Methodological Instructions for Students
Theme : Acute pyelonephritis.
Aim: To teach students to diagnose acute pyelonephritis and principles of treatment of this disease.
Professional Motivation:
Pyelonephritis is common disease. Acute pyelonephritis during the pregnancy is noted 1,5-
2,5% in pregnant women. In elder people this disease is noticed 100 patients out of 10 000 people.
Basic Level:
1. Anatomy, physiology of kidneys.
2. Symptoms of acute pyelonephritis and reasons of them.
3. X-ray, instrumental, laboratory, functional and endoscopic methods of investigation used to diagnose pathology of kidneys.
4. Principles of acute pyelonephritis treatment.
Student's Independent Study Program
I. Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:
1.
Classification of pyelonephritis.
1- The unilateral and bilateral. a-Acute /purulent, serous/ b-chronic; c-relapsing course.
2- By the mode of bacteria pathway there are differed: a- haematogenous /descending/; b- Urogenic /ascending/; c- urolithiasis /infected urinary stones; d- tuberculosis of the kidneys; e- other renal diseases.
By the course, age, stage of the organism there are differed:1- the pyelonephritis of newborn; 2 – the pyelonephritis of the aged patients; 3- the pyelonephritis of the pregnant women; 4- the pyelonephritis in diabetes mellitus patients.
The acute pyelonephritis may be complicated with purulent nephritis, carbuncle of the kidney, the renal abscess, renal insufficiency.
2.
Pyelonephritis aetiology and pathogenesis.
The pyelonephritis arises because of entry of the bacteria into the kidneys and development of the inflammatory process within the interstitial tissue, renal pelvis and calyces.
Etiologic Spectrum. The spectrum of etiologic agents is similar in uncomplicated upper and lower UTI, with Escherichia coli the pathogen in approximately 70–95% and
Staphyolococcus saprophyticus in over 5% of the cases. Occasionally, other Enterobacteriaceae, such as Proteus mirabilis and Klebsiella species or enterococci, are isolated. In as many as 10–
15% of symptomatic patients, bacteriuria cannot be detected with routine methods.
Due to urine pH changes or antibiotics instillations these bacteria transform into L-forms and protoplasts. When the conditions become better they transfer back to the vegetative form.
That’s why there is no growth at the culture mediums while laboratory diagnosis and there isn’t an effect of common treatment. The peculiarity of the pyelonephritis is mixed infections with the resistant bacterial strains.
For practical clinical reasons, urinary tract infections (UTIs) and male genital tract infections are classified according to entities with predominating clinical symptoms:
(1) uncomplicated lower UTI (cystitis); (2) uncomplicated pyelonephritis; (3) complicated UTI with or without pyelonephritis; (4) urosepsis; (5) urethritis, and (6) prostatitis, epididymitis, orchitis.
3.
Primary acute pyelonephritis (clinical signs, diagnosis).

The general symptoms include shaking chills associated with intermittent fever moderate to excessive sweating, headache, mialgia, artralgia, nausea, vomiting, the patients appear quiet ill.
The local signs are pain at the lumbar region that irradiates to the upper portion of the abdomen, into back. The fist percussion over the costovertebral angle overlying the affected kidney is rather painful, positive Pasternatskiy’s symptom. The overlying muscles’ spasm, abdominal distention may be marked. The enlarged painful kidney also may be palpated on first days. The laboratory findings play the main role.
Significant bacteriuria in adults:
1. a10 3 uropathogens/ml of midstream urine in acute uncomplicated cytstitis in female;
2. a10
4
uropathogens/ml of midstream urine in acute uncomplicated pyelonephritis in female;
3. a10
5
uropathogens/ml in midstream urine of women or 104 uropathogens/ml of midstream urine in men (or in straight catheter urine in women) with complicated UTI.
In a suprapubic bladder puncture specimen any count of bacteria is relevant.
Asymptomatic bacteriuria (ABU). ABU is defined as two positive urine cultures taken more than
24 h apart with 105 uropathogens/ml of the same bacterial strain (mostly only the species is available).
