTI.

Studies have shown tat a 14 day course of oral therapy is highly effective for the woman with clinical evidence of pyelonephritis without sepsis, nausea or vomiting. Quinolones such as ofloxacin (Floxin), ciprofloxacin (Cipro) and norfloxacin (Noroxin) are highly effective and probably the drugs of choice in this setting, except for pregnant women, for whom they are contraindicated. Trimethoprim-sulfamethoxazole (Bactrim, Septra) could also be used, although resistance of 5% to 15% of pathogens may be a more important factor in the selection of therapy for pyelonephritis than for cystitis.

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