Pyonephrosis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Harsh Vardhan Chawla, M.B.B.S.[2]
Overview
Pyonephrosis is a surgical emergency. Hemodynamically unstable patients may require aggressive fluid resuscitation with crystalloids and pressor agent (dopamine) to maintain adequate blood pressure. All patients with pyonephrosis should be empirically treated with intravenous long-acting, broad-spectrum antibiotics like ampicillin + gentamicin combined with urgent drainage of the pus. After treating the infection, additional investigations are required to find the cause of the obstruction e.g., nephrolithiasis, tumors, etc. for definitive treatment.
Medical therapy
- Pyonephrosis is a urological emergency.[1]
- Hemodynamically unstable patients may require aggressive fluid resuscitation with crystalloids and pressor agent (dopamine) to maintain adequate blood pressure.
- Before initiating antimicrobial treatment for suspected pyonephrosis, urine and blood culture and susceptibility test should always be performed.
- All patients with pyonephrosis should be empirically treated with intravenous long-acting, broad-spectrum antibiotics which may be later narrowed based on culture report.
- Presence of pyonephrosis and obstruction reduces the efficacy and penetration of antibiotics. Therefore, drainage of the pus should be done immediately after administering the antibiotics.
- Intravenous Ampicillin + Gentamicin is a good initial option that covers both gram-positive and negative organisms.
- Anaerobic coverage with clindamycin, antifungal, or antitubercular agents may be required depending upon the clinical scenario.
- Carbapenem-resistant enterobacteriaceae can be treated with ceftazidime-avibactam, ceftolozane-tazobactam[2], meropenem-vaborbactam[3], and imipenem-cilastatin-relebactam.[4][5]
- After treating the infection, additional investigations are required to find the cause of the obstruction e.g., nephrolithiasis, tumors, etc. for definitive treatment.
Antimicrobial Therapy
Antibiotics are started only after the sample has been drawn for urine and blood culture to identify the causative organisms and their antibiotic sensitivity. For pyonephrosis, treatment with IV antibiotics is continued until the patient is afebrile for 24-48 hours.[6] Rapid decompression with ureteral catheterization or nephrostomy drainage is warranted to prevent septic shock. Following this treatment, a 2-week course of PO regimen for uncomplicated pyelonephritis is also recommended.
- Pyelonephritis empiric therapy[7]
- Inpatient treatment
- Preferred regimen (1): Ampicillin 1 g IV q6h +Gentamicin 1 mg/kg IV infusion q8h.
- Preferred regimen (2): Ceftriaxone 1 gm IV q24h
- Preferred regimen (3): Ciprofloxacin 400 mg q12h
Refernces
- ↑ Ludvigson AE, Beaule LT (2016). "Urologic Emergencies". Surg Clin North Am. 96 (3): 407–24. doi:10.1016/j.suc.2016.02.001. PMID 27261785.
- ↑ Wagenlehner FM, Umeh O, Steenbergen J, Yuan G, Darouiche RO (2015). "Ceftolozane-tazobactam compared with levofloxacin in the treatment of complicated urinary-tract infections, including pyelonephritis: a randomised, double-blind, phase 3 trial (ASPECT-cUTI)". Lancet. 385 (9981): 1949–56. doi:10.1016/S0140-6736(14)62220-0. PMID 25931244.
- ↑ Dhillon S (2018). "Meropenem/Vaborbactam: A Review in Complicated Urinary Tract Infections". Drugs. 78 (12): 1259–1270. doi:10.1007/s40265-018-0966-7. PMC 6132495. PMID 30128699.
- ↑ Kuiper SG, Leegwater E, Wilms EB, van Nieuwkoop C (2020). "Evaluating imipenem + cilastatin + relebactam for the treatment of complicated urinary tract infections". Expert Opin Pharmacother. 21 (15): 1805–1811. doi:10.1080/14656566.2020.1790525. PMID 32820669 Check
|pmid=value (help). - ↑ Doi Y (2019). "Treatment Options for Carbapenem-resistant Gram-negative Bacterial Infections". Clin Infect Dis. 69 (Suppl 7): S565–S575. doi:10.1093/cid/ciz830. PMC 6853760 Check
|pmc=value (help). PMID 31724043. - ↑ Hooton TM (2012). "Clinical practice. Uncomplicated urinary tract infection". N Engl J Med. 366 (11): 1028–37. doi:10.1056/NEJMcp1104429. PMID 22417256.
- ↑ Ng CK, Yip SK, Sim LS, Tan BH, Wong MY, Tan BS; et al. (2002). "Outcome of percutaneous nephrostomy for the management of pyonephrosis". Asian J Surg. 25 (3): 215–9. doi:10.1016/S1015-9584(09)60178-0. PMID 12376218.