A 36-year-old man presents to his GP with dysuria, fevers, rigors and left-sided loin pain. On examination he is tender over the left renal angle and he has a temperature of 38.6°C.
- What is the most likely diagnosis?
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This patient has symptoms and signs consistent with a diagnosis of acute pyelonephritis. He also has signs of sepsis and it would therefore be prudent to refer him to hospital for inpatient treatment.
- When is hospital admission recommended for this condition?
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NICE recommend admission for patients with pyelonephritis who:
- Are significantly dehydrated or who are unable to take oral fluids and medications
- Have signs of sepsis, including:
- A temperature greater than 38°C or less than 36°C, and
- Marked signs of illness (such as impaired level of consciousness, perfuse sweating, rigors, pallor, significantly reduced mobility), or
- Significant tachycardia, hypotension, or breathlessness
- Are pregnant and pyrexial
- Are frail, elderly residents in care homes who have recently been hospitalized or who have had recurrent urinary tract infections
- Fail to improve significantly within 24 hours of starting antibiotics
3. Which antibiotic protocol should be used for this patient?
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The current recommendations by NICE and the BNF on the treatment of acute pyelonephritis are:
- A broad spectrum cephalosporin (e.g. cefuroxime) or a quiniolone (e.g. ciprofloxacin)
- Suggested duration of treatment 10-14 days (but longer treatment may be necessary in complicated pyelonephritis)
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Very useful clinical scenario.