Approach

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] 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][47]​​ 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]

  • 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][50][51]​​​

The disease rarely involves both kidneys.[52]​ Available evidence does not support serial progression from one kidney to the other. While surgery may represent optimal treatment, postoperative complications are common.[53]

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] 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][55]

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][18][56][57]​​​​ 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]

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][50][51]​​​

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