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06-05-2009, 09:41 AM
Acute pyelonephritis


Cause:

►Organisms
© E. coli. © Klepsiella - pseudomonas.
© Proteus. © Staph - strept.

► Route of infect:.
˛ Ascending from urethra&bladder(Peri urethral colonization)
˛ Haematogenous
˛ Lymphatic (periurethral & periureteric lymphatic)

►Predisposing factors :

Sex : ♀>♂ - short urethra
absence of bactericidal prostatic fluid.

Obstruction: -youg young,stone ,B
- old prostate

Pregnancy : - hormones : relaxation of ureters stasis.
pressure of uterus

Neurogenic blader e.g paraplegia


Catheter.



Vesico ureteric reflux :
during micturation, urine may pass upward in ureters recurrent.
Reflux infection

a Reflux reflux nephropathy.
Renal diseases oligurea Æwashout of urine ­liability to infection.
Systemic disease D.M

C/P
Classic F A H M.
rigors - loin pain.
± dysuria, frequency.
±turbid urine.
tender renal angle.
Child fever without localization
Sometimes fever reflex vomiting

misdiag. As G. E.
Pregnancy:UTI may occur without symptoms asympt.
Bacteriuria i.e org. > 100.000 ml + no sympt
40 % of cases pyelonephritis. So
asympt. Bacteriuria must be treated.
D.M. severe pyelonephritis with necrosis of the papilla
acute necrotizing papillitis.
( = acute papillary necrosis = acute renal failure)

D.D. Appendicitis.
Prenephric absess. no urinary symp. or finding.
pain & tenderness in loin.
Investig :
Urine culture +ve
pus cells ­
WBCs casts as it is an upper U.T.I
Blood ESR ­ , C.R. protein, leucocytosis
Investig. of the cause esp. in ♂
•plainUT stone • IVP stone, stricture. •sonar.
•micturating cystogram (for reflux). •D.M

N.B. prophylactic measures in ♀ with recurrent UTI
Fluids 2 L / D
Regular emptying of bladder / 3 hrs.
Double micturation if reflux present.
Emptying bladder before and after intercourse.

ttt:
You start with sutrim tab. 2 tab / twice. Or Amoxacillin
cap. 500 mg / 6 hrs. tills culture results.
Then give Ab according to culture for 7-10 days.
We do culture during course & then 2 cultures, 7 & 21 days after ttt must be -ve.
If culture +ve
Same org. within 7 d other org. or the same after 2 wks
with -ve Bacteriuria

relapse reinfection

search for the cause & ttt if no apparent cause with resistant org.
give Ab for 2-6 wks according to culture.

Drugs used in U. tract inf:.

Sutrim. 2 tab / 12 hrs.
Ampicillin 500 mg / 6 hrs.
Amoxacillin 500 mg / 6 hrs. (better than Ampicillin)
Nitrofurantoin 100 mg / 8 hrs orally.
Nalidixic acid 500 mg / 6 hrs.
Garamycin 3 mg / kg / d in divided dose.
Nephrotoxic Amp 80 mg / hrs.
3 rd G. Cephalosporines
e.g. Cefotaxime 2 gm / d I.M. & I.V.
(minimal nephrotoxicity).
8- Ofloxacin 400 mg / 12 hrs.


Alteration of PH :
Alkaline urine (Na HCO3) potentiate sulpha
aminoglycosides.
Acidic urine (vit C) potentiate tetracycline.

Fluid intake :
­ urine output ­ washout of urine.
Dilute the urinary conc. of Ab harmful ?!.

Source: Internal Medicine Book of Dr.Osama Mahmoud (Ain Shams University)