Pyuria. The requirement for pyuria is 10 white blood cells per high-power field (E400) in the resuspended sediment of a centrifuged aliquot of urine or per mm3 in unspun urine. For the routine also a dipstick method can be used, including leukocyte esterase test, hemoglobin and probably nitrite reaction.
The quantitative research of culture in 1 ml of urine, kind of pathogen flora, leukocyturia and Shternheimer-Malbin cells are found out. There are other changes that are typical: erythrocyturia /from 2 to 30-40 in field of vision/, proteinuria /up to 1g/l.
4. Treatment of the primary acute pyelonephritis.
The main scheme includes the diet, bed rest, hydratation, desintoxication, general strengthening and specific antibacterial treatment. The bed rest and hospitalization are required. The difficulties of the treatment include the bacterial resistance to the drugs, change of the bacterial strains, alergisation. The diet should be sparing. The energetic support provides carbohydrates and plants fats. The source of proteins may be cheese, hen eggs, then boiled fish and meat.
Spices are forbidden. Vitamins and a lot of fluid are necessary. The salt is limited. Perorate hydratation includes to 3-l of fluid during a day on equal portions. The parenteral hydratation means the endovenous infusion of isotonic, Ringer-Lokk’s, glucose, Polyglycine solutions with vitamins and antibacterial agents. 1,5-2l of the certain solution may be infused for two times a day.
Short courses of antimicrobials are highly effective and are desirable because of the improved compliance that they promote, lower cost, and lower frequency of adverse reactions. Single-dose therapy is generally less effective than longer courses with the same antibiotic. For mild cases, an oral fluoroquinolone for 7 days is recommended as first-line drug. If a Gram-positive organisms is seen on the initial Gram’s stain, an aminopenicillin plus a BLI may be recommended. More severe cases of acute uncomplicated pyelonephritis should be admitted to a hospital and treated parenterally. With improvement, the patient can be switched to an oral regimen using a fluoroquinolone or TMP/SMZ (if active against the infecting organism) to complete the 1- or 2-week course, respectively. In areas with increased resistance rate of E. coli against fluoroquinolones and in situations in which fluoroquinolones are contraindicated, e.g. pregnancy, lactating women, adolescence, a 2nd or 3rd generation oral cephalosporin is recommended. The treatment options are summarized in table 2.
.
5. Secondary acute pyelonephritis (clinical signs, diagnosis).
The main causes of Secondary acute pyelonephritis are urolitiasis, abnormality of urinary system and neoplasms. The excretory urograms show the enlargement of the infected kidney.

The outline of the ileopsoas muscle is absent sometimes, the diffuse shadow about the kidney and moderate scoliosis at the side of the disease are present. There is a slow excretion of the contrast. Calyces are flattered and clubbed, they are filled with contrast later than normal kidney.
The intravenous excretory urogram shows the significant atrophy of the parenchyma of the affected kidney, its deformation because of infiltrates and atonia of the ureter.
Chromocystoscopia shows the range even sometimes the cause of the functional loss of the urine outflow. There can be seen the bullous edema of the uretral orifice because of calculus at the intravesical portion, ureterocele, tumour compression.
The noninvasive methods are useful. These are radionuclide scintygrpahia, nondirect angiography, ultrasonography.
6. Treatment of secondary acute pyelonephritis.
The secondary pyelonephritis requires draining of the kidney, sometimes even the purulent source removal. Before the urine outflow isn’t restored the antibacterial mediums are dangerous especially of the strong action. The bacteriemic shock may develop.
