Pyelonephritis overview

# Overview
Pyelonephritis is usually an ascending urinary tract infection that has reached the pyelum (pelvis) of the kidney (nephros in Greek). If the infection is severe, the term "urosepsis" is used interchangeably (sepsis being a systemic inflammatory response syndrome due to infection). It requires antibiotics as therapy, and treatment of any underlying causes to prevent recurrence. It is a form of nephritis. It can also be called pyelitis.

# Historical Perspective
Urinary tract infections have been a long time concern with the first documented description in the Ebers Papyrus dated to 1550 BC. In 1836, Philadelphia surgeon Joseph Parrish described three cases of severe lower urinary tract symptoms without the presence of a bladder stone. Pyelonephritis is a type of upper urinary tract infection. The report of complicated pyelonephritis goes back to 1908.

# Classification
Pyelonephritis is an upper urinary tract infection. Pyelonephritis may be classified according to the duration of disease and etiology into 5 subtypes: acute uncomplicated, acute complicated, chronic, emphysematous, and xanthogranulomatous pyelonephritis. Most cases of Pyelonephritis are acute uncomplicated and occur in normal healthy individuals with no history of a structural urinary tract anomaly or any long-term disease. Classification of pyelonephritis helps understand dynamics and specify treatments according to the duration, severity and the type of pyelonephritis.

# Pathophysiology
Pyelonephritis is caused by the spread of the infection to the renal parenchyma. The infection, which is the most common cause of pyelonephritis, can either be classified as ascending or descending. Ascending infections stem from a urinary tract which can either be a result of urethritis or cystitis. Descending infections from the blood (hematogenous spread) are a less common cause of pyelonephritis than ascending infections. The Urine is normally sterile and the normal flow of urine washes away bacteria, if any, so that they do not accumulate in a significant amount to cause an infection. Any mechanism that disturbs this normal process like the presence of a catheter, a stone or a tumor can result in stasis and abnormal accumulation of bacteria. These bacteria can ascend through the urethra into the urinary bladder and from the bladder through the ureters to the kidneys and their parenchyma. This results in pyelonephritis and its manifestations.

# Causes
Causes of uncomplicated and complicated pyelonephritis are mostly similar. Common causes of complicated pyelonephritis include infections such as E. coli, Enterococcus faecalis, Proteus, Klebsiella, and Pseudomonas aeruginosa.

# Differential Diagnosis
Pyelonephritis must be differentiated from other causes of dysuria such as cystitis, urethritis, prostatitis, vulvovaginitis, urethral strictures or diverticula, benign prostatic hyperplasia, STDs and neoplasms such as renal cell carcinoma and from causes of abdominal pain such as ectopic pregnancy, renal stone, peritoneal or iliopsoas abscess, and rib fracture.

# Epidemiology and Demographics
Acute pyelonephritis is reported to cause more than 100,000 hospitalizations each year with the number of people acquiring pyelonephritis being closer to 250,000, yearly. Pyelonephritis is very common, with 120-130 cases annually per 100,000 women and 30-40 cases per 100,000 men. Females are more commonly affected with pyelonephritis than males.

# Risk Factors
Most risk factors of pyelonephritis are similar to those for cystitis and urethritis, since they themselves predispose the individual to pyelonephritis. Common risk factors in the development of pyelonephritis include renal calculi, urinary tract catheterization, pregnancy, diabetes mellitus, and benign prostatic hyperplasia.

# Screening
There are no known screening tests for pyelonephritis in general population. However, there are few situations that screening for bacteriuria is performed. Asymptomatic bacteriuria must be screened in pregnancy, prior to urologic surgery, and for research purposes.

# Natural History, Complications, and Prognosis
Pyelonephritis is distressful condition requiring emergent medical management. Most individuals who are treated adequately with antibiotics do not have complications. A surgical management with removal of stone or obstructing tumor may sometimes be required to prevent complications and prevent obstructive pyelonephritis and stop the course of chronic pyelonephritis. The most common complication of pyelonephritis is recurrent infections. Most episodes of pyelonephritis are uncomplicated and are easily treatable. The prognosis of pyelonephritis varies depending on the type of pyelonephritis and on the timing and duration of treatment. The mortality in case of UTI is between 5% to 33%.

# Diagnosis

## Diagnostic Study of Choice
Urinalysis and urine culture with susceptibility testing might confirm the diagnosis of pyelonephritis. Pyelonephritis must be suspected if the patient has urinary symptoms including dysuria, urgency, frequency, or suprapubic pain, along with fever, chills, flank pain, pelvic or perineal pain. Imaging would not be necessary for patients with pyelonephritis, unless in patients with severe and refractory illness or suspected urinary tract obstruction.

## History and Symptoms
Pyelonephritis patients usually present in the emergency department with sudden development of pain radiating to the flank in the presence of dysuria and fever. The differentiation of pyelonephritis from other causes of dysuria is based on severity of symptoms and the typical radiation of pain. A thorough history and examination is required to differentiate pyelonephritis from other causes of dysuria and flank pain.

