Clinical guidelines for pyelonephritis. Clinical guidelines for pyelonephritis Acute pyelonephritis clinical guidelines
Pyelonephritis, clinical recommendations for treatment of which depend on the form of the disease, is an inflammatory disease of the kidneys. Factors influencing the occurrence of pyelonephritis: urolithiasis, abnormal structure of the urinary canals, renal colic, prostate adenoma, etc.
Anyone can get kidney inflammation. However, girls aged 18 to 30 are at risk; older men; children under 7 years old. Doctors distinguish two forms of pyelonephritis: chronic and acute.
Symptoms, diagnosis and treatment of acute pyelonephritis
Acute pyelonephritis is an infectious kidney disease. The disease develops quickly, literally within a few hours.
Symptoms of acute kidney inflammation:
- a sharp increase in temperature to 39 ° C and above;
- sharp pain in the lower back at rest and upon palpation;
- lower back pain during urination;
- increased blood pressure;
- nausea or vomiting;
- chills.
If symptoms occur, you should immediately contact a urologist or nephrologist and do not self-medicate! The doctor must conduct diagnostic tests to confirm the diagnosis. The fact of acute kidney inflammation will be revealed by general urine and blood tests (the level of leukocytes will be significantly higher than normal) and an ultrasound of the kidneys. The doctor may additionally prescribe an MRI or CT scan.
Acute pyelonephritis should be treated inpatiently. At the same time, it is necessary to eliminate not only the symptoms, but also the causes of the disease themselves. If treatment is not started in time, acute pyelonephritis can develop into chronic, and then even into kidney failure.
Therapeutic treatment of acute inflammation includes antibacterial drugs (antibiotics) and vitamins. If the inflammation is severe, surgical intervention may be necessary. In the first days of the disease, bed rest must be observed. At the same time, you are not even allowed to get up to go to the toilet, which is why it is so important to undergo inpatient treatment.
- Stay warm. You can't get too cold.
- Drink plenty of fluids. An adult needs to drink more than 2 liters of fluid per day. Children - up to 1.5 liters. During this period, it is useful to drink sour citrus juices (grapefruit, orange, lemon). The fact is that an acidic environment kills bacteria, and the treatment process will be faster and easier.
- Follow a diet. Eliminate all fried, fatty, spicy, baked foods and baked goods from your diet. Dramatically reduce the consumption of salt and strong meat broths.
- If all recommendations are followed, treatment will take about 2 weeks. But complete recovery occurs after 6-7 weeks. Therefore, you should not stop taking medications. You need to complete the full course of treatment as prescribed by your doctor.
Symptoms, diagnosis and treatment of chronic pyelonephritis
According to statistics, about 20% of the world's population suffers from chronic pyelonephritis. This is an inflammatory kidney disease that can develop from acute pyelonephritis, but mostly occurs as a separate disease.
Symptoms of chronic kidney inflammation:
- frequent urination;
- an unreasonable increase in temperature no higher than 38 ° C, usually in the evenings;
- slight swelling of the legs at the end of the day;
- slight swelling of the face in the morning;
- aching pain in the lower back;
- extreme fatigue, often for no reason;
- high blood pressure.
Blood and urine tests can confirm the diagnosis. A general blood test will show low hemoglobin, and a urine test will show increased leukocytes and bacteriuria. In case of a chronic disease, it makes no sense to do an ultrasound of the kidneys - it will not show anything. It is important to understand that only a doctor can make a diagnosis. You should not self-medicate.
Chronic pyelonephritis can be treated at home, but only if the temperature and blood pressure do not increase, there is no nausea and vomiting, acute pain and suppuration. For treatment, the doctor must prescribe antibiotics and uroseptics. Therapeutic treatment lasts at least 14 days.
During treatment, as in the case of acute inflammation, it is worth following the following regimen:
- Rest as much as possible without putting stress on the body. Lie down a lot, and in the first days of illness even stay in bed.
- Don't get too cold.
