1. Emphysematous urinary tract infections 2012.09.19 신장내과 유진영

2. Introduction Emphysematous urinary tract infections (UTIs) –infections of lower or upper urinary tract associated with gas formation –cystitis, pyelitis, or pyelonephritis The first case was reported by Kelly and MacCullum in 1898. In 1962, Schultz and Klorfein, use of ‘emphysematous pyelonephritis’ term Mortality rate of up to 78% until the late 1970s but, over the last two decades, mortality rate 21%

3. Introduction DM, major risk factor for emphysematous UTI –more than 80% with emphysematous pyelonephritis –60~70% with emphysematous cystitis Risk of developing EPN secondary to urinary tract obstruction, 25~40% Drug abuse, neurogenic bladder, alcoholism, anatomic anomaly Most patients were women, over age 60. –Female : Male = 6 : 1 –Increased susceptibility to UTI

4. MEDLINE, PubMed, EMBASE, CINAHL and the Cochrane Library from 1966 to 2006.

5. Pathogenesis, poorly understood –Elevated tissue glucose levels in DM provide a more favorable microenvironment for gas-forming microbes –Impaired blood supply –Reduced host immunity –Obstruction within the urinary tract

6. DIAGNOSIS Plain film of abdomen / CT –air in the renal parenchyma, bladder, or surrounding tissue in 50 to 85% –CT scan, more sensitive than plain film extent of gas formation and any obstructing lesions in the urinary tract Imaging, particularly CT scanning, classify emphysematous pyelonephritis to estimate prognosis & guide therapy

9. EMPHYSEMATOUS PYELONEPHRITIS AND PYELITIS

10. Clinical features Indistinguishable from severe, acute pyelonephritis –fevers, chills, flank or abdominal pain, nausea, vomiting –onset of symptoms, abrupt or evolve slowly over two to three weeks Laboratory testing –hyperglycemia, leukocytosis, elevated serum creatinine, pyuria –acute, anuric renal failure, uncommon complication in bilateral infection or unilateral disease in a solitary functioning kidney

11. Clinical features Urine or pus culture (+), nearly 70% Bacteremia, more than 50% All organisms isolated from blood cultures were simultaneously found in cultures of the urine or renal pus. Almost infections were due to E. coli (69%) or K. pneumoniae (29%). In rare cases, anaerobic microorganisms including Clostridium septicum, Candida albicans, Cryptococcus neoformans and Pneumocystis jiroveci

12. Treatment In the past, usually nephrectomy or open drainage along with systemic antibiotics However, selected patients can be managed successfully with antibiotics, percutaneous catheter drainage (PCD) of gas & purulent material All patients are treated with parenteral antibiotics; antibiotics for the management of acute complicated pyelonephritis

14. Prognostic classification Two classification system, based upon CT scan finding Type I : Renal parenchymal necrosis with absence of fluid collection or presence of streaky or mottled gas pattern Type II : Renal or perirenal fluid accompanied by bubbly gas pattern or gas in the collecting system Radiology 1996, 198, 433-438. Type I EPN is associated with worse prognosis Mortality rate Type I 69 % VS Type II 18 %

15. Prognostic classification Class 1: Gas in the collecting system only Class 2: Gas in the renal parenchyma without extension to the extrarenal space Class 3A: Extension of gas or abscess to the perinephric space, between the fibrous renal capsule and the renal fascia Class 3B: Extension of gas or abscess to the pararenal space, space beyond the renal fascia and/or extension to adjacent tissue Class 4: Bilateral emphysematous pyelonephritis or solitary functioning kidney with emphysematous pyelonephritis Arch Intern Med 2000 Mar 27;160(6):797-805.

20. Suggested approach All patients are treated with parenteral antibiotics. Class 1 with no abscess formation or obstruction : antibiotics alone Others with class 1 and class 2 : antibiotics plus PCD Class 3A or 3B at low risk (none or one of the following risk factors: thrombocytopenia, ARF, impaired consciousness, shock) : initially, antibiotics plus PCD > unsuccessful, nephrectomy Class 3A or 3B with two or more of risk factors : antibiotics plus immediate nephrectomy Class 4 : initially, antibiotics plus bilateral PCD > nephrectomy, last option

22. PCD, drainage time varies from 5 days to 12.6 weeks Commonly irrigate & aspirate PCD tube to ensure maximum drainage Chen et al, recommend a repeat CT after 4 to 7 days to look for other noncommunicating air/fluid collections, to plan nephrectomy for non-responders to PCD. J Urol 1997;157:1569-73 Elective nephrectomy for prolonged fever and sepsis

23. EMPHYSEMATOUS CYSTITIS

24. Clinical presentation Predominance of older women with DM Abdominal pain m/c symptom, up to 80 % By comparison, classic symptoms of acute cystitis (dysuria, urinary frequency, and urinary urgency) occurred in only about one-half of pts Laboratory testing, pyuria and hematuria with positive urine cultures m/c pathogens were E. coli and K. pneumoniae, 75~80% Bacteremia was present in approximately one-half of cases.

25. BJU Int. 2007 Jul;100(1):17-20.

26. Therapy Usually be treated with medical therapy alone However, bladder irrigation may be needed if, blood clots are present or pt cannot adequately void. Surgical procedures that may be performed. include debridement, rarely partial or total cystectomy In a review of 135 published cases, 10% required combined medical and surgical therapy overall mortality rate 7%

27. 이 O 선 (F/50) C/C : Fever, chill, Lt. flank pain DM (2000’) : No medication, HbA1c 15.9 % CBC 5,500 (Neut. 94.7%) – 13/38.1-211K, CRP 13.54 Glucose 623 BUN/Cr 11/0.65 (eGFR 102.5) Na/K/Cl/TCO2 130 – 4.0 – 87 - 28 RUA glucose 2+, protein 1+, blood 2+, leukocyte 1+ RBC 5-9/HPF, WBC 10-29/HPF

28. Emphysematous pyelonephritis Class 2

29. Tabaxin inj. 4.5g [Tazobactam/Piperacillin sodium] q 8hr IV PCD insertion