## Physical Examination
Pyelonephritis is a medical emergency and requires a thorough physical examination after getting a detailed history and review of symptoms. Typically the patient has acute onset of high grade fever, dysuria and pain radiating to the flank. A sonopalpation test, which is an ultrasound guided palpation, is usually positive and helpful in detecting the exact anatomical structure and position as the cause of tenderness.

## Laboratory Findings
Pyelonephritis can be diagnosed with the help or urinalysis and urine culture. Urine culture should always be obtained before administration of antibiotics if pyelonephritis is suspected. A combination of leukocyte esterase test and nitrite test (with either of the two test being positive) is considered to be very effective with a sensitivity ranging from 75-84 and a specificity ranging from 82-98 percent. A blood culture is usually done but may not necessarily yield any findings.

## Electrocardiogram
There are no ECG findings associated with pyelonephritis.

## X Ray
An x-ray may be helpful in the diagnosis of pyelonephritis, its risk factors, and complications. Some patients with pyelonephritis have kidney stone which might be visible on x rays of the kidneys, ureters, and bladder (KUB).

## Echocardiography and Ultrasound
There are no echocardiography findings associated with pyelonephritis. Ultrasonography is an effective non-invasive technique in the diagnosis of pyelonephritis. It is sometimes used as a replacement of cortical scintigraphy in the diagnosis of acute pyelonephritis in children.

## CT scan
A CT scan can be used to detect diffuse or complicated pyelonephritis and its suspected complications. It is used when the suspicion of pyelonephritis is accompanied by other differentials. CT scan is very sensitive and CT urography is sometimes used for imaging of the urinary tract. The extent of damage to the parenchymal tissue can also be witnessed in detail with a CT scan.

## MRI
MRI is sometimes used to diagnose complicated pyelonephritis. It is the preferred modality for diagnosing complicated pyelonephritis when the patient is allergic to iodinated contrast material. A comprehensive idea of the extent of damage to the kidneys can be estimated with an MRI.

## Other Imaging Findings
Other investigations might be used to diagnose pyelonephritis. Voiding cystourethrogram (VCUG), contrast nephrograms, intravenous pyelography, and urography are helpful in diagnosing pyelonephritis and its complications.

## Other Diagnostic Studies
Other diagnostic studies for pyelonephritis include dimercaptosuccinic acid scintigraphy and histopathological exam.

# Treatment

## Medical Treatment
Treatment of Pyelonephritis is usually medical. In case of any risk factors like catheters or obstructing stones or masses, the management includes removing the risk factors to prevent further progress of the disease and the pathogen accumulation. All patients with pyelonephritis should be treated empirically with antimicrobial therapy. Mild pyelonephritis may be managed with oral antimicrobial therapy, and an initial intravenous dose may be administered depending on local resistance patterns. Patients with dehydration, nausea, vomiting, or signs of sepsis should be admitted and should receive parenteral therapy. Medical therapies for pyelonephritis include fluoroquinolones, TMP-SMX, -lactams, or aminoglycosides.

## Interventions
Different interventions might be used to diagnose or treat pyelonephritis. Flexible ureteroscopy is done for the treatment of obstructive pyelonephritis. Double J stenting, also known as DJ Stenting, is a conservative management method for emphysematous pyelonephritis. Percutaneous nephrostomy is an effective treatment option for emphysematous pyelonephritis which is characterized by necrotizing damage to the parenchyma of the kidney and its adjoining tissue leading to gas formation. Percutaneous nephrolithotomy or transperitoneal laparoscopic ureterolithotomy (TLU) are effective surgical treatment options for pyelonephritis.

## Surgery
Pyelonephritis is usually managed medically. In recurrent infections, additional investigations may identify an underlying abnormality like a stone, a tumor, or an underlying pathological process that has to be aggressively dealt with. Surgery is usually indicated in a patient who does not improve after 48 hours of IV antibiotics or deteriorates. Occasionally, surgical intervention is necessary to decrease of recurrence and to prevent devastating complications. Various renal conditions like obstructive pyelonephritis with presence of stones in the presence of an infected kidney can be fatal and requires urgent management.

## Primary Prevention
Preventative measures to avoid pyelonephritis include the measures for preventing a urinary tract infection which include voiding after intercourse, use of barrier contraception, increasing fluid intake and frequency of urination, cleaning the urethral meatus after intercourse and use of estrogen (among postmenopausal women). Single-dose prophylactic antimicrobial therapy prior to sexual intercourse may be administered to patients who have recurrent episodes of cystitis that are associated with sexual activity. Prevention of recurrence of cystitis may also be helpful in preventing development of pyelonephritis.

## Secondary Prevention
Pyelonephritis can be prevented secondarily in some cases by giving long term prophylactic antibiotics. Correction of a structural defect that leads to the initial episode of pyelonephritis may also be helpful in eliminating chances of recurrence of pyelonephritis.