Pyelonephritis

Li Xiao
Department of Nephrology, Ruijin hospital
Shanghai Jiao Tong University School of Medicine

Urinary Tract Infection (UTI)

UTI occurs in all populations, from the
neonate to the geriatric patient, but it has a
particular impact on :

females of all ages (especially during pregnancy)

males at the two extremes of life
kidney transplant patients
anyone with functional or structural abnormalities
of the urinary tract

Urinary Tract Infection (UTI)

upper UTIpyelonephritis
lower UTI cystitis

Pyelonephritis

DEFINITION

BACTERIOLOGY

PATHOGENESIS

PATHOLOGY

CLINICAL PRESENTATIONS

DIAGNOSTIC EVALUATION

TREATMENT

DEFINITION
Pyelonephritis means inflammation of
the kidney and its pelvis, but from a
historical point of view and through
common usage, the term has come to
designate a disorder of the kidney resulting
from bacterial invasion.

Pyelonephritis

DEFINITION

BACTERIOLOGY

PATHOGENESIS

PATHOLOGY

CLINICAL PRESENTATIONS

DIAGNOSTIC EVALUATION

TREATMENT

Bacteriologic Findings Among 250

Outpatients and 150 Inpatients with UTI

Bacterial Species Outpatients (%)

Escherichia coli
89.2
Proteus mirabilis
3.2
Klebsiella pneumoniae
2.4
Enterococci
2.0
Enterobacter aerogenes
0.8
Pseudomonas aeruginosa
0.4
Proteus species
0.4
Serratia marcescens
0.0
Staphylococcus epidermidis 1.6
Staphylococcus aureus
0.0

Inpatients (%)
52.7
12.7
9.3
7.3
4.0
6.0
3.3
3.3
0.7
0.7

Fungal Pathogens

The most common form of fungal

infection of the urinary tract is caused by
Candida species. Most such infection occurs
in patients :
with indwelling Foley catheters
receiving broad-spectrum antibacterial
therapy
diabetes mellitus
on corticosteroids

Other Pathogens
C. Trachomatis--- important cause of the
acute urethral syndrome
U. Urealyticum, M.Hominis--- less common
Adenoviruses--- 1/4~1/2 of hemorrhagic
cystitis in school children

Pyelonephritis

DEFINITION

BACTERIOLOGY

PATHOGENESIS

PATHOLOGY

CLINICAL PRESENTATIONS

DIAGNOSTIC EVALUATION

TREATMENT

PATHOGENESIS
How microorganisms, especially bacteria,
reach the urinary tract in general and the
kidney in particular?

PATHOGENESIS
Two potential routes :
(1) the hematogenous route, with seeding of
the kidney during the course of bacteremia;
(2) the ascending route, from the urethra to
the bladder, then from the bladder to the
kidneys via the ureters.

Hematogenous Infection
Because the kidneys receive 20% to 25% of
the cardiac output, any microorganism that
reaches the bloodstream can be delivered to
the kidneys.
The major causes of hematogenous
infection are S. aureus, Salmonella species,
P. aeruginosa, and Candida species.

Hematogenous Infection
Chronic infections (skin, respiratory tract)
blood circulation
small abscess
renal pelvis

kidney(cortex)
renal tubular

renal papillary

Ascending Infection
The reservoir from which urinary tract
pathogens emerge is the gastrointestinal
tract.
Females, because of the proximity of the
anus to the urethra, are at increased risk for
UTI .

Ascending Infection
The ability of host defense
Urinary tract mucosal cells damaged
The power of bacterial adhesions(toxicity)
organisms
urethra,periurethral tissues
bladder
ureters
renal pelvis
renal medulla

PATHOGENESIS
The normal bladder is capable of clearing itself of
organisms within 2 to 3 days of their introduction.
Defense mechanisms
(1) the elimination of bacteria by voiding
(2) the antibacterial properties of urine and its
constituents
(3)the intrinsic mucosal bladder defense mechanisms
(4) an acid vaginal environment (female)
(5) prostatic secretions (male)

PATHOGENESIS
Factors predisposing to pyelonephritis
Urinary Tract Obstruction
Vesicoureteral Reflux
Instrumentation of the Urinary Tract
Pregnancy
Diabetes Mellitus

Diabetes Mellitus
UTI are 3-4 times more common in diabetic
women than in nondiabetic ones
Diabetic neuropathy affects bladder emptying
Diabetic vascular disease increases pressures
within the urinary tract resulting from poor
bladder emptying
The effects of hyperglycemia on host defense

PATHOGENESIS
Relapsing infection
Reinfection

Relapsing infection
This is defined as recurrence of bacteriuria with
the same organism within 3 weeks of completing
treatment which, during treatment, rendered the
urine sterile.
Relapse implies that there has been a failure to
eradicate the infection. This most often occurs in
association with renal scars, stones, cystic disease,
or prostatitis, or in those who are immunocompromised.

