My Synopsis of "Diagnosis and Treatment of Acute Pyelonephritis in Women"

My Synopsis of:
Diagnosis and Treatment of Acute Pyelonephritis in Women
RICHARD COLGAN, MD, and MOZELLA WILLIAMS, MD, University of Maryland School of Medicine, Baltimore, Maryland JAMES R. JOHNSON, MD, University of Minnesota, Minneapolis, Minnesota
Am Fam Physician. 2011 Sep 1;84(5):519-526.
http://www.aafp.org/afp/2011/0901/p519.pdf

     Pyelonephritis occurs when a bacterial infection from the bladder spreads up the ureter to the kidney and renal pelvis. It is most prevalent in females between 15-29 years old.  The most common bacteria is E. coli, followed by K. pneumoniae, S. saprophyticus, P. aeruginosa, GBS, and enterococci.  Risk factors include having sex at least three times a week per month,  previous UTIs, new sexual partners, spermicide use, and a family history of UTIs. Complicated pyelonephritis occurs in patients with an abnormal genitourinary tract.  Imaging (CT with contrast) is not necessary unless the symptoms are not resolving and an abnormal tract is suspected. Kidney function and metformin use will need to be addressed when contrast is used. These patients may present with a polymicrobial infection and a higher likelihood of antibiotic resistance.
     Clinical findings of pyelonephritis include urinary frequency, urinary urgency, dysuria, abdominal pain, fever, chills, malaise, nausea, vomiting, anorexia, and flank pain. Urinalysis will show leukocyte esterase, pyuria, hematuria, and WBC casts. A urine culture will grow at least "10 to the fifth degree" CFUs. A peripheral blood smear will show leukocytes. A blood culture is only used if the patient is sick enough to be admitted.
     Uncomplicated pyelonephritis can be managed as an outpatient. Patients who may need hospitalizations are those with comorbid conditions, hemodynamic instability, male, pregnancy, toxic appearance, severe flank or abdominal pain, or anorexia. Treatment in outpatient cases can be done with fluoroquinolones as long as the community resistance of E. coli is less than 10%.  Patients can get there first dose intravenously and then step down to an oral preparation. IV route is also better if the patient is having nausea and vomiting.  If E. coli resistance is above 10%, then a dose of ceftriaxone or gentamicin is given first. TMP/SMX is only effective in patients with known sensitivity. In certain cases it is given empirically with ceftriaxone or gentamicin.
    Complicated pyelonephritis usually gets admitted. They are started on a fluoroquinolone, an aminoglycoside, a broad spectrum cephalosporin, or a carbapenem.  They can also eventually step down to an oral medication. Pregnant women are given a second or third generation cephalosporin.
     Patients should improve in two to three days. If not, then a different treatment or alternative diagnosis should be considered.