- Drink about 3 liters of liquid per day. Particularly useful are lingonberry or cranberry fruit drinks, fruit juices, still mineral water, and rosehip decoction.
- Go to the toilet more often.
- Stop drinking coffee and alcohol during treatment.
- Exclude mushrooms, legumes, smoked meats, marinades, and spices from the diet.
- Reduce the amount of salt in food.
In the case of a chronic disease, traditional medicine will also help. It is worth drinking kidney herbal teas. Herbal medicine course - 2 times a year (autumn and spring). Spa treatment with mineral waters will also have a healing effect.
The main thing in the treatment of pyelonephritis is to identify the disease in time. In addition, in the future it is important not to get too cold, drink plenty of fluids and maintain hygiene.
Chronic pyelonephritis - sluggish, periodically exacerbating bacterial inflammation of the interstitium of the kidney, leading to irreversible changes in the pyelocaliceal system with subsequent sclerosis of the parenchyma and wrinkling of the kidney.
By localization chronic pyelonephritis May be one-sided or bilateral, affecting one or both kidneys. Commonly found bilateral chronic pyelonephritis.
Often chronic pyelonephritis (CP) results from improper treatment acute pyelonephritis (OP).
In a significant proportion of patients who underwentacute pyelonephritisor exacerbationchronic pyelonephritis,relapse occurs within 3 months after the exacerbationchronic pyelonephritis.
Prevalence rate chronic pyelonephritis in Russia is 18-20 cases per 1000 people, while in other countries acute pyelonephritis is completely cured without progressing to chronic.
Although complete cure has been proven all over the world acute pyelonephritis in 99% of cases, and the diagnosis "chronic pyelonephritis" is simply absent in foreign classifications, mortality from pyelonephritis in Russia, according to data on causes of death, ranges from 8 to 20% in different regions.
Low effectiveness of treatment acute and chronic pyelonephritis c is associated with the lack of timely rapid testing by general practitioners using test strips, the appointment of lengthy unfounded examinations, incorrect empirical prescription of antibiotics, visits to non-specialized specialists, attempts at self-medication and late seeking medical help.
Types of chronic pyelonephritis
Chronic pyelonephritis - code according to ICD-10
- No. 11.0 Non-obstructive chronic pyelonephritis associated with reflux
- No. 11.1 Chronic obstructive pyelonephritis
- No. 20.9 Calculous pyelonephritis
According to the conditions of occurrence, chronic pyelonephritis is divided into:
- primary chronic pyelonephritis, developing in an intact kidney (without developmental anomalies and diagnosed disorders of urodynamics of the urinary tract);
- secondary chronic pyelonephritis, arising against the background of diseases that interfere with the passage of urine.
Chronic pyelonephritis in women
Women suffer from pyelonephritis 2-5 times more often than men, which is due to the anatomical features of the body. In women, the urethra is much shorter than in men, so bacteria easily penetrate through it from the outside into the bladder and from there through the ureters can enter the kidneys.
Development chronic pyelonephritis In women, factors such as:
- pregnancy;
- gynecological diseases that impair the flow of urine;
- presence of vaginal infections;
- use of vaginal contraceptives;
- protected sexual intercourse;
- hormonal changes in the premenopausal and postmenopausal periods;
- neurogenic bladder.
Chronic pyelonephritis in men
In men chronic pyelonephritis often associated with difficult working conditions, hypothermia, poor personal hygiene, and various diseases that impair the flow of urine (prostate adenoma, urolithiasis, sexually transmitted diseases).
Reasons chronic pyelonephritis men may have:
- prostatitis;
- stones in the kidneys, ureters, bladder;
- unprotected sex;
- STDs (sexually transmitted diseases);
- diabetes mellitus
Causes of chronic pyelonephritis
In the formation of primary chronic pyelonephritis, an important role is played by the infectious agent, its virulence, as well as the nature of the body’s immune response to the pathogen. The introduction of an infectious agent is possible through ascending, hematogenous or lymphogenous routes.
