[Bilateral acute purulent destructive pyelonephritis after retrograde ureteroscopy and lithotripsy]

The problem of urinary stone disease and acute destructive pyelonephritis remains to be relevant in the current urologic practice. The acute pyelonephritis is the most common infectious and inflammatory complication after retrograde ureteroscopy. According to data of leading urologists in Russian Federation and worldwide, the incidence of acute purulent pyelonephritis ranges from 0.1 to 0.2%. Infectious and inflammatory complications of retrograde ureteroscopy often require urgent interventions. Acute pyelonephritis can result in destructive changes in the renal parenchyma. In case of ineffective conservative measures, pyelonephritis can progress into sepsis with the development of multiple organ failure. Therefore, infectious and inflammatory complications require to start combined antibacterial, anti-inflammatory and detoxification therapy, as well as to resolve any upper urinary tract obstruction. If acute pyelonephritis leads to destructive phase with a formation of a carbuncle or an abscess in the kidney, an open surgery is indicated. Despite being minimally-invasive, retrograde ureteroscopy can lead to serious complications requiring an open surgical intervention. In some cases, the severity of the patients condition may require nephrectomy.

Effects on renal outcome of concomitant acute pyelonephritis, acute kidney injury and obstruction duration in obstructive uropathy by urolithiasis: a retrospective cohort study

OBJECTIVE

Obstruction release from urolithiasis can be delayed with a lack of suggested time for preventing the deterioration of renal function. The objective of this study was to investigate the effect of obstruction duration, concomitant acute kidney injury (AKI) or acute pyelonephritis (APN) during the obstruction on the prognosis of renal function.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

1607 patients from a urolithiasis-related obstructive uropathy cohort, between January 2005 and December 2015.

OUTCOME MEASURES

Estimated glomerular filtration rate (eGFR) decrease ≥30% and/or end-stage renal disease (ESRD), and eGFR decrease ≥50% and/or ESRD, according to obstruction duration, AKI and APN accompanied by obstructive uropathy.

RESULTS

When the prognosis was divided by obstruction duration quartile, the longer the obstruction duration the higher the probability of eGFR reduction >50% (p=0.02). In patients with concomitant APN or severe AKI during hospitalisation with obstructive uropathy, an eGFR decrease of >30% and >50% occurred more frequently, compared with others (p<0.001). When we adjusted for sex, age, hypertension, diabetes mellitus, APN, AKI grades and obstruction release >7 days for multivariate analysis, we found that concomitant APN (HR 3.495, 95% CI 1.942 to 6.289, p<0.001), concomitant AKI (HR 3.284, 95% CI 1.354 to 7.965, p=0.009 for AKI stage II; HR 6.425, 95% CI 2.599 to 15.881, p<0.001 for AKI stage III) and an obstruction duration >7 days (HR 1.854, 95% CI 1.095 to 3.140, p=0.001) were independently associated with an eGFR decrease >50%. Tree analysis also showed that AKI grade 3, APN and an obstruction duration >7 days were the most important factors affecting renal outcome.

CONCLUSIONS

In patients with urolithiasis-related obstructive uropathy, concomitant APN was strongly associated with deterioration of renal function after obstruction release. The elapsed time to release the obstruction also affected renal function.

ABILITY TO FORM BIOFILMS BY PYELONEPHRITIS CAUSATIVE AGENTS IN CHILDREN

The work is dedicated to the study of biofilms formation process by main pyelonephritis causative agents in children in vitro using methods of light, fluorescent and scanning microscopy. To study biofilms formation bacteria were cultivated in liquid substratum on glass in polystyrene Petri dishes d=40mm. The study demonstrated that all isolates formed biofilms. Adhesion of bacteria planktonic forms took place on the first stage, intracellular matrix formation took place on the second stage, and biofilms formation took place on the third stage. During the study of E. coli and Proteus sрр bacteria preparations with the use of scanning and light microscopy ordered bacteria arrangement was seen in the form of separate structures or tiny clusters of bacterial cells united by matrix. During the study of the ability to form P. aeruginosa isolates biofilms with the help of scanning microscopy it was stated that the adhesion of separate bacterial cells occurs by conglomerates formation surrounded by matrix with further biofilms formation. Bacterial cells in the form of dense elongated sticks were seen under the film. P. аeruginosa isolates daily biofilms were stated to have dense structure in the form of gel. Packed biofilms areas with cells clusters with good fluorescence were found with the help of fluorescent microscopy. During daily K.рneumoniae isolates biofilms study by methods of scanning and fluorescent microscopy it was found that K.рneumoniae biofilms were covered with dense matrix and riddled with multiple canals in the form of apertures. During morphological peculiarities study of E. faecalis isolates biofilms formation with the use of scanning and fluorescent microscopy it was found that bacterial cells were densely packed and united by intracellular matrix under which bacteria of spherical shape were seen. Thus biofilms, the nature of which depends on the type of bacteria, are formed on the surface of conglomerates consisting of bacterial cells. Peculiarities of course and appearance of pyelonephritis chronic form and relapses in children is explained by biofilms formation.

Clinical impact of perinephric fat stranding detected on computed tomography in patients with acute pyelonephritis: a retrospective observational study

Perinephric fat stranding (PFS) is often detected on computed tomography (CT) in patients with acute pyelonephritis (APN). However, its clinical impact remains unclear. This study aimed to evaluate the clinical impact of PFS detected on CT in patients with APN. This retrospective observational study included patients with APN who underwent CT (median age, 79.5 years). Patients were classified into PFS (patients with PFS observed on CT) and non-PFS (patients without PFS observed on CT) groups, which were further classified into bacteraemia and non-bacteraemia groups. Clinical findings between the groups were compared. Among 194 patients who underwent CT, 111 (57.2%) patients demonstrated PFS. The rate of bacteraemia was significantly higher in the PFS group than in the non-PFS group (55.2 vs. 23.1%, p < 0.001). CT findings other than PFS were not associated with bacteraemia. The median peak body temperature was significantly higher in the PFS group than in the non-PFS group (38.8 vs. 38.5 °C, p < 0.001); however, the duration of fever and in-hospital mortality rates were not significantly different between the groups. Concordance between blood and urine culture results was observed in 75.0% of the patients; the presence of PFS was not different between patients with concordant and discordant results, regardless of the pre-treatment antibiotic used. Our findings suggest that the presence of PFS in patients with APN predicts bacteraemia; thus, clinicians should consider obtaining blood cultures if PFS is found on CT in patients with APN, even if the patients had received antibiotics prior to admission.

