Acute Pyelonephritis: Clinical Characteristics and the Role of the Surgical Treatment Dong-Gi Lee, Seung Hyun Jeon, Choong-Hyun Lee, Sun-Ju Lee, Jin Il Kim, and Sung-Goo Chang Department of Urology, School of Medicine, Kyung Hee University, Seoul, Korea.

Acute Pyelonephritis Annual incidence is 250,000 cases in US Incidence of hospitalized APN is 11.7 cases per 10,000 population among females and 2.4 cases per 10,000 population among males Renal parenchyma damaged  sepsis Treatment of APN: current characteristics of the community, causative bacterial spectrum, and antibiotic resistance patterns.

Acute Pyelonephritis AB resistance is on the gradual increase Ampicillin and trimethoprim/sulfamethoxazole (TMP/SMX): – first-line antibiotics not showing effective sensitivity any longer Complicated APN shows high-(+) rate with blood culture and more severe clinical symptoms than those of simple APN. Current clinical characteristics and the necessity of surgical treatment in 1,026 cases of APN patients for the past 5 yrs.

Materials & Methods n = 1026 patients in Kyung Hee University Medical Center (Jan 2000-Dec 2004) – Medical records: clinical symptoms, causes, causative microorganisms, antibiotic sensitivities, and curative urological procedures 3 of the following 5 criteria: – 1) clinical symptoms of APN (chilling, nausea, vomiting, flank pain) – 2) CVA tenderness – 3) leukocytosis (higher than 10,000/µL) – 4) fever (higher than 38.5 ℃ ) – 5) WBC count ≥5 cells/hpf on centrifuged urine sediment

Materials & Methods Identification of bacteria and AB sensitivity were assessed by disk diffusion test In diagnosing complicated APN, group examined the presence of following diseases: – structural and functional abnormalities (urinary tract stone disease, neurogenic bladder, vesicoureteral reflux, obstructive uropathy, prostate disease) – underlying diseases which contribute to the persistence of infection (DM, immunosuppressive state, cystic renal disease). T-test: comparison of continuous variables between independent two groups Pearson chi-square test : analysis of the comparison of the frequency, criterion of the determination of significance was p<0.05

Patient Characteristics Among 1026, 118 M, 908 F; M:F ratio 1:7.7 Mean age 45.5±17.8 yr, – M 49.0±19.2 yrs, F 45.0±17.5 yrs – Diff. between genders not detected (p>0.05) In males, group of over 60 was 38.1%, which was the most prevalent age group Particularly, females in their 20s and 30s were 38.6% of the entire female patients.

Clinical Presentation Flank pain: – R kidney 56.3%, L kidney 32.9% – both kidneys 10.7%, Duration of fever: 3.1 days Duration of flank pain: 3.7 days Duration of the CVA tenderness: 4.2 days No statistical difference between gender

Complicating Factors 32.7% of total APN (335 cases, 73 men, 262 women) were complicated APN. Among the complicated APN, the cases with structural and functional abnormality were 214 patients (63.9%), the cases with underlying medical diseases were 106 patients (37.9%), and the cases caused by the urologic manipulation were 8 cases (2.4%).

Underlying disease of complicated acute pyelonephritis

Complicating Factors In complicated APN, the duration of the flank pain and the CVA tenderness was significantly longer than in simple APN Complicated APN M:F ratio (1:3.6) was higher than that of the simple APN M:F ratio (1:1.14)

Radiologic Findings Abdominopelvis UTZ: performed on 788 cases (76.8%) – 428 cases (54.3%) showed normal findings – 360 cases (45.7%) showed abnormal findings nephromegaly (18.8%) hydronephrosis (12.1%) renal stone (4.2%) renal cyst (2.9%) ureter stone (2.1%)

Bacterial Culture and AB Sensitivity 504 cases (49.1%): bacteria were isolated by urine culture Escherichia coli was the most prevalent bacteria found in urine culture, 84.3%

Bacterial Culture

Curative Urological Procedures In treating complicated APN, urological procedures were performed on 94 cases (9.2%) – most frequent procedure: urinary lithotripsy (42 cases, 44.7%) – percutaneous nephrostomy (23 cases, 24.5%), clean intermittent catheterization (14 cases, 14.9%), ureteroneocystostomy (10 cases, 10.6%), nephrectomy (5 cases, 5.3%) and percutaneous pus drainage (3 cases, 3.2%).

Discussion UTI more prevalent in females – prevalent age range: yrs (38.6% in our study) Many studies: young women who are sexually active, use diaphragms or spermicide  UTI Proportion of female cases >60 yrs is 23.7% – DM and cerebral vascular disease due to aging

Cultured Bacteria E. coli: 84.3% cause for UTI In cases with risk factors such as neurogenic bladder, kidney transplantation, urethral stricture – Pseudomonas was cultured – microorganism was found in 80% of the male population, which was prevalent

AB Sensitivity AB resistance of ampicillin and TMP/SMX is higher than that of western countries. AB sensitivity test to E. coli – Ampicillin: 27.7% – Ampicillin/sulbactam: 77.1% – Ciprofloxacin: 79.0% – TMP/SMX: 44.7% – Amikacin: 92.1% – Gentamicin: 77.1% In other countries, it has been reported that antibiotic sensitivity for TMP/SMX was %, % for ciprofloxacin and % for ampicillin.

Antibiotic Sensitivity

Sepsis Sepsis: lethal complication Present in 10.1% of the population In cases where bacteria were isolated in blood culture – the duration of flank pain was significantly longer than other cases.

Antibiotic Use efficacy of ampicillin or TMP/SMX as the first- line treatment is very low. Ciprofloxacin showed 79.1% sensitivity against E. coli, and 88.3 % against K. pneumoniae – can be recommended as the first-line oral therapy

Complicated UTI 32.7% of the population Structural or functional disorders – urinary tract stone disease – vesicoureteral reflux – neurogenic bladder – ureteral obstruction – benign prostate hyperplasia Among 335 complicated APN patients, 94 patients received the curative urologic procedures. To treat urinary tract stones, ESWL, ureteroscopic stone removal or other lithotripsy were performed in 42 cases In hydronephrosis due to ureteral obstruction, percutaneous nephrostomy was performed in 23 cases

Conclusion One third of APN is complicated APN, and over 60% of its origin is urological diseases. Bacteria were isolated in urine culture in 49.1% – Use of ABs without prescription prior to admission. AB resistance shows a trend on the rise; – Particularly, ABresistance to ampicillin and TMP/SMX is high therefore – reconsideration of their selection as first-line drugs is required.