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PubMed2005

Clarithromycin: immunomodulatory therapy of experimental sepsis and acute pyelonephritis by Escherichia coli.

The potency of clarithromycin as immunomodulator was assessed in an experimental model of sepsis based on acute pyelonephritis by susceptible Escherichia coli. 55 rabbits were utilized; 5 for preliminary pharmacokinetic study and 50 for treatment. The latter were divided into 5 groups of treatment, A: controls; B: clarithromycin pretreatment; C: amikacin pretreatment; D: clarithromycin treatment on presentation of pulmonary oedema; and E; amikacin treatment on presentation of pulmonary oedema. Survival was recorded; tumour necrosis factor-alpha (TNFalpha), and malondialdehyde (MDA) were estimated in serum; activities of caspase-3 in monocyte cytosolic extracts were studied; and bacterial counts made in various organs. Median survival of animals of groups A, B, C, D and E was 1.0, 21.0, 12.5, 2.0 and 5.0 d, respectively. TNFalpha and MDA and monocyte caspase-3 activity of group A increased over time; no increases were detected in groups B and C. Concentrations of MDA and activities of monocytic caspase-3 were decreased after administration of clarithromycin in group D, an effect not occurring in group E. Bacterial load was decreased in renal tissue of group D compared to group A. It is concluded that intravenous clarithromycin might constitute a promising immunomodulator in sepsis even in the advent of pulmonary oedema.

Acute Disease↗
PubMed2003

Analysis of 39 cases of xanthogranulomatous pyelonephritis with emphasis on CT findings.

OBJECTIVE: In this retrospective study a review of the clinical, laboratory and radiologic features of 39 cases of xanthogranulomatous pyelonephritis (XGP) is presented. CT characteristics of XGP are analyzed in detail and the relevant literature is reviewed in order to determine the most typical among them. MATERIAL AND METHODS: Pathologic material from 39 patients suffering from XGP was reviewed in order to confirm the initial diagnosis. Data compiled from the previous history of the patients, clinical, laboratory, urographic and CT findings, preoperative diagnosis, operative findings and postoperative period were analyzed. RESULTS: Diffuse and focal forms of XGP were recognized in 38 and 1 cases, respectively. Fever, pain in the flank or abdomen, chills and malaise were the commonest symptoms. A non-functioning kidney and/or staghorn calculus were the commonest urographic findings. When available (15 cases), CT revealed multiple fluid-filled cavities in the affected kidney and demonstrated the extension of the disease to the perinephric spaces in all cases. All patients had undergone nephrectomies, which were characterized as difficult in 60% of cases, whereas two patients developed postoperative complications requiring re-exploration. CONCLUSIONS: Nephrectomy for XGP may be followed by severe complications and appropriate patient preparation and operation planning is of great importance. CT is considered the imaging technique of choice for diagnosing the disease preoperatively and a plethora of CT characteristics have been described to date. Low-density fluid-filled areas within the renal parenchyma and findings indicating perinephric extension should be considered the most typical CT features of XGP.

Adult↗
PubMed2006

Outcome of nephrectomy and kidney-preserving procedures for the treatment of emphysematous pyelonephritis.

OBJECTIVE: Emphysematous pyelonephritis (EPN) is an acute necrotizing infection of the kidney characterized by gas formation. In order to compare the outcome of nephrectomy and kidney-preserving procedures for the treatment of EPN we reviewed our experiences of EPN over the past 18 years. MATERIAL AND METHODS: The medical records of 17 patients with EPN treated between October 1986 and September 2004 were retrospectively reviewed. Abdominal X-ray and/or CT were used as diagnostic methods. RESULTS: Women outnumbered men (12 vs five), and all patients had diabetes. Obstruction of the corresponding reno-ureteral unit was found in one patient. Thirteen of the 17 patients (76%) had poorly controlled diabetes (hemoglobin A1c>7%). The diagnosis of EPN was confirmed by gas in the parenchymal or perinephric space as detected by abdominal X-ray or CT. Escherichia coli was the commonest organism present in urine cultures (52%), followed by Klebsiella pneumoniae (24%). Prompt efforts were made to control diabetes, and i.v. antibiotics were given. Nephrectomy was performed in 10 patients and nine patients survived (90% success rate). The success rate among those who received medical therapy only was 50% (2/4 patients). Percutaneous drainage was performed in three patients, two of whom survived (67% success rate). The overall mortality rate was 17.6% (3/17 patients). CONCLUSIONS: Immediate nephrectomy with glycemic control measures and antibiotic administration is crucial for the successful treatment of EPN. However, in inoperable cases, percutaneous drainage can be an effective treatment option.

Adult↗
PubMed1993

Outpatient parenteral antibiotic therapy. Management of serious infections. Part II: Amenable infections and models for delivery. Pyelonephritis.