Assessment the Effect of Dexamethasone on Urinary Cytokines and Renal Scar in Children with Acute Pyelonephritis

INTRODUCTION

One of the most serious complications of acute febrilepyelonephritis in children is the development of renal scar. Thisstudy aimed to investigate the effect of dexamethasone on urinarycytokine levels and renal scar in children with acute pyelonephritis.

METHODS

In a double-blind randomized clinical trial, 60 childrenaged 3 months to 12 years with acute febrile pyelonephritis enrolled.The experimental group was treated with a combination of antibioticand dexamethasone, and the control group underwent treatmentwith antibiotic and placebo. The urinary levels of interleukin -6(UIL-6) and -8 (UIL-8) were measured before treatment as baselineand were repeated four days later.

RESULTS

52 cases (23 patients with mean age of 34.19 ± 30.82 monthsin the dexamethasone group, and 29 patients with mean age of50.55 ± 44.41 months in the control group) completed the study. Inthe control group, the UIL-6 and UIL-8 level became significantlylower after four days treatment (P < .05). In the dexamethasonegroup, there was a statistically significant difference between bothUIL-6 and UIL-8 levels before and after treatment (P < .05). Inpatients who had scar on DMSA scan, the mean UIL-8 and UIL-6levels were significantly high before and after treatment.

CONCLUSION

Results of this study showed that dexamethasone plusantibiotic have no clear superiority to antibiotic therapy alone indecreasing inflammatory cytokines and scar formation. We foundout that patients with scar had sustained high levels of biomarkersbefore and after treatment.

Urinary excretion of pentraxin-3 correlates with the presence of renal scar following acute pyelonephritis in children

PURPOSE

Acute pyelonephritis is associated with considerable morbidity and potential for renal scarring. Pentraxin3 (PTX3) is a recently discovered mediator of inflammation. The objective of this study was to investigate the changes in serum and urine PTX3 levels in children who had a history of pyelonephritis and were diagnosed with renal parenchymal scar (RPS) and/or vesicoureteral reflux (VUR).

METHODS

The study included 88 children (31 males, 57 females) aged between 3 months and 18 years. The children included in the study were divided into four groups: VUR with RPS (Group 1), RPS without VUR (Group 2), VUR without RPS (Group 3), and healthy children without a history of hydronephrosis or UTI history (Group 4). After the initial evaluation, the participants were further divided into two more groups and re-evaluated: Children with RPS (Group 1 + 2), children without RPS (Group 3 + 4), children with VUR (Group 1 + 3), and children without VUR (Group 2 + 4).

RESULTS

We found that urine pentraxin 3 (uPTX3) and uPTX3/Creatinine levels were significantly higher in the groups with renal scar with or without VUR than the ones without RPS [mean uPTX3, 3.5 pg/ml (min-max 0.0022-12.3668) vs. 2.2 pg/ml (min-max 0.0022-18.5868) and uPTX3/creatinine, 10.5 pg/mg (min-max 0.0035-51.1) vs. 5.8 pg/mg (min-max 0.0004-78.7), p < 0.01]. uPTX3 levels were not different among the groups with and without VUR. In addition, serum PTX3 levels were not different among the groups.

CONCLUSIONS

We showed that urinary PTX3 increased only in patients with scarred kidneys. These results might be helpful to predict RPS due to past pyelonephritis.

The use of initial dosing of gentamicin in the management of pyelonephritis/urosepsis: A retrospective study

Objective

The primary objective was to determine if initial empirical intravenous dosing of gentamicin improved patient's outcomes in pyelonephritis/urosepsis compared with alternative IV antibiotic management.

Design

Retrospective cross-sectional descriptive study.

Setting

Public TertiaryTeaching Hospital serving adults in an urban centre.

Participants

All adult patient records with a recorded diagnosis of any of pyelonephritis/urosepsis, urinary tract infection, UTI, complicated urinary tract infection, bacteriuria, symptomatic bacteriuria and asymptomatic bacteriuria from 2^nd February 2012 to 10^th May 2014 were reviewed. Only patients treated with an empirical regimen of one or more IV antibiotics were included in the study.

Main outcomes

The primary outcomes were: duration of IV antibiotic treatment, time to resolution of symptoms and length of hospital stay (LOS). Secondary end points were: compliance with Therapeutic Guidelines: Antibiotic (electronic version) (eTG) for severe pyelonephritis/urosepsis and appropriateness of gentamicin use.

Data analysis

Univariate and multivariable associations between baseline and demographic variables and the main outcomes were performed using Chi-square tests and a General Linear Model using the SAS version 9.2 software.

Results

Of 295 patients reviewed 152 were prescribed one or more IV antibiotics and included in the study. Approximately half of the patients (n = 73, 48%) were prescribed IV piperacillin/tazobactam (Tazocin), while gentamicin was prescribed for 66 patients (43.4%). Of the 152 patients evaluated, 49 (32%) were given gentamicin first. Multivariable regression analysis showed that duration of IV treatment was shorter for those aged over 70 (40.2 hours vs 85.5 hours for those aged up to 70; p = 0.0074), and those who received gentamicin as first line treatment (41.3 hours vs 89.8 hours for those not receiving any gentamicin; p = 0.0312). After adjustment for age and gentamicin administration, there appeared to be no significant difference in duration of IV treatment for any other independent variables. No significant associations between the independent variables (gentamicin, age, gender, comorbidities, and eTG compliance) and either time to resolution of symptoms (median: 68 hours) or hospital LOS (median: 5 days) were observed.

Conclusions

Neither time to resolution of abnormal symptoms nor length of stay were significantly influenced by an initial dose of gentamicin when the data were subjected to multivariable analysis. The age of the patient and pattern of gentamicin treatment were the dominant factors associated with duration of IV antibiotics. Piperacillin/tazobactam is not recommended in treatment guidelines for pyelonephritis/urosepsis but was the most commonly prescribed IV antibiotic. This requires review by the appropriate hospital clinicians.