7. Pyelonephritis of pregnant women (aetiology, clinical signs, diagnosis).
The inflammatory process develops while pregnancy, delivery and puerperal period. Most frequently it is observed in pregnant (48%) more rare in puerperal (35%) women. It develops in
1 st
pregnancy, 2 trimester often. There are women 18-25 years old. That is explained by a not complete adaptation to immunologic, hormone changes of the pregnancy. It is supposed not to be a primary disease but activation of latent pyelonephritis. Diagnosis is rather difficult. The enlarged uterine hinders the palpation. The right kidney damage should be differed from the acute appendicitis and cholecystitis. X-ray imaging is inadmissible exclusive rare occasions. The endoscope investigation isn’t recommended too. In case of the suspicion of purulent process the complete clinical research is required including chromocystoscopia, radionuclide renography, scanning, excretory urography, ultrasonography.
8. Treatment of pyelonephritis in pregnant women.
Antibiotics shouldn’t be harmful to fetus. The natural and semisynthetic penicillines are recommended at the 1 st
trimester. Wider choice of antibiotics is at the 2 nd
and 3 rd
trimesters because placenta has its barrier function then. The puerperal women may transfer drugs to child with milk. Treatment should be continuous. Nitrofuranes are admissible after 2 nd
month in dosage 50-100mg per day. Nalidixone acid is admissible after the 4 th
month of pregnancy (2g per day for 2-3 weeks). But its administration must be stopped before delivery.
Usually a 7-day course of antibiotics is recommended, but some authors recommend short-term therapy as for acute cystitis. One to 4 weeks after treatment and at least once more before delivery, follow-up cultures should be obtained. Most symptomatic UTIs in pregnant women represent acute cystitis. Short-term therapy is not as well established yet as in nonpregnant women. For acute pyelonephritis 2nd or 3rd generation cephalosporins, an aminoglycoside or an aminopenicillin plus a BLI may be recommended. Quinolones, tetracyclines, trimethoprim in the first trimester and sulfonamides in the last trimester should not be used during pregnancy. In cases of delayed defervescence and upper tract dilatation a ureteral stent may be indicated and antimicrobial prophylaxis until delivery should be considered. For recurrent UTI low-dose cephalexin (125–250 mg) or nitrofurantoin (50 mg) at night are recommended for reinfection prophylaxis. Postintercourse prophylaxis may be an alternative approach.
The acute purulent pyelonephritis in pregnant women requires the obligate surgical measures. Its scope depends on form of the disease. It is necessary anyway until the delivery.
9. Apostematous pyelonephritis (clinical signs, diagnosis).
There are no change in the urine analysis initially, then proteinuria, leukocyteuria and bacteriuria appear. The hemogram shows leukocytosis and shift to the left.
A plain film of the abdomen may show the enlarging of the kidney. Excretory urograms show kidneys dysfunction. The renogram shows the abnormalities of vascularisation, secretion,

excretion. The renograms may be of the obstructive type that evident the pathologic process in the kidney. Its location may be showed by the scyntygraphia with computing. There are the focuses with decreased accumulation of radionuclide at the scanogram. The primary cause of the disease, calculus of the kidney or ureter may be found while secondary apostematous pyelonephritis at the X-ray examination.
10. Treatment of apostematous pyelonephritis.
The urgent surgical measures are required. The subcostal lumbotomia is performed. The kidney is nuded and decapsulated. The purulent focuses are incised. The retroperitoneal space should be drained and free output of the urine provided by means of the nephrostomia. The surgical drainage should be present until the urine output becomes free, inflammation disappears and renal function normalizes. The postoperative period requires the antibacterial and desintoxicative treatment that is similar to chronic pyelonephritis.
11. Abscess and carbuncle of kidney (clinical signs, diagnosis).
X-Ray-finding is very important. If the renal outline is visible the plain film may show the enlarged kidney or a bulge of the external renal contour. With the perinephral oedema, however, often the renal outline is obliterated and the psoas shadow indistinct. The shadows of the concrements may be sometimes. One can see the deformation and narrowing of the renal pelvis, deviation and indistinct outlines of the calyces on the excretory urograms and pyelograms.
Pyelonephritic changes, urolithiasis may be observed. Delayed pacification may be found.
Carbuncle may be confused with tumour sometimes while the X-ray imaging. The renal angiography usually makes the diagnosis.
