Diagnosis and treatment for emphysematous pyelonephritis: analysis of 14 cases from a single centre / 中华外科杂志

Objective: To examine the modalities of treatment and clinical outcomes of emphysematous pyelonephritis (EPN), in order to improve the survival rate of EPN patients. Methods: Totally 14 patients diagnosed as EPN between October 2011 and November 2020 at Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine were included in this article. Data collection including patient demographics, clinical manifestations, management and clinical outcomes were conducted by retrospective charts review, after receiving the institutional review board's approval. There were 11 females and 3 males with a median age of 59 years (range: 52 to 73 years). The lesions were located on the left side in 10 patients and right side in 4 patients. All the 14 patients suffered from fever, and present with severe sepsis or septic shock. The median time from symptom onset to admission to hospital was 3 days(range: 2 to 5 days). All cases had diabetes mellitus. Escherichia coli was the most common organism been cultured (11 cases), while Klebsiella pneumonia was the second (3 cases). CT scan showed bubbly or located gas in the renal parenchyma in 5 cases and presence of steaky or mottled gas in the renal parenchyma in 9 cases. All patients had been admitted to ICU for anti-septic shock therapy. Three patients had undergone percutaneous catheter drainage along with broad-spectrum antibiotics therapy while 3 patients had immediate nephrectomy, the other 8 cases had a combination of an initial percutaneous catheter drainage and second stage nephrectomy. Results: In this case series, 3 patients were died from EPN while the other 11 were survived. The median ICU stay time was 6 days (range: 3 to 11 days). Of the 3 patients died from EPN, 2 had undergone percutaneous catheter drainage along and 1 had received immediate nephrectomy. Among the 11 patients who were survived, only 1 had received percutaneous catheter drainage while the other 10 received nephrectomy (8 patients had staged nephrectomy). Follow-up was performed 6 months after discharge. Of the 11 surviving patients, 2 were lost to follow-up, and the remaining 9 patients had an creatine level of (118.4±29.4) μmol/L (range: 89 to 176 μmol/L). Conclusions: For patients coupled with diabetes who were initially diagnosed as acute pyelonephritis, the possibility of EPN should be considered when the disease progressed rapidly especially septic shock occurred. On the basis of empirical broad-spectrum antibiotics therapy and standardized anti-septic shock treatment, a combination of an initial percutaneous catheter drainage and second stage nephrectomy could be efficacious.

Infecciones del tracto urinario / Urinary tract infections

La infección del tracto urinario (ITU), con sus múltiples presentaciones clínicas, está entre las enfermedades infecciosas más frecuentes, tanto en pacientes ambulatorios como hospitalizados. El uso del examen de orina completa y de urocultivo debe ser racional. La bacteriuria asintomática no debe ser buscada ni tratada, en parte porque esto favorece el desarrollo de bacterias resistentes a antibióticos. Distintos cuadros clínicos requieren de distintas duraciones de terapia antibiótica, y tanto el exceso de días de tratamiento como su falta deben evitarse. Se requiere investigación en la búsqueda de estrategias más efectivas para prevenir las ITU recurrentes y en el desarrollo de nuevos antibióticos orales para las ITU resistentes.

Urinary tract infection, with its multiple clinical presentations, is one of the most common infectious diseases in both ambulatory and hospitalized patients. The urinalysis and urine culture should be used when appropriate. Asymptomatic bacteriuria should not be screened or treated, in part because of a concern for the selection of antibiotic resistant bacteria. The appropriate duration of treatment of urinary tract infection should be completed. Research is needed in newstrategies for prevention of recurrent urinary tract infections and development of new oral antibiotics for drug resistant bacteria.