Useful Predictive Factors for Bacteremia among Outpatients with Pyelonephritis

Objective The aim of this study was to identify predictive factors for bacteremia conveniently and quickly among outpatients diagnosed with pyelonephritis. Patients All patients who were diagnosed with pyelonephritis at the outpatient clinic in the Department of General Medicine of Juntendo University Hospital from April 1, 2008, to June 30, 2015, were enrolled. Patients from whom blood cultures had not been taken were excluded. Methods Clinical information was extracted from medical charts. Factors potentially predictive of bacteremia were analyzed using a t-test and Fisher's exact test, followed by a multivariable logistic regression model analysis. Results Blood cultures were drawn from 116 patients, and 25 (22%) presented with bacteremia. A multivariate analysis with the age, chills, platelet count and urine nitrite test results revealed that older age, positive urinary nitrite test results and chills tended to be associated with bacteremia, respectively. [older age: unit odds ratio (OR) 1.02, p=0.052, 95% confidence interval (CI) 1.00-1.05, positive urinary nitrite test findings: OR 2.5, p=0.092, 95% CI 0.86-7.7, chills: OR 2.5, p=0.096, 95% CI 0.84-7.65]. The area under the receiver operating characteristic (ROC) curve of this model was 0.77. Regardless of age, positive urinary nitrite test findings were significantly associated with bacteremia (OR 3.1, p=0.033, 95% CI 1.1-9.2), and chills tended to be associated with bacteremia (OR 2.7, p=0.07, 95% CI 0.93-7.9) The area under the ROC curve of this model was 0.75. Conclusion Bacteremia should be considered in pyelonephritis patients with rapidly assessable factors in outpatient clinic. In particular, a model including a urinary nitrite test has the potential to aid in the prediction of bacteremia.

INTENSITY OF THE ANTIOXIDANT PROTECTION SYSTEM AND OXIDATIVE STRESS FACTORS IN PATIENTS WITH NON-ALCOHOLIC STEATOHEPATITIS DEPENDING ON THE FORM OF CHRONIC KIDNEY DISEASE

The article presents a theoretical generalization of the research results the intensity of the antioxidant protection system and oxidative stress factors in patients with non-alcoholic steatohepatitis depending on the form of chronic kidney disease. The objective of the article - determining the pathogenetic role of the processes of antioxidant protection system in the development and interconnection mechanisms of non-alcoholic steatohepatitis (NASH) and obesity depending on the form and stage of chronic kidney disease (CKD). 177 patients were examined for this purpose, including: 35 patients with NASH with concomitant obesity of І-ІІ degree (1st group), 36 patients with NASH with accompanying obesity of І-ІІ degree and CKD І-ІІ stage: Chronic bilateral pyelonephritis in the phase of exacerbation (2A group), 35 patients with NASH on the background of obesity I-II st. with CKD of the 3rd stage: Chronic bilateral peyelonephritis, exacerbation (2B group), 37 patients with NASH with obesity I-II stage and gouty nephropathy (group 3), 34 patients with NASH, which developed on the background of obesity I-II stages that developed from asymptomatic hyperuricemia (AHU) (group 4). The control group consisted of 30 practically healthy persons (PHP). For the comorbidity of NASH from CKD of the I-III stages. In the form of chronic pyelonephritis, the intensity of oxidative stress increases: the accumulation of intermediate (isolated double bonds, diene conjugates) and terminal (malonic aldehyde, ketodienes and conjugated triines) products of lipids peroxide oxidation, oxidation proteins modification (aldehyde and ketone dinitrophenyl hydrazones of the main and neutral) against the background of the disintegration of the activity of antiradical protection factors (reduction of content in erythrocytes of recovered glutathione, activity of superoxide dismutase, the growth of catalase activity, glutathion-dependent enzymes). Due to the comorbidity of non-alcoholic steatohepatitis with gouty nephropathy and in conditions of asymptomatic hyperuricemia, the degree of oxidative stress is significantly lower due to the strong antioxidant properties of uric acid, but the degree of endotoxicosis predominates in steatohepatitis without kidney damage. The uncontrolled intensification of the processes of free radical oxidation of lipids and proteins in patients with non-alcoholic steatohepatitis that developed on the background of obesity and CKD I-III stages, determines the degree of pathological process activity in the liver and the degree of endotoxicosis.

History of Childhood Kidney Disease and Risk of Adult End-Stage Renal Disease

BACKGROUND

The long-term risk associated with childhood kidney disease that had not progressed to chronic kidney disease in childhood is unclear. We aimed to estimate the risk of future end-stage renal disease (ESRD) among adolescents who had normal renal function and a history of childhood kidney disease.

METHODS

We conducted a nationwide, population-based, historical cohort study of 1,521,501 Israeli adolescents who were examined before compulsory military service in 1967 through 1997; data were linked to the Israeli ESRD registry. Kidney diseases in childhood included congenital anomalies of the kidney and urinary tract, pyelonephritis, and glomerular disease; all participants included in the primary analysis had normal renal function and no hypertension in adolescence. Cox proportional-hazards models were used to estimate the hazard ratio for ESRD associated with a history of childhood kidney disease.

RESULTS

During 30 years of follow-up, ESRD developed in 2490 persons. A history of any childhood kidney disease was associated with a hazard ratio for ESRD of 4.19 (95% confidence interval [CI], 3.52 to 4.99). The associations between each diagnosis of kidney disease in childhood (congenital anomalies of the kidney and urinary tract, pyelonephritis, and glomerular disease) and the risk of ESRD in adulthood were similar in magnitude (multivariable-adjusted hazard ratios of 5.19 [95% CI, 3.41 to 7.90], 4.03 [95% CI, 3.16 to 5.14], and 3.85 [95% CI, 2.77 to 5.36], respectively). A history of kidney disease in childhood was associated with younger age at the onset of ESRD (hazard ratio for ESRD among adults <40 years of age, 10.40 [95% CI, 7.96 to 13.59]).

CONCLUSIONS

A history of clinically evident kidney disease in childhood, even if renal function was apparently normal in adolescence, was associated with a significantly increased risk of ESRD, which suggests that kidney injury or structural abnormality in childhood has long-term consequences.