Outpatient therapy is currently recommended for women with uncomplicated pyelonephritis, not those with sepsis, renal insufficiency or pathology, or significant underlying disease. Parenteral therapy is usually initiated in the emergency department, followed by oral therapy at home. Pregnant patients are hospitalized, though studies suggest that outpatient therapy may be appropriate.

Ambulatory Care↗
PubMed2002

Acute pyelonephritis: analysis of 52 cases.

Acute pyelonephritis (APN) is a frequent disease, but diagnostic approach, evolution into abscesses, and indication to hospitalization are still open problems. We have made a retrospective analysis of APN cases observed in our hospital. We identified 58 patients (pt) and selected 52 of these who presented fever and loin pain at the onset (31 were hospitalized in Nephrology and 21 in other units). Urine culture was positive in 11/48 cases (22.9%), blood cultures in 3/26 cases (11.5%) (Escherichia coli). Renal sonography was normal in 20/48 cases (41.6%) and suggestive for APN in 23/48 cases (47.9%). CT with contrast medium was normal in 9/28 cases (32.1%) and positive in 19/28 cases (67.8%), with evidence of unique or multiple hypodense areas; abscesses were found in 8 patients (28.5%). No statistically significant differences were found between patients with positive or negative CT as regards fever, leukocytosis, ESR, CRP, CRP at 20 days, urinary leukocytes, urine culture, duration of symptoms before hospitalization. Moreover no differences were found between patients with and without abscesses. CT was performed more frequently among patients hospitalized in Nephrology than among patients hospitalized in other services (24/31-77.4%-vs. 4/21-19%-, p = 0.05). NMR was abnormal in 6/9 cases. A radiographic documentation of APN was obtained in 61.53% of patients with clinical diagnosis of APN. Of these, only 18.7% had positive urine culture. In conclusion, our data suggest that demonstration of urine infection is not necessary for APN diagnosis, when clinical and/or radiologic diagnosis of APN has been made. Evolution into abscesses is frequent and not easily susceptible on clinical ground; for this reason we think it is advisable to perform CT or NMR systematically. Differences in clinical behavior between different units suggest the need for diagnostic guidelines.

Acute Disease↗
PubMed1967

The role of penicillin-induced bacterial variants in experimental pyelonephritis.

1. After injection into the renal medulla of rats Escherichia coli 06 variants reverted rapidly in vivo in the absence of penicillin. These variants had previously been shown to be stable in vitro. 2. Variants failed to survive following intramedullary injection when animals were receiving penicillin. 3. Late reversion of variants also failed to occur in animals treated with penicillin for only 1 or 2 days. 4. Variants survived and reverted more readily when injected in the renal medulla, compared with liver and spleen. Classical bacteria injected into the kidney, liver, and spleen were recovered in approximately equal numbers. 5. The histologic response to nonreverting variants, medium not containing variants, and killed variants was similar and was characterized by a fibrotic reaction with moderate round cell infiltration. 6. In contrast, the histologic response to reverting variants and to classical E. coli was characterized by an intense, acute, polymorphonuclear leukocytosis typical of acute pyelonephritis.

Animals↗
PubMed2000

Interleukin-8 receptor knockout mice have subepithelial neutrophil entrapment and renal scarring following acute pyelonephritis.

Interleukin (IL)-8 receptor knockout (KO) mice were shown to have a dysfunctional neutrophil response to urinary tract infection and to develop renal scarring. Intravesical Escherichia coli infection stimulated epithelial chemokine secretion and IL-8 receptor expression in control mice. Neutrophils migrated through the tissues and crossed the epithelial barrier into the urinary tract lumen. In murine IL-8 receptor homologue (mIL-8Rh) KO mice, infection triggered a chemokine response, and neutrophils were recruited but failed to traverse the mucosal barrier and accumulated under the epithelium. After 7 days, control mice were healthy, and infection was cleared, but mIL-8Rh KO mice had swollen kidneys, with neutrophil abscesses and high numbers of bacteria. After 35 days, they developed kidney pathology and renal scarring. The results demonstrate that chemokine receptors drive transepithelial neutrophil migration. In their absence, the neutrophils are trapped, and the tissues are destroyed. This molecular deficiency may determine the progression from acute pyelonephritis to renal scarring.

Abscess↗
PubMed2003

Long-term follow-up of women hospitalized for acute pyelonephritis.

