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.

  1. 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.

  1. 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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