The clinical impact of bacteremia on outcomes in elderly patients with pyelonephritis or urinary sepsis: A prospective multicenter study

Background

Bacteremia is common in severe urinary infections, but its influence on the outcomes is not well established. The aim of this study was to assess the association of bacteremia with outcomes in elderly patients admitted to hospital with pyelonephritis or urinary sepsis.

Methods

This prospective muticenter observational study was conducted at 5 Spanish hospitals. All patients aged >65 years with pyelonephritis or urinary sepsis admitted to the departments of internal medicine and with urine and blood cultures obtained at admission to hospital were eligible. Transfer to ICU, length of hospital stay, hospital mortality and all cause 30-day mortality in bacteremic and non-bacteremic groups were compared. Risk factors for all cause 30-day mortality was also estimated.

Results

Of the 424 patients included in the study 181 (42.7%) had bacteremia. Neither transfer to ICU (4.4% vs. 2.9%, p = 0.400), nor length of hospital stay (9.7±4.6 days vs. 9.0±7.3 days, p = 0.252), nor hospital mortality (3.3% vs. 6.2%, p = 0.187), nor all cause 30-day mortality (9.4% vs. 13.2%, p = 0.223) were different between bacteremic and non-bacteremic groups. By multivariate analysis, risk factors for all cause 30-day mortality were age (OR 1.05, 95% CI 1.00–1.10), McCabe index ≥2 (OR 10.47, 95% CI 2.96–37.04) and septic shock (OR 8.56, 95% CI 2.86–25.61); whereas, bacteremia was inversely associated with all cause 30-day mortality (OR 0.33, 95% CI 0.15–0.71).

Conclusions

In this cohort, bacteremia was not associated with a worse prognosis in elderly patients with pyelonephritis or urinary sepsis.

Urgent laparoscopic ureterolithotomy for proximal ureter stones accompanied with obstructive pyelonephritis: Is it safe and effective without preoperative drainage?

To evaluate the safety and efficacy of retroperitoneal laparoscopic ureterolithotomy (RLU) in the treatment of proximal ureteral stones accompanied with obstructive pyelonephritis without preoperative drainage.We retrospectively reviewed 21 cases of proximal ureteral stones with infected kidney undergoing RLU between July 2013 and September 2016. Stone-induced obstructive infected hydronephrosis was diagnosed using blood and urine tests and imaging modalities. Empirical effective broad spectrum antibiotic therapy was initiated immediately, and then urgent RLU was performed without preoperative drainage. During the surgical procedure, infected urine was also aspirated before stone was removed. Preoperative, intraoperative, and postoperative clinical data were collected.Operations were performed successfully without open conversion or blood transfusion. The mean operation time was 69.3 ± 12.33 minutes. For all the patients, the level of plasma procalcitonin decreased after RLU. The mean hospital stay duration was 6.4 ± 1.54 days. No septic shock or other severe complications occurred. By discharge, the body temperature and hemogram of each patient returned to normal. A 100% stone-free rate was achieved.Our study suggests that RLU is a potentially safe and effective method to treat proximal ureteral stones accompanied with obstructive pyelonephritis without any need of preoperative drainage.

[Antimicrobial resistance of uropathogens in patients with acute obstructive pyelonephritis]

RELEVANCE

Acute pyelonephritis is known to be the most complicated and severe urinary tract infection occurring in all age groups and accounting for 14% of all kidney diseases. The generally recognized standard antibiotic therapy cannot completely prevent the progression of the disease to its chronic form after relief of its acute manifestations thus leading to a high incidence of relapses. The aim of our study was to investigate the spectrum of uropathogens and their antibiotic sensitivity in acute obstructive pyelonephritis.

MATERIALS AND METHODS

The study comprised 72 patients who underwent semi-rigid ureteroscopy and ultrasonic lithotripsy for ureteral stones. In all patients, bladder urine samples collected by a transurethral catheter were tested bacteriologically using an extended set of culture media within 3 hours after hospital admission. Antibiotics used in antibiotic sensitivity testing for all uropathogens, were grouped into 4 classes (carbapenems, fluoroquinolones, cephalosporins, penicillins). Etiotropic treatment was started upon the availability of the spectrum of microbial patterns, the level of bacteriuria and antibioticogram of uropathogens, 5-6 days after administering initial empirical antibiotic therapy.

RESULTS

The study patients had a high detection rate (83.3%) of canonical uropathogens in the bladder urine identified due to using an extended set of culture media, with a bacteriuria of more or equal 103 CFU/mL. Given the results of local antibiograms, a rational antimicrobial therapy should include carbapenems, namely ertapenem or meropenem as initial empirical antibiotics. Using fluoroquinolones as the first line treatment can lead to an inadequate effect in 15.0 to 67.0% of the cases. The findings of the antibiotic resistance testing of uropathogens to cephalosporins and semisynthetic penicillins showed that they should not be used as initial empirical antibiotic therapy for acute obstructive pyelonephritis in the given department of urology.

Acute focal bacterial nephritis in a cohort of hospitalized adult patients with acute pyelonephritis. Assessment of risk factors and a predictive model

BACKGROUND

Acute focal bacterial nephritis (AFBN) is a complicated form of acute pyelonephritis (APN) characterized by single or multiple areas of localised infection in the kidney without liquefaction or abscess. Studies investigating AFBN in adults are scarce.

AIM

The present study was aimed at evaluating the prevalence, associated factors, and presence of atypical clinical and radiological manifestations in adult AFBN patients. Also, we developed a clinical prediction model to evaluate the probability of AFBN in patients with APN.

METHODS

The clinical records of 377 patients (mean age 54years, 74.0% females) admitted to a hospital over a 5-year period with APN were reviewed.

RESULTS

A total of 57 cases of AFBN were radiologically identified (prevalence, 15.1%). Patients with AFBN were younger and displayed atypical manifestations more frequently than patients without AFBN; these included both clinical and radiological (pleural effusion, gallbladder wall thickening, fluid around the gallbladder, perirenal fluid, and ascites) manifestations. Patients with AFBN showed lower systolic blood pressure and needed more days of therapy to become afebrile, longer total duration of antibiotic therapy, and longer hospital stay than patients without AFBN. Contraceptive use was more frequent in patients with AFBN. A model based on five clinical variables showed good discrimination performance for the diagnosis of AFBN (Area under the curve, 0.77 (95% CI, 0.69-0.89)).

