Predictors of failure of conservative treatment among patients with emphysematous pyelonephritis

Abstract

BackgroundEmphysematous pyelonephritis (EPN) is a severe necrotizing infection of the renal parenchyma and perirenal tissues that is caused by gas-producing bacterial pathogens. Percutaneous drainage is now the gold standard of definitive management. The aim of this study is to analyze the predictors associated with failure of conservative treatment among patients with EPN and offer the recommendation of appropriate empirical antibiotic regimen.MethodsFrom January 2001 to December 2013, 44 consecutive patients were diagnosed with EPN. The demographic characteristics, clinical presentations, management strategies, and final outcomes were analyzed retrospectively.ResultsThe overall survival rate was 88.6% (39/44). Need for emergency hemodialysis, shock on initial presentation, altered mental status, severe hypoalbuminemia, inappropriate empirical antibiotic treatment and polymicrobial infections were significantly more common in the patients who died compared with the survivors. The overall failure rate of conservative treatment was 32.6% (14/43). Severe hypoalbuminemia (p = 0.003), need for emergency hemodialysis (p = 0.03), and polymicrobial infections (p = 0.04) were significantly associated with failure of conservative treatment. Severe hypoalbuminemia was independently associated with conservative management failure (p = 0.02). Even in the patients treated with percutaneous drainage plus effective antibiotics, failure was still associated with severe hypoalbuminemia (p = 0.01). According to the in vitro susceptibility data, third-generation cephalosporins is recommended as the empirical antibiotic regimen.ConclusionsBoth appropriate empirical antibiotic and percutaneous drainage were essential for patients with EPN. Patients with severe hypoalbuminemia had a higher risk of conservative treatment failure, and additional management may be required.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-418) contains supplementary material, which is available to authorized users.

Emphysematous Pyelonephritis with Abscesses Masquerading as an Ordinary Urinary Tract Infection

“…Other microbes cultured include Proteus mirabilis, Pseudomonas aeruginosa and Enterococcus species. Anerobes such as Bacteroides fragilis and Clostridium septicum have also been implicated in emphysematous pyelonephritis (Lu et al, 2014). Organisms found in blood cultures were also simultaneously noted in the abscess and urine cultures.…”

“…Antibiotics are chosen by the same guidelines as those for patients with pyelonephritis: A third generation cephalosporin or fluoroquinolone for mild to moderate pyelonephritis (aztreonam for those with a beta lactam allergy) and broader antibiotic coverage (ampicillin-sulbactam, ticeracillin-clavulanate, piperacillin-tazobactam, meropenem, or imipenem) for those patients with severe pyelonephritis, immunosuppression and/or incomplete urinary drainage (Stamm and Hooton, 1993). Vancomycin in combination with imipenem or ceftazidime is the empiric treatment of choice in patients presenting with sepsis and septic shock Lu et al (2014). Older patients with uncontrolled diabetes presenting with symptoms of septic shock with a prior history of recently treated pyelonephritis should undergo emergent nonenhanced computed tomography scan (Chen and Chen, 2014).…”

Emphysematous Pyelonephritis: Our Institutional Experience

“…Thrombocytopenia, altered mental status, hyponatremia, severe proteinuria, severe hypoalbuminemia, and acute renal failure at EPN presentation have been associated with a poor outcome. 15,17 In a meta-analysis, systolic blood pressure less than 90 mmHg, serum creatinine levels greater than 2.5 mg/dL, and impairment of consciousness were also associated with increased mortality. 18 In parallel with these findings, all of our class 1 and 2 patients could be treated with medical therapy and/or drainage; our class 3A patients who had adverse predictive factors of thrombocytopenia and impaired consciousness did not respond to these treatment modalities and underwent nephrectomy.…”

Emphysematous Pyelonephritis Complicating an Undetected Diabetic Female: A Case Report

“…7 Lu Y et al have described predictors of failure in conservative management of emphysematous pyelonephritis. 8 Our patient required surgery because of class IV disease and kidney stone. She recovered with combined medical and surgical treatment and remained in good health and under regular follow-up.…”