Pielonefrite enfisematosa: revisão e atualização da abordagem terapêutica / Emphysematous pyelonephritis: review and update of the therapeutic

A pielonefrite enfisematosa é uma grave e rara infecção renal aguda, caracterizada por presença de ar no parênquima renal e tecidos circunvizinhos, levando a alterações sistêmicas importantes, mais comumente observadas em pacientes diabéticos, apresentando mortalidade significativa. Mudanças no manejo desta doença foram introduzidas ao longo dos anos estabelecendo uma nova abordagem terapêutica através, de técnicas menos invasivas, que resultaram em redução da morbidade e da mortalidade. Em concordância com as publicações mais recentes, alguns fatores prognósticos devem ser levados em consideração bem como o grau de extensão da lesão à tomografia computadorizada e a evolução clínica do paciente, objetivando o plano terapêutico mais adequado. O caso relatado expõe epidemiologia incomum (idade, sexo) em relação à apresentação típica da doença e mostra que a pielonefrite enfisematosa deve estar em mente como diagnóstico diferencial das infecções urinárias complicadas. Por fim, confirmamos que a abordagem conservadora, com tratamento através de antibioticoterapia e drenagem percutânea, é efetiva desde que observada criteriosamente a indicação terapêutica para cada caso.

The emphysematous pyelonephritis is a severe and rare acute renal infection, characterized by renal parenchyma and adjacent tissues air presence, inducing to important systemic complications, observed mainly in diabetic patients , bringing out significative mortality. Changes on the management of this disease had occurred over the years, turning possible a new therapeutic strategy using less invasive procedures wich resulted in a reduction of the morbity and mortality. According to the most recent publication some prognostic factors most be considered, as well as the extension of the lesions observed on the computerized tomography and clinical patient's evolution, to reach the best therapeutic strategy. This clinical case presents an uncommon epidemiology (age, sex) and show as the importance of keeping the emphysematous pyelonephritis as a possible diagnose in complicated urinary infection cases. Finally, was possible to conclude that conservative treatment using antibiotics and percutaneous drainage is effective once observed the appropriated therapy indication for each case.

Diagnostic potential of urinary tumor necrosis factor-alpha in children with acute pyelonephritis

Tumor necrosis factor-alpha [TNF-alpha] is an important mediator of the inflammatory response in serious bacterial infections. The aim of this study was to evaluate the potential of urinary TNF-alpha for diagnosis of acute pyelonephritis in children. This study was conducted from March 2006 to December 2007 on children with confirmed diagnosis of acute pyelonephritis. They all had positive renal scintigraphy scans for pyelonephritis and leukocyturia. The ratios of urinary TNF-alpha to urine creatinine level were determined and compared in patients before and after antibiotic therapy. Eighty-two children [13 boys and 69 girls] with acute pyelonephritis were evaluated. The mean pretreatment ratio of urinary TNF-alpha to urinary creatinine level was higher than that 3 days after starting on empirical treatment [P = .03]. The sensitivity of this parameter was 91% for diagnosis of acute pyelonephritis when compared with demercaptosuccinic acid renal scintigraphy as gold standard. Based on our findings in children, the level of urinary TNF-alpha-creatinine ratio is acute increased in pyelonephritis and it decreases after appropriate therapy with a high sensitivity for early diagnosis of the disease. Further research is warranted for shedding light on the potential diagnostic role of urinary TNF-alpha in pyelonephritis in children

[Characteristics of emphysematous pyelonephritis: about four observations]

Emphysematous pyelonephritis is a severe infection which necessitates a management that is both medical and surgical. Early systematic antibiotic therapy is required. Percutaneous drainage is now the first urological approach in most cases. It should not however delay, if necessary, an eventual nephrectomy. We report our experience during 15 years in four women

Pielonefritis enfisematosa: reporte de dos casos y revisión de la literatura / Emphysematous pyelonephitis: report of two cases and review

Presentamos dos pacientes mujeres diabéticas con Pielonefritis enfisematosa bilateral atendidas en nuestro hospital. Ambas tenían más de 50 años de edad. El diagnóstico se realizó por la presencia de gas a nivel de amos riñones, en la tomografía axial computarizada (TAC) abdominal. Una de las pacientes fue sometida a nefrectomía bilateral y la otra a nefrectomía derecha. Ambas pacientes tuvieron mala evolución pese al tratamiento antibiótico y quirúrgico. Debido a su alta mortalidad hacemos énfasis en el diagnóstico y tratamiento precoz.

