What is the most common pothogen of acute pyelonephritis? Acute Pyelonephritis in Adults (1) C.L.I.P.S. Diagnosis Should be suspected in patients presenting with fever and flank pain, even in the absence of typical symptoms of cystitis Pathogenesis Most are from bacterial ascent through the urethra and urinary bladder In men, prostatitis and prostatic hypertrophy causing urethral obstruction predispose to bacteria Physical Exam Findings Fever, flank pain, CVA tenderness, nausea/vomiting, prolonged cystitis symptoms >/= 5-7 days In sexually active young women, consider pelvic examination if symptoms are not convincing for a UTI to evaluate for cervical motion or uterine tenderness (think PID) Among men with symptoms of pelvic/perineal pain, DRE may be warranted to look for a tender or edematous prostate (think acute prostatitis)   Lab Findings Urinalysis: Leukocyte esterase and nitrate test has sensitivity of 75-84% and specificity of 82-98% Always obtain urine culture: IDSA states that urine culture must show at least 10,000 colony forming units (CFU) per mm3 but lower counts of 1,000 to 9,999 CFU per mm3 are of concern in men and pregnant women Get blood cultures if the diagnosis is uncertain, patient is immunocompromised, or patient is suspected of having hematogenous infection Always consider pregnancy testing in women of childbearing age What is the most common pothogen of acute pyelonephritis? Escherichia coli Updated 3/2018, E. Nicholas

What are the two most common causes of initial treatment Acute Pyelonephritis in Adults (2) C.L.I.P.S. Outpatient Versus Inpatient Treatment Inpatient treatment: Warranted for patients with anatomic urinary tract abnormalities, persistently high fever or pain, immunocompromised state, suspected sepsis, inability to maintain oral hydration, persistent vomiting, failed outpatient treatment, age >60, poor social support, poor access to follow-up care, or if urinary tract obstruction is suspected Outpatient oral therapy is successful in 90% of patients who can tolerate oral intake, will be compliant with treatment, will return for early follow-up, and have adequate social support Duration of Treatment: 7-14 days Treatment: Includes antibiotics, hydration, fever control, and pain management First Line Treatment (based on UNMH Guidelines) One time dose of either: Ceftriaxone 1g IV q24h Gentamicin 3mg/kg IV q24h Followed by either: Ciprofloxacin 500mg PO BID SMX/TMP 1DS PO BID Alternatives (based on UNMH Guidelines) Piperacillin/Tazobactam 3.375g IV q8h extended infusion Consider test of cure one week after completion of antibiotics. What are the two most common causes of initial treatment failure? Resistant organisms and nephrolithiasis