Pyelonephritis

Pyelonephritis

1. Manifestations (Lewis et al, 2014, p. 1295; Scott, Haake, Churchill, Justice & Kim, 2015)

   • Signs
     • Vomiting
     • Fever
     • Hematuria
     • Bacteriuria
     • Pyuria
     • White blood cells (WBC's) in urine
       • Patients having WBC's present in the urine indicates the presence of a bacterial infection (Kim, Yim & Yoo, 2017)
     • Urosepsis
       • Presents an emergency, if not treated promptly, can lead to irreversible damage or death (Lewis et al., 2014)
   • Symptoms
     • Mild fatigue
     • Flank pain
     • Malaise
     • Onset of chills
     • Dysuria
     • Urgency
     • Frequency
     • Costovertebral tenderness

2. Care

   • Collaborative
     • Interdisciplinary Team
       • Physician
         • Continuous collaboration is required as the health status of the patient changes
       • Nurses
         • Collaboration among the unit nurses involved for continuous care
       • Dietician
         • Diet reflects patient's nutritional needs
         • Can provide education on managing diet and fluid intake
       • Occupational Therapist
         • Ability to perform/continue ADLs
       • Pharmacist
         • Prescribed medication; dose and route are appropriate
     • LHINs
     • Personal Support Worker
     • With Patient
     • Patient's family/guardians
       • Able to Provide Support
     • Social Assistance
   • Nursing
     • Patient-Centred Care
       • Identify Realistic Goals and Outcomes
         • Develop specific care plan to reflect patient's needs
           • On-going assessments of changes in health status
             • Evaluate effectiveness of nursing interventions
               • Changes in voiding pattern
               • Patient's physical condition
               • Presence of urinary tract alteration
     • Have knowledge and understanding of manifestations related to illness
       • Identify assessments that need immediate medical intervention
       • Physical Assessments
         • Neurological
           • Decrease level of consciousness
             • fluid retention causing pressure changes in interstitial fluid
         • Cardiovascular
           • Impaired kidney function can cause changes in blood chemistry, electrolytes, and fluid volume
             • Changes in heart rate, rhythm, and contractility
             • Hyperkalemia
               • Can cause fatal heart arrhythmia
             • Increased fluid volume increases cardiovascular workload
               • High Blood pressure
                 • Ventricular Hypertrophy
                   • increased risk for heart attack and stroke
               • Right Sided Heart Failure
             • Hypokalemia
               • lead to sudden cardiac arrest
         • Respiratory
           • Hypervolemia from impaired kidney function
             • Pulmonary edema
               • shortness of breath
               • poor gas exchange
               • decreased oxygenation of blood
               • crackles during ascultation
         • Genitourinary
           • changes in output
           • painful voiding
           • change in continence
           • change in frequency
           • change in color, order and appearance
           • hematuria
         • Vital Signs
           • Heart Rate
           • Blood Pressure
           • Oxygention Saturation
           • Temperature
             • High temperature indicates fever-sign of infection
           • Respirations
           • Pain
             • Increased pain and tenderness sign of further assessment
       • Blood Lab values
         • increased white blood cells indicate infection
         • decreasing white blood cells indicate interventions are having a therapeutic effect
         • changes in electrolyte balance