Pielonefrite enfisematosa em enxerto renal: relato de caso / Emphysematous pyelonephritis in renal: allograft-case report

Pielonefrite enfisematosa é uma rara complicação após o transplante renal. Este é um relato de caso de uma paciente diabética de 42 anos de idade, do sexo feminino, que se apresentou após uma semana de tratamento de infecção do trato urinário causada por Escherichia coli, referindo uma massa palpável sobre o enxerto. A tomografia computadorizada de abdome mostrou coleção perirrenal contendo ar. Tratada com antibióticos e drenagem percutânea. Após 20 dias de drenagem, recebeu alta hospitalar com função renal estável.

Emphysematous pyelonephritis is a rare post renal transplant complication. This is a case report of a 42 year-old diabetic female, who presented a urinary tract infection caused by Escherichia coli and a palpable mass above the graft approximately 1 week after treatmtent, A computer tomography scan of the abdomen showed peri-renal collection containing air. The patient was treated with antibiotics and a percutaneous nephrostomy was performed. After 20 days of drainage, renal function was considered stable and she was discharged from the hospital.

Pielonefritis enfisematosa aguda bilateral: un desafío terapéutico / Acute bilateral emphysematous pyelonephritis: a therapeutic challenge

La pielonefritis enfisematosa es una forma poco común de infección renal, caracterizada por la presencia de bacterias coliformes productoras de gas que afecta preferentemente a los pacientes diabéticos. Comunicamos el caso de una mujer diabética de 57 años de edad que ingresó en el hospital por un shock séptico, signos de pielonefritis enfisematosa aguda bilateral y cetoacidosis diabética. En los cultivos de las muestras de orina y sangre desarrolló Escherichia coli. La paciente fue tratada exitosamente con antibióticos de amplio espectro por un tiempo prolongado, control diabético y medidas de sostén solamente. No fue necesario el drenaje con catéteres o la nefrectomía para superar esta situación potencialmente letal.

Emphysematous pyelonephritis is a rare form of kidney infection characterized by the presence of gas-forming coliform bacteria which affects more frequently diabetic subjects. We report the case of a 57-years-old diabetic woman, who was admitted in septic shock, signs of acute bilateral emphysematous pyelonephritis, and diabetic ketoacidosis. Both blood and urine cultures yielded Escherichia coli. The patient was successfully treated using longterm broad-spectrum antibiotics, diabetic control and supportive measures alone. Catheter drainage and nephrectomy were not necessary to overcome this life threatening situation.

Bilateral emphysematous pyelonephritis and emphysematous cystitis with autosomal-dominant polycystic kidney disease: Is conservative management justified?

To report a case of bilateral emphysematous pyelonephritis [EPN] and emphysematous cystitis in a 64-year-old diabetic male with autosomal-dominant polycystic kidney disease [ADPKD]. A 64-year-old diabetic male presented with worsening of renal function and fluid overload. Diagnosis was confirmed by computerized tomography [CT scan] and conservative management with broad-spectrum antibiotics was instituted. There was good clinical response and repeated CT scan showed complete resolution. This case shows that conservative management is an acceptable alternative to surgery in EPN occurring with ADPKD. However, it is recommended that patients should be closely monitored, both clinically and radiologically, and percutaneous catheter drainage or surgical intervention carried out whenever deemed necessary

Pielonefrite enfisematosa / Emphysematous pyelonephritis

Pielonefrite enfisematosa é uma infecção necrotizante renal, mais freqüentemente diagnosticada em diabéticos. A taxa de mortalidade é elevada. Relatamos um caso de pielonefrite enfisematosa bilateral em paciente diabética que se apresentou em insuficiência renal aguda e choque séptico, evoluindo para óbito após seis dias de tratamento conservador.

