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The Medical Journal of Australia May 2024
Topics: Humans; Anti-Bacterial Agents; Australia; Emphysema; Klebsiella Infections; Klebsiella pneumoniae; Pyelonephritis
PubMed: 38514253
DOI: 10.5694/mja2.52265 -
The Journal of Emergency Medicine Apr 2024In the emergency department (ED), pyelonephritis is a fairly common diagnosis, especially in patients with unilateral flank pain. Xanthogranulomatous pyelonephritis...
BACKGROUND
In the emergency department (ED), pyelonephritis is a fairly common diagnosis, especially in patients with unilateral flank pain. Xanthogranulomatous pyelonephritis (XGP) is a rare type of pyelonephritis that is associated with unique features, which may lead to its diagnosis.
CASE REPORT
A 30-year-old male patient presented to the ED for evaluation of right-sided abdominal pain that has been ongoing for the past 24 hours. He noted the pain was located predominantly in the right flank and described it as sharp in nature. The pain was nonradiating and was associated with scant hematuria. He stated that he had similar pains approximately 1 month earlier that resolved after a few days. The patient underwent a bedside ultrasound and a subsequent computed tomography (CT) scan of the abdomen and pelvis, which showed an enlarged, multiloculated right kidney with dilated calyces and a large staghorn calculus, findings that represent XGP. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report highlights an unusual variant of pyelonephritis, a relatively common ED diagnosis. XGP should be considered in patients with recurrent pyelonephritis, as treatment for XGP may require surgical intervention in addition to traditional antibiotic management.
Topics: Male; Humans; Adult; Pyelonephritis, Xanthogranulomatous; Kidney; Pyelonephritis; Tomography, X-Ray Computed; Flank Pain
PubMed: 38485571
DOI: 10.1016/j.jemermed.2023.11.021 -
The Journal of Antimicrobial... May 2024Urinary tract infections (UTIs) are commonly treated in the emergency department (ED), and unfortunately, resistance to first-line agents is increasing. (Observational Study)
Observational Study
BACKGROUND
Urinary tract infections (UTIs) are commonly treated in the emergency department (ED), and unfortunately, resistance to first-line agents is increasing.
OBJECTIVES
To characterize treatment of pyelonephritis in a nationally representative sample of ED patients and to identify patient- and treatment-specific factors associated with receiving initial inactive antibiotics.
METHODS
We conducted a multicentre, observational cohort study utilizing the Emergency Medicine PHARMacotherapy Research NETwork (EMPHARM-NET), comprising 15 geographically diverse US EDs. All patients ≥18 years of age with a diagnosis of pyelonephritis between 2018 and 2020 were included. The primary endpoint was the proportion of patients who received initial inactive empirical antibiotic therapy and to identify predictive factors of inactive antibiotic therapy.
RESULTS
Of the 3714 patients evaluated, 223 had culture-positive pyelonephritis. Median patient age was 50.1 years and patients were mostly female (78.3%). Overall, 40.4% of patients received an IV antibiotic, most commonly ceftriaxone (86.7%). The most frequently prescribed antibiotics were cefalexin (31.8%), ciprofloxacin (14.3%), cefdinir (13.5%) and trimethoprim/sulfamethoxazole (12.6%). Overall, 10.3% of patients received initial inactive therapy. After adjustment in a multivariable analysis, long-acting IV antibiotic was predictive of inactive therapy (OR 0.23, 95% CI 0.07-0.83).
CONCLUSIONS
In our prospective, multicentre observational study, we found that only 40.4% of patients with pyelonephritis received empirical IV antibiotics in the ED, contributing to inactive therapy. Receipt of long-acting IV antibiotics was independently associated with a decreased rate of initial inactive therapy. This reinforces guideline recommendations to administer long-acting IV antibiotics empirically in the ED upon suspicion of pyelonephritis.
Topics: Humans; Pyelonephritis; Female; Male; Emergency Service, Hospital; Middle Aged; Anti-Bacterial Agents; Adult; United States; Aged; Urinary Tract Infections; Patient Discharge; Cohort Studies; Practice Patterns, Physicians'
PubMed: 38482607
DOI: 10.1093/jac/dkae070 -
World Journal of Urology Mar 2024We aimed to assess the impact of the timing of urinary drainage on clinical outcomes in patients with obstructive pyelonephritis (OPN) associated with upper urinary...