Long-term outcome of acute pyelonephritis (AP) in adults is unknown. We evaluated the frequency of renal damage 10-20 years after hospitalization for AP in adult women and the utility of technetium Tc 99m-labeled dimercaptosuccinic acid (Tc 99m-DMSA) scanning for detection of renal scars; 63 of 203 women hospitalized with AP during 1982-1992 were included in the study. Tc 99m-DMSA scanning detected renal scarring in 29 women (46%). Multivariate analysis showed that pregnancy and hypoalbuminemia (albumin level, <3.2 g/dL) at hospitalization were independent risk factors for subsequent development of renal scars. At follow-up, hypertension was observed in approximately one-fifth of patients, regardless of renal scarring status. Four women with scars had a glomerular filtration rate of < or =75 mL/min; none of them developed severe renal impairment. In conclusion, the risk of developing renal scarring after AP in adult women is high. However, clinically relevant renal damage is rare 10-20 years after AP. Tc 99m-DMSA scanning is useful for detecting renal scars in adults but is not routinely needed in practice.

Acute Disease↗
PubMed2004

Extended virulence genotypes and phylogenetic background of Escherichia coli isolates from patients with cystitis, pyelonephritis, or prostatitis.

Molecular analysis of 63 Escherichia coli urine isolates showed that pyelonephritis (n=23) and prostatitis (n=17) isolates exhibited more virulence factors (VFs) among the 35 sought than did cystitis isolates (n=23). Several nontraditional VFs--including bmaE (M fimbriae), gafD (G fimbriae), fyuA (yersiniabactin receptor), ireA and iroN (novel siderophore receptors), cvaC (colicin [microcin] V), traT (serum-resistance associated), ibeA (invasion of brain endothelium), ompT (outer membrane protease T), and malX (pathogenicity island marker)--either differentiated significantly between syndromes (despite small numbers of isolates and possible multiple-comparison artifacts) or were broadly prevalent. Thus, interventions that target conserved uro-VFs may be possible, despite the likely existence of syndrome-specific pathogenetic mechanisms and/or host defense systems.

Adhesins, Bacterial↗
PubMed1999

Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA).

This is part of the series of practice guidelines commissioned by the Infectious Diseases Society of America (IDSA) through its Practice Guidelines Committee. The purpose of this guideline is to provide assistance to clinicians in the diagnosis and treatment of two specific types of urinary tract infections (UTIs): uncomplicated, acute, symptomatic bacterial cystitis and acute pyelonephritis in women. The guideline does not contain recommendations for asymptomatic bacteriuria, complicated UTIs, Foley catheter-associated infections, UTIs in men or children, or prostatitis. The targeted providers are internists and family practitioners. The targeted groups are immunocompetent women. Criteria are specified for determining whether the inpatient or outpatient setting is appropriate for treatment. Differences from other guidelines written on this topic include use of laboratory criteria for diagnosis and approach to antimicrobial therapy. Panel members represented experts in adult infectious diseases and urology. The guidelines are evidence-based. A standard ranking system is used for the strength of the recommendation and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council, the sponsor and supporter of the guideline. The American Urologic Association and the European Society of Clinical Microbiology and Infectious Diseases have endorsed it. An executive summary and tables highlight the major recommendations. Performance measures are described to aid in monitoring compliance with the guideline. The guideline will be listed on the IDSA home page at http://www.idsociety.org It will be evaluated for updating in 2 years.

Acute Disease↗
PubMed2000

Simple nephrectomy: managing the difficult case: xanthogranulomatous pyelonephritis and autosomal dominant polycystic kidney disease.

Laparoscopic surgery for kidneys with xanthogranulomatous pyelonephritis or autosomal dominant polycystic disease has proved to be technically difficult but is possible. The Harmonic Scalpel facilitates the dissection of inflammatory tissues and does not inflict burns. Hand-assisted laparoscopy may be useful. Pain relief is obtained by most patients undergoing cyst drainage, although recurrence after a year or two is common. A specific and detailed preoperative diagnosis and treatment plan are essential to a successful outcome.

Diagnosis, Differential↗
PubMed2005

Laparoscopic and open surgical nephrectomy for xanthogranulomatous pyelonephritis.

BACKGROUND AND PURPOSE: Xanthogranulomatous pyelonephritis (XGP) is a severe, chronic renal-parenchymal infection. Nephrectomy is the treatment of choice. Because of the renal and perirenal inflammatory changes that commonly accompany XGP, the laparoscopic approach is difficult. We compared our experience with laparoscopic and open surgical nephrectomy for XGP. PATIENTS AND METHODS: A retrospective chart review of all adult nephrectomy specimens with the pathologic diagnosis of XGP between January 1997 and May 2003 was performed. Preoperative presentation, operative details, and postoperative recovery and complications were included in the data collection. RESULTS: Three patients approached laparoscopically and eight patients approached with open surgery were found to have XGP on pathologic analysis. The disease was suspected preoperatively in all patients. Among the laparoscopically treated patients, there was 1 (33%) who suffered major complications; this was the only patient who required conversion to open surgery. Among the open-surgical group, there were 2 (22%) major and 3 (33%) minor complications. Postoperative hospitalization was longer in the open-surgical group (mean 13.7 v 4.7 days), and when the case of open conversion was excluded, narcotic use was less in the laparoscopy group. CONCLUSIONS: The treatment of some XGP cases with laparoscopic nephrectomy is a possible, albeit challenging, option. The incidences of intraoperative and postoperative complications were roughly equivalent in the laparoscopic and open-surgery patients in our study. If completed, laparoscopy appears to be associated with decreased postoperative morbidity. However, this may represent selection bias, and larger, prospective studies may better define the suspected benefit.