12. Treatment of abscess and carbuncle of kidney.
Treatment includes the urgent surgical measures. Lumbotomia is performed. Then decapsulation of the kidney and cone-shaped excision of the carbuncle are done. Incision, curettage and draining of the kidney or enucleating of the carbuncle with its incision may be performed too. The cone excision is organ preserving surgical operation. The cross-shaped incision is made up to the health tissues just after decapsulation (nuding) of the kidney and revision of its surface. It shouldn’t be deeper than 0,5 cm. Then the assistant pull out the internal angles by means of miniature acute hooks. The surgeon with ophthalmic scalpel removes gradually by circular incisions the necrotic masses. But the surgeon gets it out from the surface and next from the deep tissues, orientating to the colour of the tissues and bleeding range.
Moderate venous diffusion evidents the demarcating of necrosis zone from the health tissues.
The cone-shaped hollow cavity forms after the extraction. Moderate tight tamponade with gauze favors the hemostasis and outflow of the vulnus secretion.
The postoperative period requires the antimicrobial treatment with considering of the urine culture and renal tissue culture.
II. Tests and Assignments for Self-assessment
Multiple choice. Choose the correct answer/statement:
1. First change in urine which will prove acute hematogenic first pyelonephritis:
A. Bacteriuria.
B. Leukocyturia.
C. Proteinuria.
D. Haematuria.
E. Hyaline casts.
2. What should we have to do firstly to diagnose pyelonephritis of pregnant women?
1.
Retrograde urography.
2.
Excretory urography.
3.
Cystoscopy.
4.
Radiologic examination.
5.
Chromocystoscopy.

Real life situation to be solved:
1. In cabinet of urology came a women with clinical findings of acute pyelonephritis on right side (body temperature is 38 ° C-40 °С; there are proteins less, leucocytes in analysis of urine). What methods of diagnostic we should provide? What are tactics of treatment?
2. Patient K., at the age of 42, complaints of pain in left side back at the region of kidney with temperature of body is 39,2°C; he's shivering and weak. He is suffering from stone in left kidney during six years.
What complication of disease appears in this patient? What methods of examination we should do to the patient? What are tactics of treatment?
III. Answers to the self-assessment .
The correct answers to the tests:
1. A.
2. E.
The correct answers to the real life situations: l. We must do chromocystoscopy. In case when kidney won't function we should do catherization of kidney.
2. Acute chronic pyelonephritis (the complication apostematous nephritis). We must provide ultrasound screening, retrograde and excretory urography. An operative treatment.
Visual Aids and Material Tools :
1. Slides (chronic pyelonephritis, x-ray of pyelonephritis).
2. Excretory pyelogram.
3. Retrograde pyelogram.
Students' Practical Activities:
Students must know:
1. Pyelonephritis (aetiology, pathogenesis).
2. Classification of pyelonephritis.
3. Primary acute pyelonephritis (clinical signs, diagnosis).
4. Treatment of primary acute pyelonephritis.
5. Differential diagnosis of the primary acute pyelonephritis from tuberculosis of urinary system, from acute diseases of organs of abdominal cavity.
6. Secondary acute pyelonephritis (clinical signs, diagnosis).
7. Treatment of secondary acute pyelonephritis.
8. Pyelonephritis in pregnant women.
9. Treatment of pyelonephritis in pregnant women.
10. Forms of acute pyelonephritis (clinical signs, diagnosis, treatment).
11. Apostematous pyelonephritis (clinical signs, diagnosis, treatment).
12. Abscess and carbuncle of "kidney (clinical signs, diagnosis, treatment).
Students should be able to:
1. Suspect acute pyelonephritis with the complaints of a patient and anamnesis (life history).
2. Make plan of investigation.
3. Make differential diagnosis.
4.
Plan of treatment the patient suffering from acute pyelonephritis.
5.
Estimate analysis of blood and urine biochemical analysis of blood, x-ray, radioisotopical and vascular examination.