3. Treatment and Management

   • Medications
     • Antibiotics
       • Fluoroquinolone
         • These antibiotics are used as a first-line treatment when treating patients with pyelonephritis. The problem with using these streams of antibiotics is that it places the bacteria involved with the infection at a greater risk for treatment failure, that is caused by bacterial resistance (Vogler & Pavich, 2018, p. 2057).
           • The serious effects from these antibiotics are prolonged QT interval and Clostridium difficile (Vogler & Pavich, 2018, p. 2057).
             • Example: Ciprofloxacin and Levofloxacin
       • Cephalosporin
         • These antibiotics are useful in treating broad spectrum bacteria by interring with cell-wall synthesis of the bacteria. This is a reccommended antibiotic in the treatment of patients with uncomplicated pyelonephritis (Vogler & Pavich, 2018, p. 2057).
           • Example: Ceftriaxone
             • The recommended dose is 1000 mg (Vogler & Pavich, 2018, p. 2054).
       • Sulfonamides
         • This strain of antibiotics are commonly used when the causative agent of the infection is unknown (Vogler & Pavich, 2018, p. 2057). They are useful in inhibiting the growth of bacteria and are used as the first-line of treatment for pyelonephritis. The serious effects from these antibiotics are nephrotoxicity, hepatotoxicity and hypersensitivity reactions (Vogler & Pavich, 2018, p. 2057)
           • The problem with using these streams of antibiotics is that it places the bacteria involved with the infection at greater risk for treatment failure, that is caused by bacterial resistance (Vogler & Pavich, 2018, p. 2057).
             • Example: trimethoprim-sulfamethoxazole, also known as Septra
       • The usual treatment length is 14 to 21 days, starting with IV therapy when the patient requires hospitalization. The IV antibiotics involved in this treatment include an fluoroquinolone, with or without ampicillin, cephalosporin or penicillin, with or without aminoglycoside or carbapenem (Hong & Seifert, 2015).
         • When the patient is able to go home, then they are prescribed oral antibiotics when symptoms started to resolve (Lewis et al., 2014, p. 1296)
       • Due to reinfections being so common among patients with pyelonephritis, antibiotics are used as prophylaxis measures and long-term medication therapy (Lewis et al., 2014, p. 1296).
     • Nonsteroidal anti-inflammatory drugs (NSAIDS)
       • NSAIDS are given to treat the inflammation of the kidney associated with pyelonephritis.
     • Antipyretics
       • This medication is used to treat fever experienced as a result from the bacterial infection.
     • Urinary analgesics
       • These medications are used for any lower urinary tract pain or symptoms and discomfort (Lewis et a., 2014, p 1296).
   • Surgical Interventions
     • Invasive procedure often the last resort in patients with pyelonephritis.
     • Surgery is required if there are any obstructions within the kidney , resulting from kidney stones.
     • Nephrectomy
       • If the bacterial infection is so severe and comprises the function of the kidney, a nephrectomy may be indicated to remove either part of the kidney or the whole kidney (Lewis et al., 2014, p. 1323).
   • Adequate fluid intake
     • This is to ensure the patient is not dehydrated and to replace any fluids the patient may have lost through vomitting or diarrhea.

4. Infection within the kidneys or renal pelvis, occurring as a complication of an ascending urinary tract infection (UTI). The urinary tract system under normal conditions is sterile and consists of two kidneys, two ureters, the bladder and urethra, listed in descending order. Together they function as the body's drainage system, filtering wastes and fluid from the bloodstream, eliminating the aforementioned in the form of urine. Healthy kidneys control fluid balance, electrolytes (Na, K, Ca, Mg, Acid) and regulates blood pressure and red blood cell counts (Lewis et al, 2014).

   • Main Causes (Belyayeva & Jeong , 2019; Imam, 2018; Keenan, O'Rourke & Courtney, 2017; Lewis et al, 2014)
     • Acute Pyelonephritis
       • Enteric gram-negative bacteria (More Common)
         • Escherchia coli
           • Normal intestinal flora
           • 21-54% of cases
         • Proteus mirabilis
           • 1-10% of cases
         • Klebsiella
           • 2-17% of cases
         • Psuedomonas aeruginosa
           • 6-20% of cases
         • Enterobacter
           • 2-10% of cases
       • Vesicoureter Reflux
         • A congenital condition where urine flows backwards from the bladder into the kidneys, allowing any active bacteria to flow upwards (NIDDK, 2017). The vesicoureteral junction is where the ureter joins the bladder.
       • Obstruction
         • Outlfow of urine from bladder
           • Neurogenic Impairment of voiding
             • Spastic Bladder: Involuntary contractions
               • Urinary Retention: Inability to completely empty bladder
               • Detrusor-sphincter dyssynergia: Urethral sphrincter muscle contracts instead of relaxing during voiding (Stoffel, 2016).
             • Flaccid Bladder: Absence of contractions
               • Overflow Incontinence: Leaking or dribbling of overly full bladder
         • Within ureters
           • Urinary Calculie or Kidney Stones
             • Buildup of crystal-forming substances (Calcium, oxalate and uric acid) into hard, pebble-like clumps (Belyayeva & Jeong, 2019).
         • Bowel Distention
           • Constipation
           • Fecal Impaction
       • Gram-positive bacteria
         • Enterococcus faecalis
           • 1-23% of cases
         • Coagulase-negative staphylococci
           • 1-4% of cases
         • Group B streptococci
           • 1-4% of cases
     • Chronic Pyelonephritis
       • Frequent or continuous bacterial infections
       • Spinal Cord Injury
       • Bladder Tumour
       • Ureter Tumour
     • Other Risk Factors (Imam, 2018; NIDDK, 2017; Lewis et al, 2014; Rowe, 2013)
       • Age
         • Infants
         • Elderly > 60 years old
           • Nursing home associated bacterial infection
       • Anatomic Abnormaility
         • Ureteropelvic Junction Obstruction. Restricts urinary flow from kidneys to ureters. Typically within the renal pelvis.
           • Congenital
           • As a result of kidney stone scarring
           • After surgery
       • Foreign Body
         • Catheters
           • Urinary: resides in bladder
           • Ureteric: resides in ureters to treat stricutres
           • Nephrostomy: resides within kidney
       • Immunosuppressed
         • Diabetes mellitus
         • Sickle cell disease
         • Transplantation
         • Malignancy
         • Chemoradiation
         • HIV infections
         • Corticosteroid use
       • Gender
         • Female (Higher Risk)
           • Pregnancy
             • Growing fetus presses against ureters, obstructing urinary flow.
             • Increased progesterone can inhibit contractions within the urinary tract system, resulting in stagnant urine
           • Anatomy
             • Close proximity of urethra to anus.
           • Specific Birth Control Methods
             • Diaphragms
             • Spermicides
         • Male
           • Prostate Enlargement
             • Bladder neck obstruction resulting from pressure of enlarged prostate restricts urinary flow.
       • Sexual Activity
         • Sexually Transmitted Infections
         • New or multiple sexual partners
       • Undiagnosed or untreated cystitis (bladder infection)
       • Inappropriate Antibiotics
         • Resistant Organisms

