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21.04.08: Acute Pyelonephritis In Children (part III)
Acute pyelonephritis is an exudative purulent localized inflammation of the renal pelvis (collecting system) and kidney. The renal parenchyma presents in the interstitium abscesses (suppurative necrosis), consisting in purulent exudate (pus): neutrophils, fibrin, cell debris and central germ colonies (hematoxylinophils). Tubules are damaged by exudate and may contain neutrophil casts. In the early stages, glomeruli and vessels are normal. Gross pathology often reveals pathognomonic radiations of hemorrhage and suppuration through the renal pelvis to the renal cortex.
Chronic infections can result in fibrosis and scarring. As practically all cases of pyelonephritis are due to bacterial infections, antibiotics are the mainstay of treatment. Mild cases may be treated with oral therapy, but generally intravenous antibiotics are required for the initial stages of treatment. The type of antibiotic depends on local practice, and may include fluoroquinolones (e.g. ciprofloxacin), beta-lactam antibiotics (e.g. amoxicillin or a cephalosporin), trimethoprim (or co-trimoxazole) or nitrofurantoin. Aminoglycosides are avoided due to their toxicity, but may be added for a short duration. If the patient is unwell and septic, intravenous fluids may be administered to compensate for the reduced oral intake, insensible losses (due to the raised temperature) and vasodilation and to maximise urine output. In recurrent infections, additional investigations may identify an underlying abnormality. Occasionally, surgical intervention is necessary to improve chances of recurrence.
If no abnormality is identified, some studies suggest long-term preventative (prophylactic) treatment with antibiotics, either daily or after sexual intercourse. In children at risk of recurrent UTIs, the evidence is inconclusive as to whether long-term prophylactic antibiotics are of use. Ingestion of cranberry juice has been studied as a prophylactic measure; while studies are heterogeneous, many suggest a benefit. Some recommend other nutritional approaches to prevent recurrence of UTIs. Increasing fluid intake, consuming cranberry juice, blueberry juice, and fermented milk products containing probiotic bacteria, have been shown to inhibit adherence of bacteria to the epithelial cells of the urinary tract. Pyelonephritis is very common, with 12-13 cases annually per 10,000 population in women and 3-4 cases per 10,000 in men. Young women are most likely to be affected, traditionally reflecting sexual activity in that age group. Infants and the elderly are also at increased risk, reflecting anatomical abnormalities and hormonal status.
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