Most often, the infection enters the kidneys via the ascending route through the urethra. Normally, the presence of microflora is permissible only in the distal part of the urethra, but in some diseases the normal passage of urine is disrupted and urine backflows from the urethra and bladder into the ureters, and from there into the kidneys.
Diseases that disrupt the passage of urine and cause chronic pyelonephritis:
- abnormalities of the kidneys and urinary tract;
- urolithiasis;
- ureteral strictures of various etiologies;
- Ormond's disease (retroperitoneal sclerosis);
- vesicoureteral reflux and reflux nephropathy;
- adenoma and sclerosis of the prostate;
- sclerosis of the bladder neck;
- neurogenic bladder (especially hypotonic type);
- kidney cysts and tumors;
- neoplasms of the urinary tract;
- malignant tumors of the genital organs.
Risk factors (RFs) for urinary tract infections are presented in Table 1.
Table 1. Risk factors for urinary tract infections
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Examples of risk factors |
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No risk factors identified |
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Risk factor for recurrent UTI, but without risk of severe outcome |
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Extraurogenital risk factors with a more severe outcome |
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Urological risk factors with a more severe outcome, which |
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Nephropathy with a risk of more severe outcome |
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Availability of permanent |
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Causative agents of chronic pyelonephritis
The most common pathogens of pyelonephritis are microorganisms of the Enterobacteriaceae family (with Escherichia-coli accounting for up to 80%), less commonly Proteus spp., Klebsiella spp., Enterobacter spp., Pseudomonas spp, Staphylococcus Saprophyticus, Staphylococcus Epidermidis, Enterococcus Faecalis, as well as fungal microflora, viruses, L-forms of bacteria, microbial associations (E. coli and E. faecalis are often combined).
However, simple infection of the urinary tract is not enough to form chronic primary pyelonephritis. To implement the inflammatory process, a simultaneous combination of a number of conditions is necessary: the manifestation of the virulent properties of the infectious agent, the inadequacy of the body’s immune response to this pathogen, disturbances in urodynamics and/or renal hemodynamics, usually initiated by the infection itself.
Currently, the role of immune system disorders in the pathogenesis of chronic primary pyelonephritis is beyond doubt. In patients with this type of pathology, in the phase of active inflammation there is a decrease in all indicators of phagocytosis, incl. oxygen-dependent effector mechanisms as a result of depletion of the bactericidal systems of phagocytic cells.
Chronic pyelonephritis- the most common kidney disease, manifests itself as a nonspecific infectious-inflammatory process that occurs predominantly in the tubulointerstitial zone of the kidney.
The following stages of chronic pyelonephritis are distinguished:
- active inflammation;
- latent inflammation;
- remission or clinical recovery.
Exacerbation of chronic pyelonephritis
IN active phase of chronic pyelonephritis the patient complains of dull pain in the lumbar region. Dysuria(urinary disorders) is uncharacteristic, although it may be present in the form of frequent painful urination of varying severity. Upon detailed questioning, the patient may bring up a lot of nonspecific complaints:
- episodes of chills and low-grade fever;
- discomfort in the lumbar region;
- fatigue;
- general weakness;
- decreased performance, etc.
Latent pyelonephritis
IN latent phase Disease complaints may be completely absent, the diagnosis is confirmed by laboratory tests.
IN remission stage are based on anamnestic data (for at least 5 years), complaints and laboratory changes are not detected.
During development chronic renal failure(CRF) or tubular dysfunction complaints are often determined by these symptoms.
Tests for chronic pyelonephritis
As a screening method of examination for chronic pyelonephritis, general urine test and ultrasound of the kidneys, supplemented by questioning the patient about the characteristic manifestations of chronic pyelonephritis and diseases that contribute to its development.