5. Diagnostic Testing (Keenan, O'Rourke & Courtney, 2017; Lewis et al, 2014; Ramakrishnan & Scheid, 2005)

   • Physical Assessment
     • Discuss any specific and nonspecific urinary symptoms
     • Inspect flanks, ask for discomfort, if any.
     • Gently palpate the costovertebral angle (CVA) for tenderness. Inspect for enlargement, asymmetry, edema or redness, which are signs of inflammation.
   • Psychosocial Assesment
     • Look for feelings embarrassment, guilt or anxiety.
       • May be associated with sexual practices. or habits. Therefore offer a comfortable environment through support and encouragement of telling their history (Lewis et al., 2014)
   • Laboratory Assessment
     • Urinalysis
       • Urine Dipstick Testing
         • Positive leukocyte esterase
           • Indicative of the presence of white blood cells (WBC's) and pus in urine
         • Positive nitirte
           • Indicative of the presence of bacteria in urine
         • Positive hematuria
       • Proteinuria
         • Presence of the protein albumin in urine
     • Blood Cultures
       • C-reactive protein
       • Erythrocyte sedimentation rate
         • Indicators of inflammation
     • Urine Culture CARDINAL SIGN
       • Culture and Sensitivity Test using cysteine, lactose and electrolyte deficient (CLED) agar (Keenan, O'Rourke & Courtney, 2017).
         • Determines the presence of gram-negative or gram-positive organisms and the species (Lewis et al., 2014).
         • Shows the resistance of the specific organism to certain antibiotic treatments.
         • Best obtained via the clean-catch method. Patients are instructed to wipe urethra opening with sterile wipe. Urinate first into toilet. Pausing the flow of urine then urinating into urine sample cup (Ramakrishnan & Scheid, 2005)
   • Imaging Assessment
     • Intravenous urography
       • X-ray of the kidneys, ureters, bladder and urethra using a contrast dye intravenously (Ramakrishnan & Scheid, 2005)
         • Diagnoses renal infection, stones or obstructions.
     • Magnetic Resonance Imaging (MRI)
     • Computted Tomography (CT)
     • Ultrasound