Emphysematous pyelonephritis is a necrotizing renal infection most frequently seen in patients with diabetes mellitus that is associated with a high mortality rate. We report a case of bilateral emphysematous pyelonephritis who presented with renal failure and septic shock. The patient died after six days of conservative therapy.

Infecções do trato urinário / Urinary tract infections

As infecções do trato urinário representam problema de grande relevância clínica, não só pela elevada frequência com que acometem mulheres e homens vivendo na comunidade, mas também por representar a primeira causa de infecção em pacientes hospitalizados. Na presente revisão, o autor apresenta os conceitos atuais sobre a epidemiologia, os fatores etiopatogênicos, as manifestações clínicas e os métodos de diagnóstico / Urinary tract infections have an extremely high clinical prevalence in both the community as well as in nosocomial patients. This behavior justifies the efforts that habe been made to disseminate the present knowledge on urinary tract infections to the members of most clinical specialities. In the present review the authors discuss and treatment of urinary tract infections, with emphasis on the practical clinical approach to such cases...

Emphysematous pyelonephritis: Case repoet

Emphysematous pyelonephritis [EPN] is a serious and often life threatening infection of the renal and perirenal tissues. The characteristic feature of this infection is the p resence of gas within the kidney and perinephric tissues. The triad of symptoms of fever; flank pain and pyuria especially in a diabetic patient who does not respond promptly to conventional antibiotic therapy must raise the possibility of EPN. CT Scan is the investigation of choice not only to establish the diagnosis but also to plan the line of management. Renal preservation must be the aim of management. This can be achieved to a great extent by aggressive antibiotic therapy in combination with percutaneous drainage of obstructed kidneys and abscesses. However nephrectomy is indicated in life threatening fulminant infection of the kidney. A case of EPN in a diabetic patient who was successfully managed by nephrectomy is presented. Review of literature and current concepts regarding the management of EPN are discussed

Attitudes of general practitioners and pediatricians to management of acute pyelonephritis in children

To study the attitudes of different groups of physicians toward management of acute pyelonephritis in children and the impact of such attitudes on the long-term sequelae of this problem. Materials and A questionnaire, describing a case history of a child with acute pyelonephritis, was distributed to general practitioners working in 12 primary health care centers and pediatricians working in the pediatric departments of the 6 main hospitals in Kuwait. The responses of the two groups were analyzed regarding their views toward hospitalization of the child, investigations requested, the choice of antibiotics, its route of administration, duration of treatment and the need for long-term follow-up. A total of 83 general practitioners [group A] and 65 hospital pediatricians [group B] responded to the questionnaire. Hospitalization of the child was thought to be essential by 19% of group A compared to 89% of group B [p < 0.0001]. Only 25% of group A decided to fully investigate the child compared to 58% of group B [p < 0.0001]. Treatment with a single antibiotic was preferred by 72% of group A compared to 80% of group B. Only 6% of group A, compared to 74% of group B favored parenteral antibiotics [p < 0.0001]. A 7-day course of treatment was considered by 70% of group A and 52% of group B [p < 0.02]. Long-term follow-up was thought to be necessary by 63% of group A and 75% of group B. A marked discrepancy existed in the management of acute pyelonephritis between the two groups, indicating the need of a unified policy. Children presenting with such a problem can be managed by general practitioners on an outpatient basis provided that proper antibiotics are used, compliance is ensured and appropriate investigations and follow-up are provided

Pielonefritis enfisematosa: una patología poco frecuente / Emphysematous pyelonephritis: an infrequent sisease

La pielonefritis enfisematosa es una rara afección del parénquima renal, provocada por bacilos formadores de gas, que se produce casi con exclusividad en pacientes portadores de una diabetes millitus no controlada. Su caracteristica más saliente es que junto con el cuadro infeccioso hay formación de gas que puede localizarse en el parénquima renal, en el tejido perirrenal o bien en la vía excretora. Se presenta una paciente portadora de esta entidad y se hace una revisión de la bibliografía

The value of percutaneous nephrostomy; Sri Lankan experience.