What tests need to be taken for chronic pyelonephritis:
- General urinalysis (UCA)
- Complete blood count (CBC)
- Urine bacterioscopy
- Blood glucose
- Creatinine and blood urea
- Kidney ultrasound
- Pregnancy test
- Survey urography
- Bacteriological examination of urine
Urine and blood tests for chronic pyelonephritis
For routine diagnosis, it is recommended to carry out general urine test with the determination of leukocytes, erythrocytes and nitrites.
Clinical guidelines include advice on diagnosis and therapeutic measures for kidney inflammation. Based on the recommendations, the doctor examines, diagnoses and treats the patient in accordance with the form of the disease and its causes.
– an inflammatory disease that affects the renal tissue and the pyelocaliceal system (PLS). The cause of the disease is the development of an infection that successively affects the parenchyma, then the calyx and pelvis of the organ. Infection can also develop simultaneously in the parenchyma and the CLS.
In the vast majority of cases, the causative agents are Escherichia coli, streptococcus, staphylococcus, and less commonly Klebsiella, Enterobacter, Enterococcus and others.
Depending on the effect on the process of urination, inflammation can be primary and secondary. In the primary form, urodynamic disturbances are not observed. In the Tuesday form, the process of formation and excretion of urine is disrupted. The causes of the latter type can be pathologies of the formation of the organs of the urinary system, urolithiasis, inflammatory diseases of the genitourinary organs, benign and malignant tumor formations.
Depending on the location of the inflammatory process in the kidneys, the disease can be unilateral (left- or right-sided) or bilateral.
Depending on the form of manifestation, pyelonephritis occurs acutely and chronically. The first develops rapidly as a result of the proliferation of bacterial flora in the organ. The chronic form is manifested by a long course of symptoms of acute pyelonephritis or its multiple relapses during the year.
Diagnostics
Pyelonephritis is accompanied by a feeling of pain in the lower back, fever and changes in the physicochemical properties of urine. In some cases, with inflammation of the kidneys, feelings of fatigue and weakness, headaches, disorders of the digestive tract, and thirst may be present. Pyelonephritis in children is accompanied by increased excitability, tearfulness and irritability.
During diagnostic measures, the doctor must determine what led to the development of the inflammatory process in the kidneys. For this purpose, a survey is conducted to determine the presence of chronic diseases, inflammatory diseases of the urinary system in the past, anomalies in the structure of the organs of the urinary system and disorders in the functioning of the endocrine system, and immunodeficiency.
During the examination, a patient with pyelonephritis may have an elevated body temperature, which is accompanied by chills. During palpation, pain occurs in the kidney area.
To identify the inflammatory process in the kidney, tests are performed to detect leukocyturia and bacteremia. An increase in leukocytes in the urine is determined using test strips, general analysis and Nechiporenko analysis. The most accurate results are laboratory tests (sensitivity about 91%). Test strips have lower sensitivity - no more than 85%.
The presence of bacterial flora will be shown by a bacteriological analysis of urine. During the study, the number of bacteria in urine is counted, the number of which determines the form of the disease. Bacteriological analysis also makes it possible to determine the type of bacteria. It is important to study the microflora of urine to determine the resistance of the pathogen to antibiotics.
General clinical, biochemical and bacteriological blood tests help determine the clinical picture of the disease. In primary pyelonephritis, blood testing is rarely used, since the test results will not show significant deviations. With secondary pyelonephritis, changes in leukocyte counts occur, as well as in the erythrocyte sedimentation rate. A biochemical blood test is carried out according to indications, in the presence of other chronic diseases or when complications are suspected. A bacteriological blood test helps confirm the type of infectious pathogen.
Instrumental diagnostic methods will help clarify the diagnosis, determine the condition of the kidneys and organs of the urinary system, and establish the cause of the development of inflammation. Using ultrasound, you can see the presence of stones, tumors, and purulent foci in organs. The development of pyelonephritis will be indicated by an increased size of the pyelocaliceal system.
If symptoms intensify within 3 days after the start of treatment, computed tomography and x-ray diagnostics with the introduction of a contrast agent are prescribed. If malignant neoplasms are suspected and detected during ultrasound, cystoscopy is required.