6. Prevention

   • Acute
     • Cause is bacterial infection
       • Patient education on genitoury hygiene practices
         • Include frequent voiding and avoid purposeful retention as this encourages bacterial growth
         • Education for diabetic patients on the importance of managing blood sugar levels
           • High glucose levels in urine promote bacterial growth
         • importance of hand washing
         • Urinating after intercourse can help decrease lower UTI occurrence.
       • If incontinence briefs used-change frequently and provide peri-care
         • Bacteria ascend from urethra-therefore dirty environments increase risk for infection
       • seek treatment if suspected lower UTI infection
         • Antibiotics
       • Any patient that had a complicated UTI should be sent for follow up imaging to identify any abnormalities that predispose the patient to further infections.
       • Education on safe sex practices
         • Anal to vaginal intercourse increases risk of infection
       • If urinary device indicated, such as a foley, ensure area is clean and monitor surrounding skin for signs of infection
         • Redness, itching, swelling, abnormal discharge
   • Chronic
     • Reflux associated
       • Treatment includes prophylactic antibiotics, endoscopic injection of dextranomer hyaluronic acid, and antireflux surgery
     • Obstructive
       • Determine type of obstruction
         • Surgery may be indicated
         • Chronic obstruction could be caused by recurring kidney stones which my be corrected with diet restrictions
     • Patient health history
       • Recurrent UTIs
         • Frequent
           • Increased risk for acute kidney infections leading to chronic damage
             • Collaborate with physician to determine if there are underlying predisposing factors
               • Possible congenital malformation
                 • Causing urine reflux or obstruction
               • Previous injury resulting in healed obstruction
               • Cancer
                 • Tumour

7. Complications

   • Due to pyelonephritis being the inflammation of the kidneys and collecting system, if pyelonephritis is not treated promptly and with the appropriate antibiotics, serious complications can arise (Kennan, O'Rourke & Courtney, 2017, p. 18). Depending on the severity of the infection, the complications can be divided into early or late complications.
     • Early
       • Papillary necrosis
       • Abscess formation
       • Emphysematous pyelonephritis
         • This complication is early but is important to be addressed immediately because it can occur rapidly. It is characterized by a severe necrotizing infection that is accompanied by gas and/or fluid within the kidney and renal organ (Ning Sun, Zhang, Yu & Wang, 2015, p. 1846 e3.). This is of concern, because it can mimic other conditions such as an intestinal obstruction, leading the patient to become misdiagnosed (Ning Sun, Zhang, Yu & Wang, 2015, p. 1846 e3.).
       • Sepsis
       • Multi-organ failure
     • Late
       • Cortical Scarring
         • This is dangerous because it is a trigger for systemic hypertension (Kennan, O'Rourke, & Courtney, 2017, p. 19).
       • Xanthogranulomatous pyelonephritis
         • This is a rare condition that can form, resulting from pyelonephritis. Xanthogranulomatous pyelonephritis is when the kidney becomes inflamed and the functional renal structure of the kidney is replaced by cysts (Motuzko & Germaine, 2016, p. 32). This can often lead to loss of renal function and a possibility for cysts to rupture leading to severe pain and further damage to the kidney.
       • Chronic Kidney Disease
         • This is a late complication that can progress into end-stage renal disease (Keenan, O'Rourke & Courtney, 2017, p. 19).

8. Classifications

   • Acute
     • Sudden development of kidney infection
       • Bacterial infection causing inflammation
         • Can cause decreased/impaired kidney function
         • Occurs as a complication of an ascending urinary tract infection (UTI) which spreads from the bladder to the kidneys and their collecting systems
           • Symptoms usually include fever, flank pain, nausea, vomiting, burning on urination, increased frequency, and urgency.
             • most common are fever and flank pain
           • ascending infections can occur from lower UTI, obstructions (kidney stone) and incomplete bladder emptying leading to bacteria buildup
         • Gram-negative bacteria- the most common being Escherichia coli
           • E. coli can lead to an acute inflammatory response which can cause scarring of the renal parenchyma.
       • Complicated
         • Includes pregnant patients, patients with uncontrolled diabetes, kidney transplants, urinary anatomical abnormalities, acute or chronic kidney failure, as well as immunocompromised patients and those with hospital-acquired bacterial infections
         • “complicated" suggests there is a predisposing reason for the infection, including the presence of abnormal voiding (e.g., neurogenic bladder, stricture, benign prostatic hypertrophy) or a foreign body
       • Uncomplicated
         • Absent structural or functional urinary tract abnormalities and without relevant comorbidities
           • Typically occurs in healthy, young women
             • Women more prone to lower UTIs due to shorter urethra- bacteria ascend to cause upper UTI
   • Chronic
     • Long-standing infection that doesn't clear and can cause kidney scarring
       • characterized by chronic interstitial inflammation and scarring resulting in destruction of nephrons.
         • Chronic pyelonephritis is a cause of Chronic Kidney Disease and is categorized into two forms
           • Reflux-associated
             • Most common
             • Occurs when there is a reflux of urine from the bladder resulting in kidney scarring
           • Oobstructive
             • Occurs from recurrent episodes of kidney infection that result from distal obstruction
     • Signs and symptoms of chronic pyelonephritis will not be present without renal insufficiency

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