Acute pyelonephritis is a non-specific infectious inflammation of the calyx-pelvis system and the renal parenchyma. The incidence of acute pyelonephritis is 0.9-1.3 million cases per year. At the age of 2 to 15 years, girls suffer from acute pyelonephritis 6 times more often than boys, the same ratio at a young age; in old age, this disease often develops in men.
Etiology and pathogenesis. Acute pyelonephritis is a consequence of an ascending infection from foci of chronic inflammation in the female genital organs, lower urinary tract, less often – in the large intestine; it is caused by Escherichia E. Coli (in most cases), Klebsiella, Proteus, Pseudomonas. The hematogenic pathway of acute pyelonephritis is less common than the ascending one; its source is an acute or subacute inflammatory process outside the urinary tract: mastitis, furuncle, carbuncle. For the development of pyelonephritis, predisposing factors are necessary – a violation of hemodynamics or urodynamics in the kidney or upper urinary tract.
The clinic of acute pyelonephritis depends on the obstruction in the urinary tract. In the non-obstructive process, the disease begins with dysuria with a rapid increase in body temperature to high numbers. The body temperature is accompanied by chills, pain from the affected kidney; chills are replaced by a heavy sweat with a short-term decrease in body temperature; pain in the lumbar region may appear during urination and in this case manifest itself to chills and hyperemia (vesicoureteral reflux). If the pain does not recur after them (rupture of the fornix of one or more cups and resorption of urine) – fornical reflux. In obstructive acute pyelonephritis (occlusion of the ureter with a stone, products of chronic kidney inflammation, external compression-retroperitoneal fibrosis, cancer of the internal genitals in men and women, enlarged lymph nodes), the disease begins with gradually increasing or acutely developed lower back pain from the lesion, followed by the development of chills and an increase in body temperature. There are also bright eyes, blush on the cheeks, a clean tongue, pain when palpating the abdomen in the hypochondrium and a positive symptom of pounding on the lower back (Pasternatsky’s symptom) from the affected kidney.
Diagnostics. Pyuria and bacteriuria are determined in the laboratory. Ultrasound examination, computed tomography exclude anatomical and functional abnormalities of the urinary tract. Computed tomography and magnetic resonance imaging allow you to get information about the condition of the affected kidney and surrounding tissues, which is especially important in the purulent-destructive process.
Treatment. Patients should be urgently hospitalized in a urological hospital for obstructive disease, as it is necessary to restore the passage of urine.
Early administration of antibacterial therapy is necessary to prevent the development of urosepsis.
Empirical antimicrobial treatment is based on anamnesis, suspected etiology, and regional resistance of the main pathogens. If parenteral antibacterial therapy was initially prescribed, then after 1-2 days it can be replaced with an oral regimen of the drug. The usual therapy lasts 10-14 days. An increased concentration of C-reactive protein can be considered as a basis for continuing antibacterial therapy; if a CT scan, magnetic resonance imaging, or scintigraphy reveals foci of inflammation or abscesses, then it is necessary to extend therapy to 4-8 weeks. Otherwise, there may be frequent relapses of UTI with short periods of remission.
The antimicrobial spectrum of antibacterial drugs for empirical therapy should be maximally adapted to the list of the main pathogens.
In the treatment of acute pyelonephritis, cephalosporins of the II—III generation, fluoroquinolones, inhibitor-protected aminopenicillins and aminoglycosides are most often used. Due to the resistance of many uropathogens to the most commonly used antibiotics, it is necessary to prescribe fluoroquinolones. Drugs from this group, united by a common mechanism of action (inhibit the synthesis of the key enzyme of the bacterial cell-DNA gyrase) are characterized by a wide range of antimicrobial activity and favorable pharmacokinetic properties, their excretion is mainly renal: levofloxacin (tavanic) (500 mg once a day in severe infection), gatifloxacin (400 mg), moxifloxacin (400 mg), trovafloxacin (200 mg) for 7-10 days. Complete microbial eradication of the pathogen is achieved in 95.5% of cases.
Starting antimicrobial therapy with levofloxacin is justified in such cases as:
1) the presence of a history of repeated episodes of UTI in the last 6 months;
2) in patients with diabetes mellitus;
3) the presence of clinical manifestations of the disease for more than 2 days;
4) no effect within 2 days from the start of antimicrobial therapy with other drugs.
Antibiotics are combined with chemotherapy drugs, at the same time they are given a plentiful drink (cranberry juice), and detoxification therapy is carried out. For pain in the area of the affected kidney, thermal procedures (hot water bottles, warming compresses, diathermy), painkillers are indicated. Food should be sufficiently high in calories (up to 2000 kcal per day), not abundant, without limiting the intake of table salt.
Forecast. Recovery with timely diagnosis and early treatment of acute pyelonephritis. In cases of late recognition, the development of bacterial shock or urosepsis, the prognosis is unfavorable. Untimely and irrational treatment of pyelonephritis leads to chronic pyelonephritis. Patients who have suffered acute pyelonephritis are subject to dispensary observation for a year. In the coming months after recovery, heavy physical labor, work associated with cooling, dampness, and nephrotoxic substances are contraindicated.
Prevention. General strengthening measures that increase the body’s resistance, the fight against common infections, the elimination of aseptic bacteriuria (especially in high – risk groups-among preschool and school-age children, pregnant women, gynecological patients (preventive examination of women by a gynecologist, vaginal sanitation, compliance with hygiene rules)), mandatory treatment of cystitis by a urologist.