Treatment should be aimed at eliminating the source of the disease, preventing complications and relapses.
In acute primary pyelonephritis, treatment is carried out on an outpatient basis with the help of antibacterial agents. Treatment in a hospital setting is carried out according to indications or in the absence of effect from the drugs used.
Hospitalization is necessary for patients with secondary inflammation, which can lead to serious complications as a result of poisoning the body with toxic compounds.
Urgent hospitalization is also necessary for patients with one kidney, exacerbation of a chronic inflammatory process, which occurs with symptoms of renal failure. In a hospital setting, treatment is necessary in the presence of other chronic diseases (diabetes mellitus, immunodeficiency) and in case of accumulation of pus in the kidney cavity.
Treatment
Non-drug treatment involves drinking the required amount of fluid to help maintain adequate urination. Diuretics are used for this purpose. The diet excludes the consumption of fried, fatty, spicy foods, baked goods and salt.
Drug treatment involves a course of antibacterial drugs, which are prescribed taking into account their compatibility, the patient’s allergies, concomitant diseases, and the patient’s special condition (pregnancy or lactation).
Antibiotics are prescribed immediately after pyelonephritis is detected. General antibiotics are used. After the results of the bacteriological analysis, specific antibiotics are prescribed.
After 48-72 hours, the effectiveness of therapy is monitored. After the results of the analysis, if there is no effectiveness, a decision is made regarding the prescription of other drugs or increasing the dose prescribed.
To treat the primary form, fluoroquinolones, cephalosporins, and protected aminopenicillins are prescribed. In case of secondary inflammatory process, aminoglycosides are added to the specified list of drugs.
During pregnancy, pyelonephritis is treated outside the hospital with antibiotics if there is no threat of miscarriage. In other cases, hospitalization is required. Protected aminopenicillins, cephalosporins, and aminoglycosides are used for treatment. Fluoroquinols, tetracyclines, and sulfonamides are strictly contraindicated.
In case of complicated pyelonephritis, preference is given to ureteral catheterization or percutaneous nephrostomy (PPNS). These methods involve the installation of a drainage system and are aimed at normalizing the passage of urine.
Open operations are performed when pus forms, the disease prolongs, or it is impossible to use minimally invasive surgical methods.
Timely diagnosis and correctly prescribed therapy provide a great chance for a favorable outcome of pyelonephritis. Antibiotics, diet, and water regimen are used for treatment. According to indications, surgical intervention is prescribed.
High-quality and effective treatment of kidney diseases is impossible without following the recommendations of specialists. A professional approach and selection of optimal therapy will help not only completely restore the functionality of the urinary system and the filtration abilities of the kidney, but also do without surgical intervention. Regardless of the stage of the disease, therapeutic procedures are carried out in full; you cannot stop taking pills, just as you should not disturb your sleep, eating, and drinking patterns.
- urinary tract infection (UTI) characterized by the growth of bacteria in the urinary tract;
- bacteriuria - an increased number of bacteria in the urine (from 105 colony-forming units in 1 ml of urine);
- asymptomatic bacteriuria– a pathology detected in children during a targeted study, but without pronounced symptoms;
- acute pyelonephritis– inflammatory process in the pelvis, kidney parenchyma due to infection (may be due to stagnation of urine);
- acute cystitis is an inflammatory process of bacterial origin;
- chronic pyelonephritis– organ damage, characterized by fibrosis, destruction of the pelvic cups, occurring against the background of anatomical abnormalities, congenital or acquired obstructions;
- vesicoureteral reflux– a pathology in which urine flows back into the kidneys;
- reflux nephropathy– sclerotic damage to the parenchyma of a focal or diffuse nature, the root cause is vesicoureteral reflux, provoking intrarenal reflux, leading to attacks of pyelonephritis and sclerosis of the renal parenchyma;
- Urosepsis is an infectious pathology of a generalized nonspecific type, the appearance of which is associated with the penetration of microorganisms and toxic substances from the urinary system into the bloodstream.
