Plans for Diagnosis and Management of Acute Pyelonephritis

1. Plans for Diagnosis and Management of Acute Pyelonephritis

2. Plans for Diagnosis and Management 1. Immediate stabilization • Step A  = Airway: ensure that the airway is protected; if not intubate the patient. • Step B = Breathing: address oxygenation and ventilation, administer oxygen and, if intubated, commence mechanical ventilation. • Step C = Circulation: restore circulating volume with  fluid resuscitation, invasive monitoring and vasopressors if necessary

3. Plans for Diagnosis and Management 2. Complete History and Physical Exam 3 of the following 5 criteria (Acute Pyelonephritis): • clinical symptoms of APN (chilling, nausea, vomiting, flank pain) • CVA tenderness • leukocytosis (higher than 10,000/µL) • fever (higher than 38.5℃) • WBC count ≥5 cells/hpf on centrifuged urine sediment

4. Plans for Diagnosis and Management 3. Patients presenting with signs and symptoms of pyelonephritis should have a urine culture and blood culture. • The results of the urine culture may not be available for 48 hours therefore a urinalysis and CBC can be used to support presumptive diagnosis of pyelonephritis. 4. Broad spectrum IV antibiotics should be started until the results of the urine culture are available and a more selective antibiotic can be identified. 5. Paracetamol 500mg/tab, 1 tab q4h prn for fever

5. Empiric Therapy

6. Empiric Therapy • Sepsis secondary to acute pyelonephritis • Parenteral regimen: ceftriaxone 1-2 g once a day; ciprofloxacin 200-400 mg every 12 hours; ofloxacin 200-400 mg every 12 hours; gentamicin 3-5 mg/kg once a day or 1 mg/kg every 8 hours.

7. Plans for Diagnosis and Management 6. Request for chest x-ray and sputum examination for acid-fast bacilli. • A. PULMONARY TB DSSM Result: • Smear (+) • A patient with at least 2 sputum specimens positive for AFB, with or without radiographic abnormalities consistent with active TB o • A patient with 1 sputum specimen positive for AFB and with radiographic abnormalities consistent with active pulmonary TB as determined by a physician • A patient with 1 sputum specimen positive for AFB and sputum culture positive for M. tuberculosis

8. Plans for Diagnosis and Management • DSSM Result: • Smear (-) • A patient with at least 3 sputum specimens negative for AFB with radiographic abnormalities consistent with active TB, and there had been no response to a course of antibiotics and/or TBDC to treat the patient with a full course of anti-TB chemotherapy

9. Plans for Diagnosis and Management • Types: A. New – A patient who has never had treatment for TB or who has taken anti-TB drugs for less than one month. B. Relapse – A patient previously treated for TB who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) TB. C. Failure – A patient who, while on treatment, is sputum smear positive at five months or later during the course of treatment.

10. Plans for Diagnosis and Management D. Return after default (RAD) – A patient who returns to treatment with positive bacteriology (smear or culture), following interruption of treatment for 2 months or more. E. Transfer-in – A patient who has been transferred from another facility with proper referral slip to continue treatment.

11. Plans for Diagnosis and Management F. Others – All cases that do not fit into any of the above definitions. This group includes: • a patient who is starting treatment again after interrupting treatment for more than 2 months and has remained or became smear-negative • a sputum smear negative patient initially before starting treatment and became sputum smear-positive during the Rx.

12. Plans for Diagnosis and Management • Category I (2 HRZE/ 4HR) • New pulmonary smear (+) cases • New seriously ill pulmonary smear (-) cases with extensive lung lesions on CXR as assessed by TB Diagnostic Committee • New extra-pulmonary TB • Concomitant HIX infxn • Intensive phase – HRZE for 2 months • Maintenance phase – HR for 4 months • Category II (2 HRZES/ 1HRZE/ 5HRE) • failure cases • relapse cases • return after default RAD (smear +) • other ( smear+ or -) • Intensive phase – HRZES for 2 months then HRZE for 1 month • Maintenance phase – HRE for 5 months

13. Plans for Diagnosis and Management • Category III ( 2 HRZ(E) / 4HR) • new smear (-) but with minimal PTB on CXR as assessed by TB diagnostic committee • ethambutol may be omitted for non-cavitary, smear (-), fully susceptible cases • Category IV • chronic ( still smear (+) after supervised re-treatment) • refer to specialized facility or DOTS plus/ PMTM Center

14. Plans for Diagnosis and Management • Treatment regimen for category II: • 2HRZES/HRZE/4HRE • 30-37kg • Intensive phase – first 2 mon. • 2 HRZE, 0.75g streptomycin • 3rd mon. 2 HRZE. • Continuation phase – 2 HR, 1 E 400 mg • 38-54 kg • Intensive phase – first 2 mon. • 3 HRZE, 0.75g streptomycin • 3rd mon. 3 HRZE • Continuation phase – 3 HR, 2 E 400 mg

15. Plans for Diagnosis and Management • Treatment regimen for category II: • 55-70kg • Intensive phase – first 2 mon. • 4 HRZE, 0.75g streptomycin • 3rd mon. 4 HRZE • Continuation phase – 4 HR, 3 E 400 mg • >70kg • Intensive phase – first 2 mon. • 5 HRZE, 0.75g streptomycin • 3rd mon. 5 HRZE • Continuation phase – 5HR, 3 E 400 mg • Follow-up: Category II - end of 3rd month and 5th month, start of 8th month

16. Plans for Diagnosis and Management • Routine urologic evaluation (ultrasound or CT scan of the kidney) and routine use of imaging procedures are not recommended (Grade D). • Radiologic evaluation should be considered if the patient remains febrile within 72 hours of treatment to rule out the presence of nephrolithiasis, renal or perirenal abscesses, or other complications of pyelonephritis, or if there is recurrence of symptoms

17. Plans for Diagnosis and Management • In patients who are clinically responding to therapy (usually apparent in < 72 hours after initiation of treatment), there is no need for a follow-up urine culture (Grade C). • Routine post- treatment cultures in asymptomatic patients are also not indicated except in patients who initially present with sepsis (Grade C). • In women whose symptoms do not improve during therapy and in those whose symptoms recur after treatment, a repeat urine culture and sensitivity test should be performed (Grade C).

18. Plans for Diagnosis and Management • Recurrence of symptoms requires antibiotic treatment based on results of urine culture and sensitivity test, in addition to assessment for underlying genito-urologic abnormality (Grade C). • The duration of re-treatment in the absence of a urologic abnormality is 2 weeks (Grade C). For those patients who relapse with the same strain as the initially infecting strain, a 4-6 week regimen is recommended (Grade C).