PYELONEPHRITIS

GENERAL CONSIDERATION OF UTIDefinition UTI means infection of any part of urinary

tract (Kidney, Ureter, Bladder or Urethra) Infections of the urethra and bladder are

often considered superficial (or mucosal) infections

While pyelonephritis, and renal suppuration signify tissue invasion

Asymptomatic bacteriuria, acute cystitis, and acute pyelonephritis are common renal disorders in pregnancy.

…CONT… Asymptomatic bacteriuria- is defined as

the presence of actively multiplying bacteria in the urinary tract excluding the distal urethra in a patient without any obvious symptoms

Incidence during preg.is 10%. The diagnosis is based upon isolation of

microorganisms with a colony count > 105 organisms per milliliter of urine in a clean-catch specimen.

…CONT… If asymptomatic bacteriuria is left

untreated in pregnancy, up to 40% of patients will develop symptoms of UTI.

Approximately 25–30% of women will develop acute pyelonephritis. With treatment, the rate is 10%

The increased risk is due to: decreased ureteral tone, decreased ureteral peristalsis, temporary incompetence of the

vesicoureteral valves, Bladder catheterization

ETIOLOGY Escherichia coli ( 80% ). The Klebsiella-Enterobacter-Serratia

group, Staphylococcus aureus, group B Streptococcus, enterococcus Proteus are responsible for the

remainder of the case

CYSTITIS AND URETHRITIS. Dysuria, urgency and frequency-the

symptom. Pyuria,bacteriuria and microscopic

hematuria. Frequency, urgency, dysuria ,pyuria but

urine culture with no growth may be urethritis caused by C.trachomatis.

The bacteria causing acute cystitis are similar to those in asymptomatic bacteriuria

ACUTE PYELONEPHRITIS Acute pyelonephritis is the infection of

the renal pelvis and the kidneys. It is one of the most common causes of

hospitalization and serious medical complication of pregnancy.

Complicates 1-2% of pregnancies. Develops more frequently in second

trimester. Isolates from urine or blood are-

E.coli(75-80%),others K .pnuemonia, enterobacter or proteus

RISK FACTORS Asymptomatic bacteruria-the single

most important risk factor. aprevious history of pyelonephritis, Gravidity(primi) urinary tract malformation, urinary calculi. Maternal DM Sickle cell trait

CLINICAL FEATURES Fever(usually > 390C) shaking chills, bilateral flank pain, Nausea, vomiting and possibly diahrrea headache, increased urinary frequency, and

dysuria CVA tenderness.

DIFFERENTIAL DIAGNOSIS

chorio-amnionites, appendicites, labor, placental abruption, red degeneration of myoma Renal caliculi

COMPLICATIONSmaternal fetal

bacterial endotoxemia, endotoxic shock renal

insufficiency(ARF) anemia, leukocytosis, thrombocytopenia, Pulmonary dysfunction

(mild cough,rispiratory infiltrat to sever ARDS)

low birth weight(small for GA)

premature delivery neonatal death

INVESTIGATIONS CBC(Hct,Hgb,WBC(leukocytosis),pletlet) Blood group and RH Serum HCG Blood sugar level U/S,IVP

DIAGNOSTIC TESTINGUrine culture: Significant bacteriuria= 105 cfu/ml symptoms: 1 +ve cuture = infection Symptoms: 102 cfu/ml = propable infection Asymptomatic: 2 +ve cultures = infection False negative : antibiotics, antiseptics,

renal TB, diuresis.

…CONT…Microscopy of urine Assessed with Gram-stained uncentrifuged urine Microscopic bacteriuria is found in >90% of

specimens with colony counts of at least 105 /mL The detection of bacteria by urinary microscopy

constitutes firm evidence of infection, but the absence of microscopically detectable bacteria does not exclude the diagnosis

Pyuria (WBC > 5/HPF) is demonstrated in nearly all acute bacterial UTIs and its absence calls for the diagnosis of UTI in question

Look also for RBCs, WBC casts Associated hematuria may indicate urinary calculi.

…CONT… Sterile pyuria Pyuria in the absence of bacteriuria Indicate infection with unusual agents such

as C. trachomatis, U. urealyticum, or Mycobacterium tuberculosis or with fungi

May also occur in noninfectious urologic conditions such as calculi, anatomic abnormality, vesicoureteral reflux, interstitial nephritis, or polycystic disease

MAMAGMENT OF PREGNANT MOTHER WITH PYELONEPHRITIS

1. Hospitalization2. Urine and blood

cultures,RFT,electrolyte3. Monitor vital signs frequently, including

urinary output; consider indwelling catheter

4. Intravenous crystalloid to establish urinary output to 30 mL/hr

5. IV antimicrobial therapy(sulfonamides and cephalosporin are reasonable choices.)

…CONT…6. Chest radiograph if there is dyspnea or

tachypnea7. Repeat hematology and chemistry

studies in 48 hours8. Change to oral antimicrobials when

afebrile9. Discharge when afebrile 24 hours;

consider antimicrobial therapy for 7 to 10 days