The prevalence of pyelonephritis in children is more than 18%. The frequency of manifestation of the pathology depends on the age and gender of the patient; children in the first year of life are most often affected. For infants, UTI is one of the most severe infectious pathologies, observed in 10-15% of cases.
Important! Until the age of 3 months, UTIs are more common in boys, then the pathology more often develops in girls. After the first illness, the risk of relapse increases with a frequency: in girls from 30% within 12 months after the first episode, in boys 15-20% within 12 months after the first episode.
Consultation with pediatric specialists is necessary at the first signs of leukocyturia or primary dysuritic disorders (inability to urinate with a clear desire, pain during urination, decreased volume of daily urine, change in smell, color of urine, etc.). The cause of the pathology may be local inflammation of the genitals or the presence of phimosis.
Important! In acute forms of the disease, children may not experience damage to the upper respiratory tract even during nephropathic fever. In the first 12 months of a child’s life, an ultrasound examination of the kidneys and bladder is mandatory to eliminate the threat of developing pathology.
Primary prevention of childhood pyelonephritis according to the clinical recommendations of specialists includes the following points:
- regular (do not tolerate) emptying the bladder and bowels;
- compliance with the drinking regime;
- body hygiene.
Rehabilitation activities for children include:
- regular examinations if episodes of infection recur;
- in the first 90 days after an exacerbation of chronic pyelonephritis or during the course of acute pathology, collecting clinical urine samples once every 10 days, for 3 years once a month, then once a quarter;
- analysis of urine culture for leukocyturia is carried out with unmotivated rises in temperature;
- Ultrasound of the kidneys once a year;
- instrumental examination once every 2 years.
The prognosis for complete cure for pyelonephritis in children is positive. Active diagnosis and early treatment reduces the risk of focal organ shrinkage to 10-12% (in the presence of relapses and refluxes), scar changes do not exceed 24% in children and 13% in children under 14 years of age.
The types of infectious diseases in adults are identical to those in children, but preventive measures are aimed at normalizing kidney function and preventing relapses. If acute or chronic pyelonephritis develops, the following recommendations must be followed:
- hygiene of the external genitalia: proper washing in women (from front to back due to the anatomical proximity of the exit channels and the possibility of infection, infection with ascending pyelonephritis);
- maintaining optimal body temperature balance: warm feet, warm clothes, but without excessive overheating;
- no hypothermia;
- timely emptying of the bladder;
- maintaining a physical activity regime without overload: normal activity is only beneficial, as it normalizes metabolic processes and restores the body’s water balance;
- swimming at a water temperature below +21 C is prohibited, overheating in the bathhouse/sauna is prohibited, taking a contrast shower is prohibited;
- compliance with diet therapy with abstinence from alcohol, spicy and fatty foods (basic detailed nutritional recommendations will be given by a specialist observing the patient);
- compliance with the drinking regime in sufficient quantities (but only without the presence of cardiovascular and other pathologies);
- fasting no more than once a week for 1-2 days with the use of immunostimulating agents (consultation with a doctor is required in advance, as active protein breakdown occurs and waste is removed by the kidneys, which is not always useful for inflammatory processes in the filtration organs);
- compliance with therapeutic methods of treatment after suffering from seasonal colds (drugs indicated for complete cure should be taken in full course);
- Avoid working in hot workshops that involve inhaling gasoline fumes, heavy metal salts and heavy physical exertion.
Important! Chronic pyelonephritis allows for treatment at home with normal body temperature, absence of nausea, vomiting, acute local or widespread pain. Therapeutic drugs in the form of antibiotics and uroseptics are used in full, the diet and regimen are followed.
As a rule, the course of therapy lasts no more than 14-21 days. In acute cases of pathology, the patient must be hospitalized and be kept in bed. It’s a good idea to take herbal remedies once every six months to prevent exacerbations. The type and volume of the course will be determined by the attending doctor.
