Acute pyelonephritis has the potential to cause sepsis, septic shock, and death.
Urine culture is the cardinal confirmatory diagnostic test.
Imaging is recommended at the time of presentation for patients with sepsis or septic shock, known or suspected urolithiasis, a urine pH of 7.0 or higher, or a new decrease in the glomerular filtration rate to 40 ml per minute or lower. Subsequent imaging is indicated in patients whose condition worsens or does not improve after 24 to 48 hours of therapy.
The rising prevalence of Escherichia coli resistant to fluoroquinolones and trimethoprim–sulfamethoxazole complicates empirical oral therapy. In patients who receive oral treatment from the outset, depending on the likelihood of resistance, an initial dose of a supplemental, long-acting, parenteral antimicrobial agent (e.g., an aminoglycoside, ceftriaxone, or ertapenem) may be appropriate, and close follow-up is warranted.
Assessment of illness severity, underlying host status, and the patient’s psychosocial situation and estimation of the likelihood of pathogen resistance to relevant antimicrobial agents are critical in decisions regarding patient disposition and treatment.