CONCLUSIONS

Patients with AFBN frequently present with atypical clinical and radiological manifestations. Clinical presentation by means of a predictive model may predict the presence of AFBN. Patients with AFBN need more intensive therapy, which is followed by a favourable outcome.

Transition Hand-Off from Inpatient to Outpatient Treatment of Acute Pyelonephritis in an Elderly Male

Pyelonephritis is the progression of a urinary tract infection (UTI) to the kidney. In younger patients the infection may not be as severe and may even be treated with oral antibiotics. However, in elderly males pyelonephritis can be more complex and may require hospitalization and treatment with intravenous antibiotics. In the United States UTIs are responsible for frequent visits to emergency departments by elderly individuals. Current literature suggests that pyelonephritis in elderly males is a serious infection that may result in significant morbidity and mortality. Pharmacists are in a unique position to oversee the transition of antibiotic treatment from the inpatient to outpatienT SETTING.

Derivation of decision rules to predict clinically important outcomes in acute flank pain patients

OBJECTIVE

Routine CT for patients with acute flank pain has not been shown to improve patient outcomes, and it may unnecessarily expose patients to radiation and increased costs. As preliminary steps toward the development of a guideline for selective CT, we sought to determine the prevalence of clinically important outcomes in patients with acute flank pain and derive preliminary decision rules.

METHODS

We analyzed data from a randomized trial of CT vs. ultrasonography for patients with acute flank pain from 15 EDs between October 2011 and February 2013. Clinically important outcomes were defined as inpatient admission for ureteral stones and alternative diagnoses. Clinically important stones were defined as stones requiring urologic intervention. We sought to derive highly sensitive decision rules for both outcomes.

RESULTS

Of 2759 participants, 236 (8.6%) had a clinically important outcome and 143 (5.2%) had a clinically important stone. A CDR including anemia (hemoglobin <13.2g/dl), WBC count >11000/μl, age>42years, and the absence of CVAT had a sensitivity of 97.9% (95% CI 94.8-99.2%) and specificity of 18.7% (95% 17.2-20.2%) for clinically important outcome. A CDR including hydronephrosis, prior history of stone, and WBC count <8300/μl had a sensitivity of 98.6% (95% CI 94.5-99.7%) and specificity of 26.0% (95% 24.2-27.7%) for clinically important stone.

CONCLUSIONS

We determined the prevalence of clinically important outcomes in patients with acute flank pain, and derived preliminary high sensitivity CDRs that predict them. Validation of CDRs with similar test characteristics would require prospective enrollment of 2100 patients.

Corticosteroids for renal scar prevention in children with acute pyelonephritis

Question Acute pyelonephritis in children is of great concern and I usually refer these patients to a pediatrician or send them to the emergency department owing to the risk of renal scarring. Are steroids an acceptable treatment to reduce risk of scarring? Answer Several agents have been studied in an effort to prevent renal scar formation following acute pyelonephritis in children. Use of corticosteroids, in conjunction with standard therapy for acute pyelonephritis, shows promising findings. However, evidence is very limited and steroids should not be offered on a regular basis as part of treatment.

[Acute complicated and uncomplicated pyelonephritis in the emergency department: process-of-care indicators and outcomes]

OBJECTIVES

To assess process-of-care indicators and outcomes in acute pyelonephritis (APN) in a general hospital emergency department, and compare them between uncomplicaed and complicated APN.

MATERIAL AND METHODS

Retrospective study of consecutive patients discharged with a diagnosis of APN. We studied health processof- care indicators (percentage admitted, avoidable hospitalization, appropriate initial antibiotic therapy, urine and blood cultures) and outcomes (hospital length of stay [LOS], discharge from the emergency department, revisits, mortality, yields of microbiological tests ordered).

RESULTS

A total of 529 cases (59% of them complicated) were included. Patients with uncomplicated APN were significantly younger on average (mean, 39 years) than patients with complicated APN (56 years). Escherichia coli was the most common pathogen identified, although the percentage of E coli infection was lower in patients with complicated APN (78%) than in patients with uncomplicated APN (95%). The rates of admission and orders for urine and blood cultures were significantly higher and hospital LOS was longer in the group with complicated APN. Moreover, these patients had even longer stays if the initial antibiotic therapy was inappropriate. Significantly more patients with uncomplicated APN were discharged from the emergency department. Sixty-one percent of patients with uncomplicated APN were admitted; 9% of these cases were considered avoidable hospitalizations.

CONCLUSION

Complicated APN is diagnosed more often in older patients, and E coli infection causes a smaller proportion of these cases. Hospital LOS is longer in complicated APN and more urine and blood cultures are ordered. Patients with uncomplicated APN are more often discharged from the emergency department, although the number of avoidable hospitalizations seems high based on the rate found in this study.

Pyelonephritis can lead to life-threatening complications

Acute pyelonephritis is suggested by the constellation of fever (temperature ≥ 38.5° C), flank pain (typically unilateral), nausea and vomiting, and costovertebral angle tenderness. Complaints typical of lower UTI are variably present. The severity of symptoms ranges from a mild pyrexial illness to life-threatening sepsis. The diagnosis of acute pyelonephritis should be suspected on the basis of the history and clinical examination. If the urine dipstick is negative for nitrites and leukocyte esterase this does not exclude the diagnosis, but it should prompt a re-evaluation of the clinical features and consideration of other potential diagnoses. Antibiotic therapy should be initiated without delay; this can be modified subsequently depending on the culture result. Antibiotics that are typically effective in lower urinary tract infections are frequently inadequate in acute pyelonephritis, and more prolonged therapy is necessary. Review of the clinical course and urine culture results is necessary to ensure that the patient is improving. Patients who have not improved within two days of commencing antimicrobial treatment should be referred to secondary care unless the infecting pathogen is not susceptible to the agent originally used, an alternative appropriate antibiotic is available, and the patient remains well enough for community care.

