Pyelonephritis and Urosepsis

• Pyelonephritis involves inflammation of the renal parenchyma and collecting system, commonly due to bacterial infection, but fungi, protozoa, or viruses can also be the cause.
• Urosepsis is a systemic infection stemming from a urologic source, requiring immediate diagnosis and treatment to avert septic shock and potential fatality.
• Pyelonephritis typically begins with the colonization and infection of the lower urinary tract, with bacteria such as E. coli, Proteus, Klebsiella, or Enterobacter species
• Vesicoureteral reflux or lower urinary tract dysfunction, such as benign prostatic hyperplasia (BPH), stricture, or stones, can be contributing factors.
• Acute pyelonephritis often initiates in the renal medulla and extends to the cortex.
• Pregnancy-induced changes in the urinary system are a key risk factor for acute pyelonephritis.
• Recurring pyelonephritis, especially with obstructive abnormalities, may lead to chronic pyelonephritis.

Clinical Manifestations and Diagnostic Studies

• Classic signs include fever/chills, nausea/vomiting, malaise, and flank pain and there may be lower urinary tract symptoms (LUTS) like dysuria, urgency, and frequency.
• Costovertebral angle tenderness to percussion (CVA pain) is typically present on the affected side.
• Renal scarring and reduced kidney function can occur in some cases.
• Urosepsis can be potentially life-threatening.
• Urinalysis may show pyuria, bacteriuria, and varying degrees of hematuria.
• WBC casts in urine may indicate renal parenchyma involvement.
• Urine cultures with sensitivities are performed when pyelonephritis is suspected; blood cultures may be done on hospitalized patients with severe illness.
• Ultrasounds identify anatomic abnormalities, hydronephrosis, renal abscesses, or obstructing stones.
• CT scans are preferred imaging studies for assessing kidney infection and complications like impaired renal function, scarring, chronic pyelonephritis, or abscesses.

Interprofessional Care

• Patients with severe infection or complicating factors, such as nausea and vomiting with dehydration, may need hospitalization.
• Mild symptoms may be treated as an outpatient with antibiotics for 5 to 14 days.
• IV antibiotics are often initially given in the hospital to rapidly establish high serum and urinary drug levels.
• Oral antibiotics may be prescribed for 14 more days once acute symptoms resolve and the patient tolerates oral intake.
• Symptoms typically improve within 48 to 72 hours after starting therapy.
• Relapses may be treated with a different course of antibiotics and antibiotic prophylaxis may be used for recurrent infections.
• Therapy effectiveness is based on bacterial growth on urine culture.
• Urosepsis is characterized by bacteriuria and bacteremia, requiring close monitoring and vital sign checks.
• Prompt recognition and treatment of septic shock are essential to prevent irreversible damage or death.

Nursing Management

• Assessment involves obtaining subjective and objective data similar to a UTI patient.
• The overall goals are normal renal function, no complications, pain relief, and no symptom recurrence.
• Health promotion includes early cystitis treatment to prevent ascending infections and emphasizing regular medical care for patients with urinary tract abnormalities.
• Interventions include teaching about the disease process, stressing adherence to antibiotic therapy, scheduling follow-up urine cultures, and recognizing recurrence signs.
• Patients should drink at least 8 glasses of fluid daily, even post-treatment, and rest to increase comfort.
• Long-term, low-dose antibiotics may be prescribed for frequent relapses or reinfections, with an emphasis on patient understanding to increase adherence.
• Expected outcomes are the same as for UTI.

Chronic Pyelonephritis

• Chronic pyelonephritis involves continual kidney infection, leading to inflammation, fibrosis (scarring), potential loss of renal function, and renal atrophy (shrinkage).
• It typically results from significant anatomic abnormalities, such as vesicoureteral reflux, or recurring upper urinary tract infections, and rarely from a substantial inflammatory response from an infection.
• Radiologic imaging confirms the diagnosis and identifies contributing factors.
• A renal biopsy can show loss of functioning nephrons, parenchyma infiltration with inflammatory cells, and fibrosis.
• The level of renal function depends on whether one or both kidneys are affected, the extent of scarring, and the presence of coexisting infection.
• It can progress to end-stage renal disease (ESRD).
• Monitoring and treating infection and correcting underlying contributing factors are important and must be completed.