OBJECTIVE: To identify the most useful indications for image-guided percutaneous nephrostomy (PCN). DESIGN: Retrospective analysis of immediate outcome of the procedure in 46 patients. SETTING: Department of Radiology, The National Hospital of Sri Lanka, Colombo. PATIENTS: 46 patients on whom 59 PCNs done between June 1995 and August 1996. RESULTS: 57 PCNs were successful and 2 failed. Clinical improvement was observed in all patients with acute obstructive renal failure, pyorenephrosis and fistulae. Benefits were minimal in patients with chronic obstruction and none with terminal malignancy.

Infección urinaria complicada en niños: tratamiento con ceftibuten / Urinary infections complicated in child: treatment with ceftibuten

Se comunica la experiencia obtenida en un estudio prospectivo, abierto y no comparativo utilizando ceftibuten a dosis de 9 mg x Kg, en dosis única diaria durante 12 días en el tratamiento de 22 niños con edades comprendidas entre 1 y 12 años de vida con diagnóstico de infección urinaria complicada (pielonefritis). Se documentó el diagnóstico, además del urocultivo positivo, por la presencia en el ultrasonido renal de hallazgos ecográficos sugestivos de compromiso renal y/o indicadores biológicos de inflamación positivos como la proteína C reactiva, velocidad de sedimentación y leucocitosis mayor de 15000 glóbulos blancos x mm al cubo. La E. coli fue la bacteriana causal en 17 niños (77.18 por ciento), siendo resistente en el antibiograma al trimetoprin sulfa y a la ampicilina en 30 y 70 por ciento, respectivamente. Veinte niños (90.08 por ciento) tuvieron manifestación total de las manifestaciones clínicas con un urocultivo control posttratamiento negativo. Se concluye que el ceftibuten fue efectivo y seguro en el tratamiento de niños con pielonefritis

Aspectos de las infecciones urinarias / Aspects of the infections urinary

El conocimiento a cabalidad de las infecciones urinarias por el médico general y el especialista, llevará a disminuir la morbilidad y letalidad de las infecciones urinarias en nuestro medio. Es importante recalcar que será la única forma, con un tratamiento adecuado, evitar el paso hacia los procesos crónicos de las vías urinarias. Evitando así con ello, la insuficiencia renal crónica. El tratamiento está orientado predominantemente al tratamiento de E.coli, agente causal primordial en las infecciones urinarias.

Estudio comparativo entre ciprofloxacina oral y ampicilina. Gentamicina parenteral en el tratamiento de la pielonefritis aguda

Tradicionalmente la pielonefritis aguda ha requerido de tratamiento médico urgente con hospitalización hasta observar la respuesta a la terapia administrada, generalmente con ampicilina/gentamicina parenteral, actualmente este esquematerapéutico se ha limitado por la alta prevalencia de E. Coli uropatógena resistente a los antibióticousados, también por el costo que significa un tratamiento hospitalario, y la posibilidad de presentar infecciones nosocomiales. En un estudio experimental randomizado, comparativo, se realizó una evaluación temprana (72 horas) del efecto terapéutico de la ciprofloxacina oral (500 mg. cada 12 horas) comparada con ampicilina (1 gr. cada 4 horas) y gentamicina parenteral, a dosis terapéutica según aclaramiento de creatinina y peso, en el tratamiento de la pielonefritis aguda complicada o no complicada. La muestra se conformó de 46 pacientes, 5 hombres y 41 mujeres asignados aleatoriamente a los dos grupos de estudio; a. 22 grupo ciprofloxacina y B. 24 grupo Ampicilina/gentamicina, los pacientes ingresaron al Hospital IESS Riobamba con diagnóstico de pielonefritis aguda.