Impact of timing of urinary drainage on clinical outcomes in patients with obstructive pyelonephritis associated with upper urinary tract stones: a propensity score-matched analysis.
OBJECTIVE
We aimed to assess the impact of the timing of urinary drainage on clinical outcomes in patients with obstructive pyelonephritis (OPN) associated with upper urinary tract (UUT) stones.
METHODS
We retrospectively evaluated the multicenter dataset of 240 patients with OPN associated with UUT stones who underwent urinary drainage. We divided the patients into two groups depending on the timing of urinary drainage; emergency drainage, defined as within 12 h from admission, and delayed drainage, defined as between 12 and 48 h from admission. The outcomes were the length of hospital stay, time to leukocyte normalization, and time to body temperature normalization. One-to-two propensity score matching (PSM) was applied to minimize the effect of confounders between the two groups. Subsequently, predictive patient factors for emergency drainage were analyzed using the logistic regression model.
RESULTS
Only the time from admission to normal body temperature was significantly shorter in the emergency drainage group when compared with the delayed drainage group (median: 2 vs. 3 days; p = 0.02), while there was no difference in time from drainage to body temperature normalization between the two groups. On multivariable analysis, high pretreatment C-reactive protein (CRP) was associated with implementing emergency drainage within 12 h.
CONCLUSIONS
The timing of urinary drainage was only associated with the duration of high fever, but it did not affect the postdrainage course. Emergency urinary drainage is more likely to be performed in severe patients, such as high pretreatment CRP.
Topics: Humans; Drainage; Propensity Score; Pyelonephritis; Retrospective Studies; Urinary Calculi; Urinary Tract; Multicenter Studies as Topic
PubMed: 38478082
DOI: 10.1007/s00345-024-04871-z -
BMC Microbiology Mar 2024Multi-drug resistance (MDR) has notably increased in community acquired uropathogens causing urinary tract infections (UTIs), predominantly Escherichia coli....
OBJECTIVE
Multi-drug resistance (MDR) has notably increased in community acquired uropathogens causing urinary tract infections (UTIs), predominantly Escherichia coli. Uropathogenic E. coli causes 80% of uncomplicated community acquired UTIs, particularly in pre-menopausal women. Considering this high prevalence and the potential to spread antimicrobial resistant genes, the current study was conducted to investigate the presence of clinically important strains of E. coli in Pakistani women having uncomplicated cystitis and pyelonephritis. Women belonging to low-income groups were exclusively included in the study. Seventy-four isolates from urine samples were processed, phylotyped, and screened for the presence of two Single Nucleotide Polymorphisms (SNPs) particularly associated with a clinically important clonal group A of E. coli (CgA) followed by antibiotic susceptibility testing and genome sequence analysis.
RESULTS
Phylogroup B2 was most prevalent in patients and 44% of isolates were positive for the presence of CgA specific SNPs in Fumarate hydratase and DNA gyrase subunit B genes. Antibiotic susceptibility testing showed widespread resistance to trimethoprim-sulfamethoxazole and extended-spectrum beta-lactamase production. The infection analysis revealed the phylogroup B2 to be more pathogenic as compared to the other groups. The genome sequence of E. coli strain U17 revealed genes encoding virulence, multidrug resistance, and host colonization mechanisms.
CONCLUSIONS
Our research findings not only validate the significant occurrence of multidrug-resistant clonal group A E. coli (CgA) in premenopausal Pakistani women suffering from cystitis and pyelonephritis but also reveal the presence of genes associated withvirulence, and drug efflux pumps. The detection of highly pathogenic, antimicrobial-resistant phylogroup B2 and CgA E. coli strains is likely to help in understanding the epidemiology of the pathogen and may ultimately help to reduce the impact of these strains on human health. Furthermore, the findings of this study will particularly help to reduce the prevalence of uncomplicated UTIs and the cost associated with their treatment in women belonging to low-income groups.
Topics: Humans; Female; Escherichia coli; Escherichia coli Infections; Anti-Bacterial Agents; Pakistan; Urinary Tract Infections; Drug Resistance, Multiple; Pyelonephritis; Cystitis; Uropathogenic Escherichia coli
PubMed: 38454332
DOI: 10.1186/s12866-024-03221-8 -
Hinyokika Kiyo. Acta Urologica Japonica Feb 2024A 19-year-old man had been aware of dysuria and urinary incontinence since childhood but did not seek medical attention. He was diagnosed with acute pyelonephritis due...