Reinfection
It is defined as eradication of bacteriuria by
appropriate treatment, followed by infection
with a different organism after 7 to 10 days.
Reinfection does not represent failure to
eradicate infection from the urinary tract but
is due to reinvasion of the system.
Prophylactic measures must be initiated.

Pyelonephritis

DEFINITION

BACTERIOLOGY

PATHOGENESIS

PATHOLOGY

CLINICAL PRESENTATIONS

DIAGNOSTIC EVALUATION

TREATMENT

PATHOLOGY
Acute pyelonephritis
Macroscopic: kidneys are enlarged and contain a
variable number of abscesses on the capsular
surface and on cut sections of the cortex and
medulla
Histologic: interstitial edema, inflammatory cells
infiltration, tubular cell necrosis

PATHOLOGY
Chronic pyelonephritis
Macroscopic: kidneys are smaller than
normal, renal scarring, consisting of
corticopapillary scars overlying dilated,
blunted, or deformed calices
Histologic:unequivocal
evidence
of
pelvocaliceal inflammation, fibrosis, and
deformity

Pyelonephritis

DEFINITION

BACTERIOLOGY

PATHOGENESIS

PATHOLOGY

CLINICAL PRESENTATIONS

DIAGNOSTIC EVALUATION

TREATMENT

CLINICAL PRESENTATIONS
Cystitis
dysuria (burning or discomfort on urination)
frequency
nocturia
suprapubic discomfort

CLINICAL PRESENTATIONS
Acute Pyelonephritis

recurrent rigors and fever

back and loin pain
colicky abdominal pain
nausea and vomiting
dysuria, frequency, and nocturia
Gram-negative sepsis
septic shock

CLINICAL PRESENTATIONS
The physiologic derangements that result
from the long-standing tubulointerstitial
injury
hypertension
inability to conserve Na+
decreased concentrating ability
tendency to develop hyperkalemia and acidosis

Complications
Sepsis
Peri-renal abscess
Acute renal failure
Renal papillary necrosis

Pyelonephritis

DEFINITION

BACTERIOLOGY

PATHOGENESIS

PATHOLOGY

CLINICAL PRESENTATIONS

DIAGNOSTIC EVALUATION

TREATMENT

DIAGNOSTIC EVALUATION
History and Physical Examination
Chemical tests for the presence of bacteriuria
Urinary concentrating ability
Measurement of urinary enzymes
Measurement of C-reactive protein
Measurement of antibody responses to bacteria
Radiologic and Urologic Evaluations

Laboratory findings
Urine dipstick
pyuria on microscopic examination
urine WBC
Middle stream urine culture
bacterial account > 105/ml
blood culture

Laboratory findings
Urinary concentrating ability
Maximal urinary concentrating test SG
Urinary enzymes
NAG, 2-MG
Urinary tract X-ray
KUB+IVU
(children, adult man, women recurrent UTI)

upper UTI
+

Fever
Percussion of the
costovertebral angle
+
WBC casts
+
Urinary concentrating
ability
decrease
Urine NAG, 2-MG increase
Ab-coated bacteria
in urine
+
Recurrent early, same bacteria
IVU
may abnormal

lower UTI
normal
normal
late, new bacteria
usually normal

Pyelonephritis

DEFINITION

BACTERIOLOGY

PATHOGENESIS

PATHOLOGY

CLINICAL PRESENTATIONS

DIAGNOSTIC EVALUATION

TREATMENT

Treatment
Rest
Drinking large amount of water
Antibiotics: 10-14 days until symptom free
Treat related diseases: diabetes, renal stones,
vaginal infection, etc

Antimicrobial therapy
Three goals
- control or prevention of the development of
urosepsis
- eradication of the invading organism
- prevention if recurrences
Medications
- trimethoprim-sulfamethoxazole
- fluoroquinolones
- ampicillin, amoxicillin, first-generation
cephalosporins

Antimicrobial therapy
Short-course therapy
single-dose therapy
a 3-day course of therapy
Extended course
a prolonged 4- to 6-week course of therapy
Low-dose prophylactic regimen
low-dose antibiotics three times weekly at
bedtime for to 1 year

Women who present with complaints

of dysuria and frequency
Treat with short-course therapy
Follow-up 4-7 days later
Asymptomatic
No further
intervention
Both
negative

observe
treat with
urinary
analgesia

Symptomatic
urinalysis, urine culture
pyuria
no bacteriuria

treat for
chlamydia
trachomatis

bacteriuria
with or
without pyuria
treat with
extended
course