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Acute Pyelonephritis: Clinical Characteristics and the Role of the Surgical Treatment

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.

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Acute Pyelonephritis: Clinical Characteristics and the Role of the Surgical Treatment

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  1. 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.

  2. 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.

  3. 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.

  4. 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

  5. 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

  6. 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.

  7. 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

  8. 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%).

  9. Underlying disease of complicated acute pyelonephritis

  10. 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)

  11. 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%)

  12. 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%

  13. Bacterial Culture

  14. 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%).

  15. Discussion • UTI more prevalent in females • prevalent age range: 20-30 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

  16. 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

  17. 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 67-83.2%, 78-98.1% for ciprofloxacin and 25-82.3% for ampicillin.

  18. Antibiotic Sensitivity

  19. 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.

  20. 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

  21. 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

  22. 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.

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