[A Case of Neuropathic Lower Urinary Tract Dysfunction Due to Spina Bifida Occulta Discovered at the Age of 19 Years and Successfully Treated with Multidisciplinary Therapy].
A 19-year-old man had been aware of dysuria and urinary incontinence since childhood but did not seek medical attention. He was diagnosed with acute pyelonephritis due to lower urinary tract dysfunction associated with spina bifida occulta and tethered cord syndrome (TCS) due to spinal cord lipoma. After placement of a urethral catheter and antibacterial chemotherapy, the patient was cured of acute pyelonephritis. He was treated with solifenacin and started clean self-intermittent catheterization (CIC). Shortly after the start of CIC, the acute pyelonephritis flared up again, and he was managed with a reinserted urethral catheter until an untethering operation. Preoperative video urodynamics showed that the bladder morphology was Ogawa classification grade III with vesicoureteral reflux (VUR) at 92 ml infusion. With the combination of an untethering operation and additional mirabegron, the functional bladder capacity was increased to 353 ml and VUR improved, allowing for safe urinary management of the CIC. TCS can be diagnosed at any age and requires appropriate urinary management and therapeutic intervention as early as possible after diagnosis.
Topics: Male; Humans; Child; Young Adult; Adult; Urinary Bladder; Spina Bifida Occulta; Urinary Incontinence; Vesico-Ureteral Reflux; Pyelonephritis
PubMed: 38447946
DOI: 10.14989/ActaUrolJap_70_2_55 -
BMJ Case Reports Mar 2024A primipara in her late 20s presented with abdominal pain and pain in the left flank 14 days after a ventouse delivery. She was treated with antibiotics, antiemetics and...
A primipara in her late 20s presented with abdominal pain and pain in the left flank 14 days after a ventouse delivery. She was treated with antibiotics, antiemetics and analgesics with the initial differential diagnosis of cystitis, pyelonephritis or nephrolithiasis. Despite the treatment, the patient experienced increased colic pain and nausea. An ultrasound showed an enlarged left kidney, suggesting pyelonephritis, and thereby, the antibiotic treatment was adjusted accordingly. Despite additional pain medication, pain relief could not be achieved. The diagnosis of ovarian venous thrombosis was considered, and an abdominal CT scan confirmed the diagnosis. The patient was treated with anticoagulant therapy. Hypercoagulability work-up revealed a heterozygous mutation of the Factor V Leiden. Our patient awaits a haematologic follow-up.
Topics: Female; Humans; Pregnancy; Abdominal Pain; Anti-Bacterial Agents; Delivery, Obstetric; Excipients; Pyelonephritis; Renal Veins; Thrombosis; Adult
PubMed: 38442978
DOI: 10.1136/bcr-2023-258877 -
BMJ Case Reports Mar 2024An elderly female patient with left pyelonephritis developed worsening left flank pain, hypotension and a drop in haemoglobin (Hb) from 97 g/L to 67g/L on the third day...
An elderly female patient with left pyelonephritis developed worsening left flank pain, hypotension and a drop in haemoglobin (Hb) from 97 g/L to 67g/L on the third day of her admission. There was no recent trauma, history of coagulopathy or risk factors for renal malignancy or vascular disease.A contrasted CT scan of the kidneys revealed a 3.8 cm left renal subcapsular haematoma with no active contrast extravasation. Her atraumatic subcapsular haematoma fulfils two out of three clinical features of Lenk's triad (acute flank pain, hypovolaemic shock), suggestive of Wunderlich syndrome. Urine and blood cultures grew and she was managed conservatively with culture-directed antibiotics, fluids and blood products.Wunderlich syndrome is a rare complication of pyelonephritis and should be considered in patients with pyelonephritis who develop acute severe flank pain, Hb drop and haemodynamic instability. Appropriate medical and surgical therapies need to be instituted early to ensure good outcomes.