Adult↗
PubMed1996

Xanthogranulomatous pyelonephritis: report of nonsurgical management of a case and review of the literature.

A case of focal xanthogranulomatous pyelonephritis (XPN) in a child, successfully cured with antibiotics only, is presented, and this report is followed by a review of the literature on XPN in both children and adults. XPN is a rare inflammatory disease of the kidney. Factors strongly implicated in the development of XPN are genitourinary obstruction and urinary tract infection, although other contributing factors have been suggested. The clinical presentation of the disease is remarkably nonspecific and variable; it therefore is frequently misdiagnosed as other, more common diseases that cause focal or diffuse renal masses, including renal neoplasms, abscesses, and tuberculosis. Diagnosis requires acquisition of renal tissue for special pathological staining. The long-standing mainstay of therapy for XPN has been nephrectomy or partial nephrectomy. However, this report and other recent reports of the successful medical management of focal XPN suggest that a trial of antibiotics prior to surgery is warranted in cases of focal XPN.

Adult↗
PubMed1975

Role of urease in pyelonephritis resulting from urinary tract infection with Proteus.

The role of urease in induction of pyelonephritis was studied by treatment of proteus-infected rats with acetohydroxamic acid, a potent inhibitor of urease. Infection was produced by introduction of Proteus mirabilis into the bladder along with a zinc disk. Controls were treated identically but received no acetohydroxamic acid. The number of bacteria per milliliter of urine was the same in both groups. The number of bacteria in the kidneys and the extent of renal damage was much greater in controls. Common enterobacteraceal antigen was not detected in the renal parenchyma of rats treated with acetohydroxamic acid. Treatment with acetohydroxamic acid thus prevented invasion of and damage to kidney tissue without reduction of urinary infection. Thus new evidence was found that the invasive properties of Proteus in the urinary tract are dependent on alkalinization of urine by urease and the resulting damage to the renal epithelium.

Acute Disease↗
PubMed1978

Influence of pili on the virulence of Proteus mirabilis in experimental hematogenous pyelonephritis.

The ability of heavily and lightly piliated Proteus mirabilis to infect the renal parenchyma was compared in a model of hematogenous pyelonephritis. Cortical abscesses occurred in 13 of 24 rats injected with lightly piliated P. mirabilis but in none of 24 rats challenged with heavily piliated organisms (P less than 0.001). Lightly and heavily piliated organisms were cleared from the vasculature equally rapidly and were also delivered to the kidney in equal numbers. During the first 24 hr, however, titers of the lightly piliated organisms in the kidney increased by 4 logs, whereas the heavily piliated P. mirabilis were virtually all eliminated. Pili are believed to mediate attachment to cell surfaces, and heavy piliation has been correlated with enhanced virulence when P. mirabilis invades the kidney across the pelvic mucosa. The results in this study suggest, however, that pili may adversely affect bacterial survival within the renal parenchyma.

Animals↗
PubMed1979

Prevention of pyelonephritis due to Escherichia coli in rats with gentamicin stored in kidney tissue.

Although gentamicin is known to accumulate and persist in the kidneys after systemic administration, its antibacterial activity at this site has not been determined. In the present study the accumulation of gentamicin in rat kidneys before infection prevented obstructive pyelonephritis due to Escherichia coli despite heavy urinary tract infection on the obstructed pelvis; thus the kidneys were protected against infection in the absence of effective levels of gentamicin in the urine. Stored gentamicin also protected pyelonephritic rats from relapse after complete obstruction of the kidneys. The level of antimicrobial activity of gentamicin in whole kidney tissue was 95% less than that anticipated on the basis of levels measured after dilution of kidney tissue homogenates; this low level of activity apparently was due in part to high concentrations of solutes. In view of these results in rats, the possibility must be considered that despite reduced activity, gentamicin storage might be useful in the prophylaxis of kidney infection in patients with abnormalities of the urinary tract. In the treatment of established kidney infection, the dose of gentamicin could be reduced and the interval of its administration increased for minimal toxicity.

Ampicillin↗