Pyelonephritis

You are the urology CT1 asked to see a 32-year old lady with 12-hour history of fever of 39C, rigors and right costo-vertebral angle pain. She had been treated for cystitis by her GP 1 week ago, however she only completed 3 days worth because she lost the tablets. How would you proceed?

Example answer introduction

I suspect that this lady may have complicated pyelonephritis. I would take a focused history, perform a focused examination and request the relevant investigations depending on my clinical suspicions. I would then initiate treatment and escalate to my registrar for senior review. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications 

  • Past medical history – Previous renal tract infections or calculi, gynaecological history, sexual history, (pelvic inflammatory disease is an important differential, as is prostatitis in men)

  • Last meal

  • Events leading up to this point – duration of symptoms, nausea and vomiting, dysuria, frequency, hesitancy, urgency, haematuria, nocturia, when last passed urine and amount

Abdominal examination and initial investigations

Abdominal examination

 

  • Inspect – distention, surgical/traumatic scars, 

  • Auscultate – bowel sounds 

  • Palpate – Localised costo-vertebral tenderness, suprapubic tenderness. Guarding, rebound tenderness, peritonism should be absent

  • Pelvic examination may be indicated if symptoms are not convincing for a UTI – assess cervical motion, uterine tenderness – with chaperone present 

 

I would then request further investigations – 

 

  • Urine dip – looking for blood, leukocytes, nitrites, glucose, ketones

  • Send urine for microscopy and culture

  • Bladder scan

  • Depending on my findings she may require a CT kidneys, ureters and bladder (KUB) but I would discuss this with the registrar first. 

Example questions to progress the station

Q1 What are the indications for imaging in acute pyelonephritis?

Immunocompromised patients such as poorly controlled diabetics, AIDS and organ transplant patients. Septic patients or those in septic shock. Failure to improve with 48-72 hours of antibiotic therapy and in those in whom an obstructed system is suspected (decline in renal function on admission). 

 

Q2 She is septic, and her urine dip shows pyuria. You suspect she has pyelonephritis. What would you do next?

I would implement the sepsis-6 protocol and treat her with antibiotics according to local protocol. I would then inform the urology registrar to review and decide need for further imaging. 

Initial management

  • IV antibiotics according to local protocol 

  • Catheterise

  • Analgesia according to the WHO pain ladder

  • IV crystalloids to maintain urine output of 0.5ml/kg/hr 

  • Keep nil-by-mouth

  • Prep for theatre – if CT showed obstructed system or renal abscess. 

  • Keep patient and any relatives informed

  • Document, document, document!!!

Escalation
I would inform the Registrar to review the patient in a timely manner, to ensure my diagnosis and management plan were correct.
It may be expected of you to put the patient on the emergency list so close communication with theatre staff and anaesthetics may be necessary. 
Rarely patients with urosepsis can become haemodynamically compromised. Be aware that liaising with HDU/ICU may be necessary. 
Useful Resources

International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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