00:01
In the laboratory, we look
for the presence of pyuria
and 10 white cells per microliter of
midstream urine in a ounting chamber
is the gold standard.
00:15
However, a counting
chamber's not available that often.
00:20
So we can use just centrifuge urine and look for 5
to 10 white cells per high power microscopic field.
00:30
We also have the dipstick,
leukocyte esterase test
Leukocyte esterase is present in the granules of
neutrophils.
00:38
So if the leukocyte esterase
is positive, then by inference,
you can say there are white cells in the urine.
00:45
And the sensitivity and specificity are
decent, 75 to 96% sensitive, 94 to 98% specific.
00:54
Once again, if a patient does
not have microscopic hematuria,
it's probably not coming
from the urinary tract.
01:03
The source of the fever is somewhere else.
01:07
The urine culture in pyelonephritis certainly
should have at least 10 to the fifth bacteria per ml.
01:14
And a poor man's culture is to look under
the microscope looking for microorganisms.
01:21
You can do it by Gram stain.
01:23
If you see one organism per microscopic
field, you can basically conclude
that there are at least 10 to the fifth
organisms per ml of that infected urine.
01:39
When do we need to image people?
Well, for uncomplicated pyelonephritis,
when the diagnosis is clear,
and the patient's moderately
ill, we don't need to image them.
01:51
We need to image them for
complicated pyelonephritis
when we suspect a
structural urologic abnormality,
when we're not sure what's going on,
and urinary tract infection
pyelonephritis is up high on the list.
02:07
If someone obviously is unusually severely
ill with symptoms of a urinary tract infection
and it would be prudent in an
immunocompromised patient to get imaging
because they may have not only
urologic abnormalities, but they may have
serious abscess in the kidney
or other organs in the abdomen.
02:29
And then obviously patients who fail to
improve from the choice of therapy we give them
for pyelonephritis or for males who
have suffered recurrent infections.
02:44
And what's the sequence of imaging?
We start looking with a plain film and
what we're looking for are calculi stones
because that can be a reason for either
the first time or recurrent pyelonephritis,
and also we can detect some soft tissue masses.
03:01
Renal ultrasound is the next step.
03:04
And a renal ultrasound can tell you
not only the presence of pyelonephritis,
but perinephric abscess.
03:10
And if it's necessary, a CT scan can
show you intrarenal or perinephric abscess
and I think you can see the perinephric
abscess on this particular projection
For uncomplicated cases, empiric therapy of mild to
moderate pyelonephritis can be done as an outpatient.
03:28
Patients will undergo a urine Gram stain,
culture and antibiotic susceptibility testing.
03:34
There are some basic general
guidelines for the initial antibiotic therapy.
03:37
The treatment choices can
become complex in certain cases.
03:41
The patient's improvement
must be followed very closely
and there should be a low threshold to reevaluate
or admit them should their condition worsen.
03:48
If there is no risk for multi drug
resistant gram negative infections,
for example, patients living in
hospital or long term care facility,
there are three possible treatment choices.
03:57
First, if the patient is not
allergic to fluoroquinolones,
they can be given a 5 to7
day course of Ciprofloxacin.
04:04
If there's more than a 10% community
resistance of E. coli to fluoroquinolones,
intramuscular IV Ceftriaxone is started
and then followed by 5 to 7 days of Cipro.
04:15
And finally, if the patient has
an allergy to fluoroquinolones,
intramuscular IV ceftriaxone is given first and
followed then with trimethoprim sulfamethoxazole
for 5 to 7 days.
04:26
On the other hand, if it's
determined that there are risk factors
for a multidrug resistant gram negative
infection, we have two different options.
04:33
First, if the patient has no
allergies to fluoroquinolones,
they should be started on intramuscular or IV
ertapenem, followed by Cipro for 5 to 7 days.
04:43
If they are allergic to
fluoroquinolones, on the other hand,
they should be started on ertapenem daily
until the cultures and susceptibility results
allow for the transition to a more narrow coverage.
04:53
Empiric therapy for severe cases of pyelonephritis
are generally taken care of as an inpatient
to best allow for the treatment of sepsis
or urinary tract obstruction should it occur.
05:03
The process still involves collecting urine
Gram stain, culture and susceptibility testing.
05:07
But as we will see on the following
slide, the treatment is a bit more complex.
05:12
In treating severe cases,
appropriate imaging must be obtained
usually in conjunction with the specialist.
05:17
Patients are started on a broad spectrum
regimen that has ESBL and MRSA coverage,
such as imipenem plus vancomycin.
05:25
If there's no risk for multi drug
resistant gram negative infection,
patients are then
transitioned to IV Ceftriaxone.
05:32
Vancomycin can be added to this regimen if
the Gram stain shows any gram positive bacteria.
05:37
On the other hand, if the patient does not have
risk factors for the multi drug resistant infections,
patients are transitioned to
piperacillin tazobactam to MIB.
05:46
Again, we cannot bank if the Gram
stain shows gram positive organisms.
05:50
Once the cultures and sensitivities are
finalized, the antibiotic coverage can be narrowed.
05:56
For complicated pyelonephritis you
need to do imaging studies of the kidneys
like CT to determine
the extent of pathology.
06:02
If there's a perinephric
abscess, this should be drained.
06:05
If there is an obstruction, this should be relieved
either by Cystoscopy or with other urologic measures.
06:11
It is very important to carefully select the pair
internal antibiotics based on culture and sensitivity