Acute Pyelonephritis

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Acute Pyelonephritis refers to sudden and severe kidney infection which can be life-threatening. The kidneys are the organs responsible for urine production, and therefore, form part of the urinary tract. Infection affecting any part of the urinary tract can also affect the kidney.

What are the symptoms of acute pyelonephritis?

Symptoms of acute pyelonephritis include:

  1. Fever associated with chills
  2. Nausea and vomiting 
  3. Loin pain
  4. Painful urination
  5. Frequent urination
  6. Inability to hold urine till a convenient time / place (urinary urgency)
  7. Cloudy and foul-smelling urine

What are the causes of acute pyelonephritis?

  1. Ascending bacteria from the lower tract – Bacterial infection may ascend from the urethra to the bladder, and from there, through the ureters to the kidneys; multiplying and increasing in number as they progress in their movement. 
  2. Infection from the blood stream – Bacteria in the blood stream, which may have got there through other organs in the body, can spread to the kidneys as the blood circulates round the body.

What is the mechanism of getting pyelonephritis?

Interruption to free flow of urine constitutes a major pathway to pyelonephritis. When urine flow is sluggish, due to obstruction along the urinary tract, abnormal calibre of the ureters or delay in emptying the bladder, this gives any bacteria that find their way into the urinary tract an ample time to multiply. When they become significant in number, they begin to cause the symptoms listed above. 

Obstruction to urine flow may be caused by kidney or ureteric stone as well as enlarged prostate gland. Also, during pregnancy, the uterus may impinge on the ureters, reducing urine flow. The ureters may be abnormally dilated in some individuals, enhancing accumulation of urine in them due to delayed emptying of their content.

Increased progesterone in pregnancy causes relaxation of smooth muscles (which include the ureters), thus reducing urine flow. People with damage to the nerves controlling the bladder such as those with spinal cord injury are prone to urinary stasis from excess accumulation of urine in the bladder because the bladder has lost the ability to contract in order to empty its content. 

In people with lowered immunity or immune dysfunction such as people with diabetes, HIV/AIDS, cancer or those on prolonged steroid therapy, their ability to fight infective bacteria and other foreign agents is reduced, thus allowing them to multiply once they find their ways into the body. The immune system in the elderly is not as strong as in the young people. Therefore, the ability to resist foreign organisms at old age is reduced.

Sometimes, microorganisms may be introduced into the urinary tract due to instrumentation along the genital tract such as insertion of urinary catheter or its retention for too long; procedures such as bladder examination with cystoscope (an instrument used to view the bladder) or surgery along the urinary tract. If strict infection control mechanism is not put in place during any of these procedures, microorganisms can easily be introduce into the urinary tract which may then culminate in pyelonephritis. 

Bacteria that find their ways into the blood from other infected organs in the body (e.g. lungs) may lodge in the kidneys to multiply and produce symptoms of pyelonephritis. In this case, symptoms of lower utinary tract infection may be absent. There may or may not be symptoms of disease of the primary organs affected from where the infective agent got into the blood stream.

Investigations for acute pyelonephritis

The following investigations may be necessary in management of pyelonephritis:

  1. Urine analysis – This may reveal the presence of bacterial in urine. Other parameters which may point to urinary tract infection include: blood in the urine, nitrite, protein and white blood cells.
  2. Urine culture – This helps to identify the bacteria present in the urine and their antibiotics sensitivity so as to know which antibiotics is best for treatment. The most common organism responsible for urinary tract infection such as pyelonephritis is Escherichia coli (E. coli). Other organisms include Staphylococcus aureus, Proteus mirabilis etc.
  3. Ultrasound – Ultrasound scan may be useful in identifying obstruction to urine flow such as tumours (swelling), stones etc in the kidneys or along the urinary tract. It may also help to detect abnormal size of the urinary tract.
  4. CT Scan – This may help detect any obstruction within the urinary tract, not detected by ultrasound and help to locate the exact site of the obstruction.

What is the treatment modality for acute pyelonephritis?

1. Antibiotics – Antibiotics are the mainstay of treatment of pyelonephritis. At the point of diagnosis, before antibiotics sensitivity is obtained (which may take up to 48 hours), broad spectrum antibiotics may be used for treatment. These are antibiotics that many organisms respond to. Oral or intravenous route may be used, depending on the severity of the symptoms.

If you require intravenous drugs, hospital admission may be necessary. Once you can tolerate orally, your drugs may be converted to oral, except if the particular drug which the organism is sensitive to is not available in oral form. Once the antibiotics sensitivity is obtained, the drug of treatment may be changed to the one the organism is sensitive to.

However, if you are already getting improvement on the drug you are currently taking, there may not be need to change based on sensitivity, The drug dosages should be completed, even if the patient gets relieved with the first few doses. This is necessary for complete cure and to prevent the organism from developing resistance.

2. Analgesics – Pain relief drugs may be necessary if you have severe pain. This helps to give you comfort while the antibiotics take care of the bacteria causing the infection.

3. Hydration – During treatment, you need to drink plenty water. If oral intake cannot be tolerated, the water may be given to you through you veins. This is important to increase urine flow along the urinary tract. Increased urine flow helps flush the bacteria along the urinary tract away. 

Complications of acute pyelonephritis - If there is delay in treating acute pyelonephritis or it is not properly treated, complications may ensue. Some of these complications include:

  1. Spreading of infection to other organs of the body
  2. Sepsis (infection in the blood)
  3. Acute kidney failure
  4. Chronic kidney disease
  5. Kidney abscess (pus in the kidney) 

Prevention of acute pyelonephritis

  1. Adequate water intake to increase urine flow and flush bacteria from the urethra.
  2. Women should wipe from front backwards after using the toilet.
  3. Urinating after sex helps to wash away bacteria which may have been pushed into the urethra during sexual intercourse.
  4. Urethral catheter should not stay for too long. If prolonged catheterisation is necessary, frequent change of the catheter can help prevent urinary tract infection.
  5. Bladder emptying should not be delayed when there is urge to urinate .
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