ACUTE PYELONEPHRITIS P 1127 1129 Pyelonephritis o Inflammation of the renal parenchyma and collecting system including the renal pelvis o Bacterial infection is the most common cause fungi protozoa and viruses also possible Bacteria from intestinal tract E coli proteus klebsiella or enterobacter o Usually begins with lower urinary tract colonization infection via ascending urethra Usually starts in the renal medulla adjacent cortex o Causes risk factors Vesicoureteral reflux retrograde urine movement from lower to upper urinary tract lower urinary tract dysfunction NPH stricture stone indwelling cath Pregnancy induced urinary system changes o Reoccurring episodes scarred poorly function kidneys and chronic pyelonephritis Urosepsis o Systemic infection arising from a urologic source o Septic shock can occur if not diagnosed and treated quickly 15 death Outcome of unresolved bacteremia involving a gram negative organism Mild fatigue chills fever vomiting malaise flank pain and LUTS of cystitis dysuria urgency frequency Costovertebral CVA tenderness on effected side CLINICAL MANIFESTATIONS DIAGNOSTIC STUDIES Urinalysis o Pyuria bacteriuria and hematuria o WBC casts indicating renal parenchyma involvement CBC leukocytosis with a shift to the left with increase in immature neutrophils bands Urine cultures blood cultures if sepsis is suspected Ultrasonography of the urinary system identify anatomic abnormalities hydronephrosis renal abscess or obstructing stone o Assess for complications impaired renal function scarring abscess and chronic pyelo IVP and CT scan with IV contrast media usually contraindicated to prevent infection spread in the early stages of pyelonephritis COLLABORATIVE CARE AND DRUG THERAPY Mild symptoms uncomplicated infections o 14 21 days of antibiotic treatment o Outpatient management or short hospital stay Empirically selected broad spectrum antibiotics ampicillin vancomycin combined with an aminoglycoside tobramycin or gentamicin Results of urine and blood cultures sensitivity guided therapy trimethoprim sulfamethoxaole Bactrim Septral o Fluoroquinolones ciprofloxacin cipro ofloxacin Floxin norfloxacin noroxin and gatifloxacin tequin o NSAIDs or antipyretic drugs o Follow up urine culture and imagining studies Severe Symptoms o Hospitalization needed o Parenteral antibiotics 14 21 days therapy inpatient 14 21 days outpatient Empirically selected broad spectrum antibiotics ampicillin vancomycin combined with an aminoglycoside tobramycin or gentamicin Results of urine and blood cultures sensitivity guided therapy trimethoprim sulfamethoxaole Bactrim Septral o Oral antibiotics when patient tolerates oral intake o Adequate fluid intake parenteral initially oral when N V dehydration subside o NSAIDs and antipyretic drugs to reverse fever and relieve discomfort o Urinary analgesics o Follow up urine culture and imagining studies S S improve within 48 72 hours of therapy initiation Relapse treated with 6 weeks of antibiotic therapy Effectiveness of therapy is evaluated in accordance with the presence or absence of bacterial growth on urine culture common test question Urosepsis characterized by bacteriuria in urine and bacteremia in blood o If this is a possibility close observation and vital sign monitoring o Prompt recognition and treatment to prevent septic shock NURSING IMPLEMENTATION Patient goals no reoccurrence o Normal renal function normal body temperature no complications relief of pain and Early treatment of cystitis UTIs to prevent ascending infection to the kidneys Patients with structural abnormalities should be prompted to receive regular medical care Nursing interventions patient teaching o Continue medications as prescribed o Need for follow up urine culture to ensure proper management o Identification of risk for reoccurrence and relapse o Drink at least eight glasses of fluid every day Rest indicated to increase patient comfort Long term low dose antibiotics may be needed for frequent relapse or reinfections Proper education patient understanding of therapy rational better compliance CHRONIC PYELONEPHRITIS P 1129 AKA interstitial nephritis chronic atrophic pyelonephritis and reflux nephropathy Kidneys have become small atrophic and shrunken lost function due to scarring and fibrosis o Most often due to reoccurring infections of the upper urinary tract Can occur in absence of existing recent infection or UTI Diagnosed by radiologic imagine or histologic testing not clinical features o Images reveals small contracted kidneys with thinned parenchyma o Reveals loss of functioning nephrons infiltration of the parenchyma with inflammatory cells and fibrosis Level of function dependent on number of kidneys affected magnitude of scarring and presence of coexisting infections Often progresses to ESRD if both kidneys are involved even if infection is treated