Recurrent obstructive acute pyelonephritis: A rare form of Actinotignum (Actinobaculum) schaalii infection in a HIV-1 infected patient

Actinobaculum schaalii is a rarely reported, anaerobic, Gram-positive bacterium which role as uropathogen is emerging. We report here the case of a 47 year old HIV-1 infected woman presented with five recurrent episodes of obstructive pyelonephritis in the context of multiple renal stones. No bacteria was found until the fifth episode, during which prolonged urinary cultures as well as 16S rDNA sequencing allowed the diagnosis of A. schaalii infection. She had developed a life-threatening condition with severe renal failure. A right nephrectomy was performed and found that the intrarenal stones were attributed to the antiretroviral therapy. The renal parenchyma corresponded to an end-stage renal disease with chronic pyelonephritis without abcesses or granules. The situation improved after six months of amoxicillin therapy.

[Changes in the structure of pathogens of calculous pyelonephritis complicated with diabetes mellitus type ii, in the hospital urology of the city of Volgograd]

Among the diseases complicating the course of calculous pyelonephritis, are among the leaders of diabetes mellitus, which is associated with reduced immune response, deterioration of renal hemodynamics, the reduced sensitivity to antibacterial drugs. The purpose of the study is to improve the results of treatment of patients with calculous pyelonephritis and diabetes mellitus type 2. The materials and methods of research. We studied 179 people. This was a retrospective pharmaco-epidemiological analysis of medical records of patients who were treated in 2009 and 2013, in hospital of Volgograd. Women in the study was greater than 99(by 55.4%), males - 80 (44,6%). All patients underwent standard clinical examination, with mandatory bacteriological urine analysis, ultrasound study of kidneys.

RESULTS

During the observation period of 2009 and 2013 in patients with calculous pyelonephritis and type 2 diabetes, the major pathogens were representatives of the family Enterobacteriaceae. E.coli strains are constituted - 12 (54,5%), K. pneumoniae - 4 (18.1%) strains. In other etiologically significant microorganisms were Enterococcus spp. - 3 (13.6%) strain, P. aeruginosa - strain 2 (9%). The group of other (4.5%), we have carried pathogens isolated in the singular: Erobacter spp, S. aureus, and Klebsiella oxytoca. In patients with infection of the upper urinary tract and diabetes, there is a pronounced trend to decrease sensitivity to all groups of antibiotics. Sensitivity to unprotected penicillins and fluoroquinolones has decreased almost twice. Resistance to aminoglycosides of patients in this group increased by 23%. In patients with chronic calculous pyelonephritis and diabetes mellitus type 2 is high sensitivity of the main causative agents of infection to cephalosporins of the third and fourth generation (92%), protected beta-lactam penicillins (amoxicillin/clavulanate) - 86,4%, to carbapenemam is 89.4%.

CONCLUSIONS

For the empiric treatment of infections of the upper urinary tract in patients with diabetes mellitus, can be recommended drugs: protected beta-lactam penicillins, cephalosporins of the third and fourth generation, carbapenem.

[Bilateral nephrectomy in patients with end-stage renal failure and chronic active pyelonephritis]

This study analyzed the results of bilateral nephrectomy in 14 patients with end-stage renal disease (ESRD) and chronic active pyelonephritis. Seven patients had urosepsis, and 10 patients had a purulent form of pyelonephritis, which was one-sided in 7 of them. In the early postoperative period, on average, after 9.3 days, 9 patients died. Statistically significant risk factors for death were: chronic hemodialysis, long-term antibiotic therapy, and existing sepsis. Intraoperative complications and postoperative morbidity were not significantly associated with death. The study results imply the need of differentiated approach to bilateral nephrectomy in patients with ESRD and risk factors for fatal outcome. It must be performed on the strong indications since the intervention does not lead to eradication of sepsis. It is advisable to perform "preventive, sanation" bilateral nephrectomy in the "cold period" in patients at risk for developing urosepsis.

[Abdominal pain and fever with urinary symptoms]

A man consults for abdominal pain and fever. The diagnosis is suspected on a plain abdominal radiograph.

[Septic shock in pregnancy on the basis of an acute pyelonephritis]

OBJECTIVE

According to the World Health Organisation, sepsis is one of the four main causes of pregnancy-related mortality worldwide, together with hemorrhage, hypertensive disease and abortion. The main goal of this paper is an analysis of one case of septic shock in pregnancy.

DESIGN

A case report.

SETTING

Department of Obstetrics and Gynaecology of the First Faculty of Medicine and General Teaching Hospital, Prague.

METHODS AND RESULTS

Authors would like to draw attention to the pitfalls of diagnosis and treatment of septic shock which developed in 25th week of pregnancy on the basis of pyelonephritis due to E. coli.

CONCLUSIONS

Early diagnosis of sepsis and an interdisciplinary co-operation are the main prerequisities for successful treatment.

The role of overweight and obesity in urinary tract infection in children

This study was conducted to determine the relationship between overweight/obesity and UTI in children. A comparison was made, in terms of overweight and obesity, between 135 children with UTI (case group) and 135 healthy children (control group). UTI was diagnosed through urine culture. Dimercaptosuccinic acid renal scanning (DMSA) was also used to distinguish between lower UTI and acute pyelonephritis. Overweight and obesity were determined based on standard body mass index (BMI) curves. There were 12 (8.8%) overweight and 26 (19.2%) obese children in the case group. Four (3.0%) overweight and five (3.7%) obese children were found in the control group. There was a significant difference between the two groups regarding overweight and obesity frequencies. However, no such difference existed between children with cystitis and acute pyelonephritis. This study showed a significant relationship between overweight/obesity and UTI. Therefore, overweight and obesity may play a role in the pathogenesis of UTI in children.

