Acute Pyelonephritis: A Three-Pillar Approach for Clinicians

Tejas P. Desai, MD


October 18, 2018

I often find myself under- or overestimating the incidence of certain nephrology-related conditions. I know this "error" is, in part, due to an "exposure bias" in my practice. I tend to overestimate the incidence of conditions I commonly see and underestimate those that rarely show in my practice.

Which is why I was surprised to learn about the incidence (both national and global) of adult pyelonephritis. Given the specifics of my practice, I thought pyelonephritis was a rare condition that primarily affected women. Reading New England Journal of Medicine reminded me of my exposure bias.[1]

In the United States, the yearly incidence of pyelonephritis is between 459,000 and 1.1 million; globally, the numbers are even more eye-opening: 11-26 million. Although I rarely see pyelonephritis in my practice, these incidences behoove many of us to review our knowledge of this infectious condition and how we (nephrologists) can play our part in treating it.

Three Pillars of Decision-making for Pyelonephritis

Johnson and Russo masterfully break down pyelonephritis into a triad of considerations-something I call the "groups of three."

Treatment Venue

In the first group, one must understand the overarching triad of decision-making; to wit, the location of treatment (home, observation/emergency department, or inpatient hospitalization). The patient's clinical features will primarily determine where treatment will begin.

Individuals who are clinically judged to be suffering mild symptoms can be sufficiently treated at home with oral therapy (more on that later). As acuity worsens, close monitoring is required to ensure that the patient does not deteriorate after initial therapy. In the most severe cases, patients are at increased risk for sepsis and septic shock and require inpatient care with aggressive therapy.


Treatment Options

Once treatment venue has been established, the next triad to focus on is the treatment options. Treatment begins with supportive care: antipyretics, analgesics, antiemetics, and intravenous fluids. Naturally, not all components of supportive care will be needed and different components may be needed at different times in the course of treatment.

Generalized treatment is accompanied by specific antimicrobial therapy; choice of therapy will depend on both patient acuity and treatment venue selected (see below).

Finally, pyelonephritis can be complicated by hydronephrosis and/or kidney abscess formation. It is important for the clinical provider to monitor for slow/no treatment responsiveness and identify complications using various imaging modalities.

Selection of Antimicrobials

Specific treatment of pyelonephritis requires antimicrobial therapy. Oral antimicrobials that have a role in successful treatment include beta-lactam antibiotics (penicillin, cephalosporin), fluoroquinolones, and TMP-SMX. Ultimate selection of an oral antimicrobial will depend on clinical factors and the clinician's anecdotal experience with each option.

For patients whose clinical acuity necessitates intravenous therapy, the recommended choices include beta-lactams, carbapenems, and aminoglycosides.

Thankfully, pyelonephritis is a wholly treatable condition that can be managed by primary care providers, infectious disease specialists, and/or nephrologists. Johnson and Russo have articulated a number of triads in the decision algorithm to help any clinician reach the optimal treatment for most patients. Our infographic summarizes the decision tree and may serve as a quick bedside reminder for future patient encounters.

As always, we encourage you to read the primary article and share your thoughts with us in the comments section below.

Follow Tejas P. Desai, MD, on Twitter: @vnephondemand

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