No specific treatment is available. Renal damage incurred is not reversible and management options are limited. Eliminating recurrent urinary tract infections (UTIs) and identifying and correcting any underlying anatomical or functional urinary problems (e.g., obstruction, urolithiasis) can prevent further renal damage. However, unless ongoing infection is documented, antibiotic treatment in these patients is generally not helpful.[45]Garin EH, Olavarria F, Garcia Nieto V, et al. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics. 2006 Mar;117(3):626-32.
http://www.ncbi.nlm.nih.gov/pubmed/16510640?tool=bestpractice.com
It is recommended that patients are referred for specialist nephrology/urological consultation. Xanthogranulomatous pyelonephritis (XGP) and emphysematous pyelonephritis (EPN) are uncommon sub-sets of chronic pyelonephritis, and are managed surgically.
Xanthogranulomatous pyelonephritis (XGP)
Nephrectomy is usually the treatment of choice; however, a partial nephrectomy may be performed in patients with focal disease.
Antibiotics for the treatment of infection should be given both before and following surgery, to cover gram-negative organisms.[46]Xie L, Tapiero S, Flores AR, et al. Long-term antibiotic treatment prior to laparoscopic nephrectomy for xanthogranulomatous pyelonephritis improves postoperative outcomes: results from a multicenter study. J Urol. 2021 Mar;205(3):820-5.
http://www.ncbi.nlm.nih.gov/pubmed/33080147?tool=bestpractice.com
[47]Artiles-Medina A, Laso-García I, Lorca-Álvaro J, et al. Xanthogranulomatous pyelonephritis: a focus on microbiological and antibiotic resistance profiles. BMC Urol. 2021 Apr 7;21(1):56.
https://pmc.ncbi.nlm.nih.gov/articles/PMC8026091
http://www.ncbi.nlm.nih.gov/pubmed/33827527?tool=bestpractice.com
Antibiotic treatment includes third-generation cephalosporins, extended-spectrum penicillins, aminoglycosides, and carbapenem antibiotics. Fluoroquinolones should be considered if other treatments are not available or are contraindicated.
Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[48]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804.
https://pmc.ncbi.nlm.nih.gov/articles/PMC10056716
http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com
Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.
In the setting of increasing drug resistance in uropathogens, the following antibiotics are approved in some countries for use in adults with complicated UTI caused by susceptible organisms who have limited or no alternative options: ceftazidime/avibactam, meropenem/vaborbactam, plazomicin, cefiderocol, and imipenem/cilastatin/relebactam.[49]Dhillon S. Meropenem/vaborbactam: a review in complicated urinary tract infections. Drugs. 2018 Aug;78(12):1259-70.
https://link.springer.com/article/10.1007%2Fs40265-018-0966-7
http://www.ncbi.nlm.nih.gov/pubmed/30128699?tool=bestpractice.com
[50]Wagenlehner FME, Cloutier DJ, Komirenko AS, et al. Once-daily plazomicin for complicated urinary tract infections. N Engl J Med. 2019 Feb 21;380(8):729-40.
https://www.nejm.org/doi/10.1056/NEJMoa1801467
http://www.ncbi.nlm.nih.gov/pubmed/30786187?tool=bestpractice.com
[51]Tamma PD, Heil EL, Justo JA, et al. Infectious Diseases Society of America 2024 guidance on the treatment of antimicrobial-resistant gram-negative infections. Clin Infect Dis. 2024 Aug 7:ciae403.
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciae403/7728556
http://www.ncbi.nlm.nih.gov/pubmed/39108079?tool=bestpractice.com
The disease rarely involves both kidneys.[52]Harley F, Wei G, O'Callaghan M, et al. Xanthogranulomatous pyelonephritis: a systematic review of treatment and mortality in more than 1000 cases. BJU Int. 2023 Apr;131(4):395-407.
https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/bju.15878
http://www.ncbi.nlm.nih.gov/pubmed/35993745?tool=bestpractice.com
Available evidence does not support serial progression from one kidney to the other. While surgery may represent optimal treatment, postoperative complications are common.[53]Kelly C, Anderson S, Looney A, et al. Nephrectomy for xanthogranulomatous pyelonephritis-a not-so-simple solution. Ir J Med Sci. 2024 Apr;193(2):1055-60.