[A NOVEL SCORING SYSTEM: PREDICTING SEPTIC SHOCK AT DIAGNOSIS EASILY IN ACUTE COMPLICATED PYELONEPHRITIS PATIENTS]

(Objectives) Because acute complicated pyelonephritis can easily cause sepsis and concomitant shock status, it is a potentially lethal disease. However, the predictors for the severity of pyelonephritis is not well analyzed. In this study, we aimed at clarifying the clinical characteristic risk factors associated with septic shock in patients with acute complicated pyelonephritis. (Materials and methods) From May 2009 to March 2014, 267 patients with acute complicated pyelonephritis were treated at our institution. We investigated the characteristics of the patients associated with septic shock, and assessed risk factors in these patients. By using these risk factors, we established a novel scoring system to predict septic shock. (Results) 267 patients included 145 patients with ureteral calculi and 75 patients with stent-related pyelonephritis. Septic shock occurred in 35 patients (13%), and the mortality rate was 0.75%. Multivariate analysis revealed that (P): Performance Status ≥3 (p=0.0014), (U): Presence of Ureteral calculi (p=0.043), (S): Sex of female (p=0.023), and (H): the presence of Hydronephrosis (p=0.039) were independent risk factors for septic shock. P.U.S.H. scoring system (range 0-4), which consists of these 4 factors, were positively correlated with the rate of septic shock (score 0: 0%, 1: 5.3%, 2: 3.4%, 3: 25.0%, 4: 42.3%). Importantly, patients with 3-4 P.U.S.H. scores were statistically more likely to become septic shock than those with 0-2 score (p=0.00014). (Conclusions) These results suggest that P.U.S.H. scoring system using 4 clinical factors is useful to predict the status of septic shock in patients with acute complicated pyelonephritis.

[A Case of Emphysematous Pyelonephritis with Pneumoderma Treated by Open Surgical Drainage]

Emphysematous pyelonephritis (EPN) is an acute, severe necrotizing infection of the renal parenchyma and perirenal tissue. A 72-year-old female patient with uncontrolled diabetes mellitus was admitted to a hospital with loss of consciousness and, fever. Laboratory data suggested acute inflammation and hyperosmolar hyperglycemic syndrome. The left EPN was accurately diagnosed after abdominal computed tomographic (CT) scan revealed renal parenchymal gas and fluid within the subcutaneous tissue and mediastinum. The patient was transferred to our institution and underwent emergent open surgical drainage. However, a CT scan performed 3 days after the drainage revealed the presence of fluid in the left perinephric space. CT-guided drainage of the left perinephric fluid was performed. The patient was finally discharged after complete recovery from severe inflammation.

Effect of N-acetylcysteine on inflammation biomarkers in pediatric acute pyelonephritis: a randomized controlled trial

INTRODUCTION

This study was designed to investigate the effect of N-acetylcysteine (NAC), as a potent and safe antioxidant, on inflammatory biomarkers of acute pyelonephritis in pediatric patients.

MATERIALS AND METHODS

Children (< 15 years old) admitted with a diagnosis of pyelonephritis were recruited in a randomized placebo-controlled trial. They were randomly allocated to 2 groups and recieved placebo or NAC effervescent tablets with daily dose based on their weight, for 5 days. The children were evaluated for serum procalcitonin level, leukocyte count, C-reactive protein (CRP), serum creatinine, and clinical symptoms on the 1st and the 5th days.

RESULTS

Seventy patients, 35 in each group, with a mean age of 5.54 ± 3.10 years completed the study. There was no significant difference between the two groups in the amount of changes in procalcitonin levels after 5 days (P = .90). Within-group analysis confirmed CRP reduction in both groups (P < .001); however, between-group analysis did not show significant difference in CRP reductions, either (P = .65). No significant differences were found between the two groups in the day of resolving pyuria (P = .46), day of resolving bacteriuria (P = .81), or reductions in leukocyte count (P = .64) and neutrophil count (P = .49).

CONCLUSIONS

A short period of NAC administration with the recommended doses could not lead to a significant decrease in inflammation biomarkers. Studies on higher doses and longer duration of NAC administration along with evaluation of the long-term effects of the intervention by tools such as renal scntigraphy are suggested.

Urine Stasis Predisposes to Urinary Tract Infection by an Opportunistic Uropathogen in the Megabladder (Mgb) Mouse

PURPOSE

Urinary stasis is a risk factor for recurrent urinary tract infection (UTI). Homozygous mutant Megabladder (Mgb-/-) mice exhibit incomplete bladder emptying as a consequence of congenital detrusor aplasia. We hypothesize that this predisposes Mgb-/- mice to spontaneous and experimental UTI.

METHODS

Mgb-/-, Mgb+/-, and wild-type female mice underwent serial ultrasound and urine cultures at 4, 6, and 8 weeks to detect spontaneous UTI. Urine bacterial isolates were analyzed by Gram stain and speciated. Bladder stones were analyzed by x-ray diffractometry. Bladders and kidneys were subject to histologic analysis. The pathogenicity of coagulase-negative Staphylococcus (CONS) isolated from Mgb-/- urine was tested by transurethral administration to culture-negative Mgb-/- or wild-type animals. The contribution of urinary stasis to CONS susceptibility was evaluated by cutaneous vesicostomy in Mgb-/- mice.

RESULTS

Mgb-/- mice develop spontaneous bacteriuria (42%) and struvite bladder stones (31%) by 8 weeks, findings absent in Mgb+/- and wild-type controls. CONS was cultured as a solitary isolate from Mgb-/- bladder stones. Bladders and kidneys from mice with struvite stones exhibit mucosal injury, inflammation, and fibrosis. These pathologic features of cystitis and pyelonephritis are replicated by transurethral inoculation of CONS in culture-negative Mgb-/- females, whereas wild-type animals are less susceptible to CONS colonization and organ injury. Cutaneous vesicostomy prior to CONS inoculation significantly reduces the quantity of CONS recovered from Mgb-/- urine, bladders, and kidneys.

CONCLUSIONS

CONS is an opportunistic uropathogen in the setting of urinary stasis, leading to enhanced UTI incidence and severity in Mgb-/- mice.

Acute Urinary Tract Disorders

Acute urinary tract disorders often manifest as flank pain and are a common complaint of patients who present to the emergency department. The pain is often a vague, poorly localized sensation that may have a variety of causes. Laboratory and clinical findings, such as hematuria, are neither sensitive nor specific for determining the cause of the flank pain. Accordingly, imaging is an important tool in determining a diagnosis and management plan. Patients with acute urinary tract disorders who present with pain include those with calculi as well as renal infection, vascular disorders, and hemorrhage.