Topics: Female; Aged; Humans; Flank Pain; Pyelonephritis; Kidney; Kidney Neoplasms; Vascular Diseases; Acute Pain; Gastrointestinal Hemorrhage; Hematoma
PubMed: 38442961
DOI: 10.1136/bcr-2023-257325 -
The New England Journal of Medicine Feb 2024Carbapenem-resistant Enterobacterales species and multidrug-resistant are global health threats. Cefepime-taniborbactam is an investigational β-lactam and β-lactamase... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
Carbapenem-resistant Enterobacterales species and multidrug-resistant are global health threats. Cefepime-taniborbactam is an investigational β-lactam and β-lactamase inhibitor combination with activity against Enterobacterales species and expressing serine and metallo-β-lactamases.
METHODS
In this phase 3, double-blind, randomized trial, we assigned hospitalized adults with complicated urinary tract infection (UTI), including acute pyelonephritis, in a 2:1 ratio to receive intravenous cefepime-taniborbactam (2.5 g) or meropenem (1 g) every 8 hours for 7 days; this duration could be extended up to 14 days in case of bacteremia. The primary outcome was both microbiologic and clinical success (composite success) on trial days 19 to 23 in the microbiologic intention-to-treat (microITT) population (patients who had a qualifying gram-negative pathogen against which both study drugs were active). A prespecified superiority analysis of the primary outcome was performed after confirmation of noninferiority.
RESULTS
Of the 661 patients who underwent randomization, 436 (66.0%) were included in the microITT population. The mean age of the patients was 56.2 years, and 38.1% were 65 years of age or older. In the microITT population, 57.8% of the patients had complicated UTI, 42.2% had acute pyelonephritis, and 13.1% had bacteremia. Composite success occurred in 207 of 293 patients (70.6%) in the cefepime-taniborbactam group and in 83 of 143 patients (58.0%) in the meropenem group. Cefepime-taniborbactam was superior to meropenem regarding the primary outcome (treatment difference, 12.6 percentage points; 95% confidence interval, 3.1 to 22.2; P = 0.009). Differences in treatment response were sustained at late follow-up (trial days 28 to 35), when cefepime-taniborbactam had higher composite success and clinical success. Adverse events occurred in 35.5% and 29.0% of patients in the cefepime-taniborbactam group and the meropenem group, respectively, with headache, diarrhea, constipation, hypertension, and nausea the most frequently reported; the frequency of serious adverse events was similar in the two groups.
CONCLUSIONS
Cefepime-taniborbactam was superior to meropenem for the treatment of complicated UTI that included acute pyelonephritis, with a safety profile similar to that of meropenem. (Funded by Venatorx Pharmaceuticals and others; CERTAIN-1 ClinicalTrials.gov number, NCT03840148.).
Topics: Adult; Aged; Humans; Middle Aged; Administration, Intravenous; Anti-Bacterial Agents; Bacteremia; beta-Lactamases; Borinic Acids; Carboxylic Acids; Cefepime; Drug Therapy, Combination; Hospitalization; Meropenem; Microbial Sensitivity Tests; Pyelonephritis; Urinary Tract Infections; Drug Resistance, Bacterial
PubMed: 38354140
DOI: 10.1056/NEJMoa2304748 -
Hinyokika Kiyo. Acta Urologica Japonica Jan 2024A 65-year-old man presented with a history of rectal cancer 20 years prior that led to the development of a cutaneous ureterostomy and a colostomy. Subsequently, the...
A 65-year-old man presented with a history of rectal cancer 20 years prior that led to the development of a cutaneous ureterostomy and a colostomy. Subsequently, the patient was diagnosed with acute complicated pyelonephritis due to a right ureteral stone. After the placement of a single J ureteral stent in the right ureter for therapeutic management, the patient was referred to our institution for treatment of the right ureteral stone. An abdominal computed tomography (CT) revealed an 11×8 mm stone in the upper right ureter. A 10/12 Fr ureteral access sheath was inserted through the cutaneous ureterostomy and retrograde ureteroscopic lithotripsy was performed. Although a febrile urinary tract infection appeared postoperatively, the patient was discharged on the sixth postoperative day. At postoperative 1-month, CT showed no residual stones and no hydronephrosis. The use of a ureteral access sheath in performing retrograde ureteroscopic lithotripsy effectively managed the ureteral stone with cutaneous ureterostomy.
Topics: Male; Humans; Aged; Ureter; Ureteroscopy; Ureterostomy; Ureteral Calculi; Lithotripsy; Urinary Diversion; Pyelonephritis; Treatment Outcome
PubMed: 38321745
DOI: 10.14989/ActaUrolJap_70_1_17