https://pmc.ncbi.nlm.nih.gov/articles/PMC10961261
http://www.ncbi.nlm.nih.gov/pubmed/37610600?tool=bestpractice.com
Emphysematous pyelonephritis (EPN)
Most patients are acutely ill, and stabilisation in the emergency department with adequate fluid resuscitation and tissue oxygenation has been shown to decrease morbidity and improve mortality.[26]Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77.
https://www.nejm.org/doi/full/10.1056/NEJMoa010307
http://www.ncbi.nlm.nih.gov/pubmed/11794169?tool=bestpractice.com
Most patients with EPN are diabetic. Extremely tight glucose control has been shown to improve outcomes in experimental models of sepsis and in diabetic patients with severe infections.[54]Heuer JG, Sharma GR, Zhang T, et al. Effects of hyperglycemia and insulin therapy on outcome in a hyperglycemic septic model of critical illness. J Trauma. 2006 Apr;60(4):865-72.
http://www.ncbi.nlm.nih.gov/pubmed/16612310?tool=bestpractice.com
[55]Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004 Aug;79(8):992-1000.
http://www.ncbi.nlm.nih.gov/pubmed/15301325?tool=bestpractice.com
Depending on the severity of the disease, EPN may be treated with percutaneous drainage, antibiotics, or, if the patient is severely ill with worsening sepsis, nephrectomy.[1]Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000 Mar 27;160(6):797-805.
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485260
http://www.ncbi.nlm.nih.gov/pubmed/10737279?tool=bestpractice.com
[18]Rubenstein JN, Schaeffer AJ. Managing complicated urinary tract infections: the urologic view. Infect Dis Clin North Am. 2003 Jun;17(2):333-51.
http://www.ncbi.nlm.nih.gov/pubmed/12848473?tool=bestpractice.com
[56]Somani BK, Nabi G, Thorpe P, et al; ABACUS Research Group. Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review. J Urol. 2008 May;179(5):1844-9.
http://www.ncbi.nlm.nih.gov/pubmed/18353396?tool=bestpractice.com
[57]Nelson Z, Aslan AT, Beahm NP, et al. Guidelines for the prevention, diagnosis, and management of urinary tract infections in pediatrics and adults: a WikiGuidelines Group consensus statement. JAMA Netw Open. 2024 Nov 4;7(11):e2444495.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2825634
http://www.ncbi.nlm.nih.gov/pubmed/39495518?tool=bestpractice.com
Antibiotic treatment for the gas-forming organisms includes third-generation cephalosporins, extended-spectrum penicillins, aminoglycosides, and carbapenem antibiotics. Fluoroquinolones should be considered if other treatments are not available or are contraindicated. Empirical treatment depends in part on local bacterial susceptibility patterns.[58]Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20.
https://academic.oup.com/cid/article/52/5/e103/388285
http://www.ncbi.nlm.nih.gov/pubmed/21292654?tool=bestpractice.com
In the setting of increasing drug resistance in uropathogens, the following antibiotics are approved in some countries for use in adults with complicated UTI caused by susceptible organisms who have limited or no alternative options: ceftazidime/avibactam, meropenem/vaborbactam, plazomicin, cefiderocol, and imipenem/cilastatin/relebactam.[49]Dhillon S. Meropenem/vaborbactam: a review in complicated urinary tract infections. Drugs. 2018 Aug;78(12):1259-70.
https://link.springer.com/article/10.1007%2Fs40265-018-0966-7
http://www.ncbi.nlm.nih.gov/pubmed/30128699?tool=bestpractice.com
[50]Wagenlehner FME, Cloutier DJ, Komirenko AS, et al. Once-daily plazomicin for complicated urinary tract infections. N Engl J Med. 2019 Feb 21;380(8):729-40.
https://www.nejm.org/doi/10.1056/NEJMoa1801467
http://www.ncbi.nlm.nih.gov/pubmed/30786187?tool=bestpractice.com
[51]Tamma PD, Heil EL, Justo JA, et al. Infectious Diseases Society of America 2024 guidance on the treatment of antimicrobial-resistant gram-negative infections. Clin Infect Dis. 2024 Aug 7:ciae403.
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciae403/7728556
http://www.ncbi.nlm.nih.gov/pubmed/39108079?tool=bestpractice.com