[CHRONOBIOLOGICAL ASPECTS OF THE USE OF PROLIT SUPER SEPTO IN PATIENTS WITH INFECTIOUS AND INFLAMMATORY DISEASES OF THE URINARY SYSTEM]

This paper presents results of a study involving 120 patients with infectious and inflammatory diseases of the urinary system, divided into four groups. Groups 1 and 3 included patients with acute serous non-obstructive pyelonephritis, groups 2 and 4--patients with exacerbation of chronic recurrent bacterial cystitis. Patients in groups 3 and 4 received a 10 day course of antibiotic therapy combined with Prolit super septo while patients in groups 1 and 2--only the standard antibiotic therapy. The authors studied changes in the clinical presentation, chronorhythms and psycho-emotional condition of the patients. At baseline, all patients showed signs of severe desynchronosis and psycho-emotional disorders. Combination therapy with Prolit super septo more effectively suppressed inflammation, improved clinical symptoms, corrected patient psycho-emotional status and restored normal chronorhythms regardless of the inflammation location.

[Multicentric tubulopapillary carcinoma of the kidney associated with renal adenomatosis]

Tubulopapillary tumors of the kidney represent a particular group of the renal tumors. They cover a continuous spectrum of tumors ranging from the adenoma to the renal cells papillary carcinoma. The histological and immunohistochemical similarities, as well as the high recurrence of the association of these two entities suggest a continuity of the same biological process. Although rare, the association between adenoma and papillary carcinoma remains still subject to controversy and plead in favor of a narrow relation between them. We report the case of a multicentric tubulopapillary carcinoma of the kidney associated with multifocal adenomas, discovered by fortuity in a right nephrectomy at a 57-year-old patient operated for an obstructive chronic pyelonephritis.

Beta 2-microglobulin and other proteins as parameter for tubular function

Urinary excretion of the low molecular weight protein beta 2-microglobulin and tubular enzymes--alanine aminopeptidase (AAP), gamma-glutamyl transpeptidase (gamma-GT) and alkaline phosphatase (AP)--are very sensitive parameters for proximal tubular lesions. In patients with preeclampsia the renal excretion of beta 2-microglobulin allows to differentiate between a primary preeclampsia and a preeclampsia superimposed upon chronic pyelonephritis. In the first group the increase is 3- to 4-fold and in the second group up to 300-fold. In patients with kidney transplantation the urinary excretion of beta 2-microglobulin, AAP, gamma-GT and AP are several times higher than in normals. In case of a rejection episode a further increase of these proteins occur in more than 80% several days before clinical symptoms are present. The application of analgetics (paracetamol, acetylsalicylic acid) in healthy individuals in therapeutical dosages on 3 consecutive days does not show any tubular alteration by the measurement of urinary beta 2-microglobulin. Aminoglycosides (tobramycin, UK 18,892) lead to a cumulative increase of the renal excretion of beta 2-microglobulin and AAP while cephalosporins induce an increase of total proteins in the final urine under the same conditions.

Interstitial nephritis

There are many causes of interstitial nephritis other than pyelonephritis. The term interstitial nephritis does not connote a single etiologic or pathogenetic mechanism; it rather arbitrarily places together a wider variety of renal diseases that have a predilection for early and major involvement of the renal interstitium. The prototype of acute interstitial nephritis is acute pyelonephritis. In addition, there is a drug-related acute interstitial disease that is probably of immunological nature and usually reverses with discontinuance of the offending drug. Chronic interstitial nephritis includes many diverse illnesses. Nonobstructive pyelonephritis occurs but its prevalence is debated. Analgesic abuse nephropathy is not rare and is potentially reversible. Papillary necrosis has many causes and a wide spectrum of clinical presentations. Heavy metals, such as lead, cause interstitial nephritis. Balkan nephropathy occurs in an endemic area and although not bacterial in origin is of unknown cause.

Ceftriaxone-associated acute gallbladder enlargement - an unexpected diagnosis in the child with urinary tract infection

Biliary sludge and/or biliary pseudolithiasis occur in patients treated with ceftriaxone with prevalence of 3-57%. Biliary obstruction can be the cause of the acute gallbladder enlargement. It is a minor complication, that usually does not give clinical symptoms and resolves once the drug is discontinued. The authors present a case of a 5-month old boy treated for the acute pyelonephritis. Routine ultrasound, performed on the 5th day of treatment with ceftriaxone, showed gallbladder enlargement. In the consecutive studies small gallblader sludge was visible. Patient had no symptoms related to the gallbladder enlargement. Ultrasound performed 6 weeks from the drug discontinuation was completely normal.

CONCLUSIONS

Patients treated with ceftroiaxone should be monitored for biliary sludge and pseudolithiasis.

[Emphysematous pyelonephritis in a non-diabetic patient with a kidney tumour]

Emphysematous pyelonephritis (EPN) is a potentially life-threatening infection, where gas produced by bacteria accumulates in the kidney and the surrounding tissue. Although EPN usually presents in diabetic women, it is also associated with urinary tract obstruction and kidney tumours in non-diabetic patients. We present a case of EPN in a non-diabetic patient with a known kidney tumour, successfully treated with double-J catheter, antibiotics and delayed nephrectomy.

[The effectiveness of empirical antibiotic therapy of pyelonephritis in patients with type 2 diabetes and without depending on the availability of plasmid-mediated resistance genes]

Multi-drug resistance has been increasing in the treatment of urinary tract infections, especially complicated. The prevalence of plasmid-mediated resistance genes among urinary pathogens has nether been studied in Ukraine. So, the aim of our study was to identify the plasmid-mediated resistance genes and to determine their impact on the efficacy of the treatment. A total of 105 adult patients with chronic pyelonephritis were included in the study. Among them, 32 patients were diagnosed with type 2 diabetes mellitus. The diagnosis of pyelonephritis was verified according to the criteria EAU, 2013. Plasmid-mediated resistance genes were determined by polymerase chain reaction (PCR). The prevalence of plasmid-mediated resistance mechanisms among patients with pyelonephritis were 44,4%. ESBLs was the most common isolated genes. Favorable clinical response was seen in 11/31 (35,5%) infected with ESBL-producing organisms compared with 59/74 (79,7%) patients with non-ESBL-producing organisms (p<0,05). In 16% of patients with resistance organisms antimicrobial agent was changed. Antibiotic efficiency was reduced in patients with complicated pyelonephritis due to presence of plasmid-mediated resistance genes. Therefore, prоpеr mаnagеment fоr prescriptiоn of аntibiоtics and also idеntificаtiоn of ESBL-prоducing bаcteria in cоmmunitiеs arе impоrtant fоr prevеntion.