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acute pyelonephritis diagnosis clinical features urinalysis urine culture E. coli
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acute pyelonephritis treatment ceftriaxone antibiotic management hospitalization
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Case Study Presentation: Acute Pyelonephritis
Patient Overview
| Parameter | Detail |
|---|---|
| Age / Sex | 22-year-old female |
| Occupation | Medical student |
| Setting | Outpatient clinic |
| Presentation | 2-day history of fever, chills, right flank pain |
Chief Complaint & History
The patient presented with a sudden-onset high fever reaching 39.2 °C, accompanied by:
- Shaking chills and profuse sweating
- Severe, constant right lumbar (flank) pain — worsens with movement, non-radiating
- Dysuria (burning sensation during micturition)
- Urinary frequency
- Nausea and complete anorexia
Physical Examination
| Finding | Value / Result |
|---|---|
| General appearance | Acutely ill |
| Heart rate | 110 bpm (tachycardia) |
| Blood pressure | 115/70 mmHg |
| Respiratory rate | 20 breaths/min |
| Right CVA tenderness | Markedly positive |
| Pasternatsky's sign | Positive (right) |
| Left kidney | Non-tender |
| Suprapubic tenderness | Absent |
| Lungs | Clear |
The combination of fever + flank pain + CVA tenderness is the classic triad that should prompt immediate workup for upper urinary tract infection. As noted in clinical guidelines, when all three elements are present, timely antibiotic initiation is warranted (Urinary Tract Infections in Pregnant Individuals, p. 7).
Differential Diagnosis
| Condition | For | Against |
|---|---|---|
| Acute pyelonephritis | Fever, CVA tenderness, dysuria, pyuria | — |
| Urolithiasis with obstruction | Flank pain, unilateral | Pain non-radiating, no colicky pattern, no hematuria |
| Lower UTI (cystitis) | Dysuria, frequency | No systemic symptoms expected, no CVA tenderness |
Investigations Ordered
Laboratory:
- Complete blood count (CBC)
- C-reactive protein (CRP)
- Procalcitonin
- Urinalysis
- Urine culture + antibiotic susceptibility testing
Imaging:
- Renal ultrasound
Results Summary
Laboratory
| Test | Result | Interpretation |
|---|---|---|
| WBC | 15 × 10⁹/L | Leukocytosis — systemic infection |
| CRP | 120 mg/L | Markedly elevated — significant inflammation |
| Procalcitonin | 0.15 ng/mL | Normal — suggests no systemic sepsis/bacteremia yet |
| Urine WBC | 40–50/HPF | Pyuria — hallmark of UTI |
| Urine nitrites | Moderate positive | Gram-negative bacteriuria |
| Urine protein | 0.33 g/L (trace) | Renal parenchymal involvement |
| Urine bacteria | Numerous | Active infection |
| Urine culture | E. coli > 10⁵ CFU/mL | Diagnostic — susceptible to ceftriaxone |
Imaging — Renal Ultrasound
- Diffuse thickening of the right renal parenchyma
- Preserved corticomedullary differentiation
- No hydronephrosis (excludes obstructive uropathy)
- No calculi (excludes urolithiasis)
Diagnosis
Acute Uncomplicated Pyelonephritis (right kidney) Caused by Escherichia coli — the most common uropathogen, responsible for ~80% of cases.
The diagnosis was supported by the clinical triad, significant pyuria, positive urine culture (>10⁵ CFU/mL), and ultrasound confirming parenchymal inflammation without obstruction or abscess.
Management
Inpatient Care
The patient was hospitalized given the severity of systemic symptoms — this aligns with guidelines recommending inpatient management for acute pyelonephritis due to risks of sepsis and clinical deterioration (Urinary Tract Infections in Pregnant Individuals, p. 8).
Antibiotic Therapy
| Phase | Agent | Dose / Route | Duration |
|---|---|---|---|
| Empiric (before culture) | Ceftriaxone | 1 g IV twice daily | Started at admission |
| Definitive (post-antibiogram) | Ceftriaxone (continued) | 1 g IV twice daily | Total 7 days IV |
| Step-down (at discharge) | Cefixime (oral) | Standard dose | 3 additional days |
Ceftriaxone is a first-line broad-spectrum cephalosporin for pyelonephritis. Therapy was appropriately de-escalated once culture confirmed susceptibility — consistent with antimicrobial stewardship principles (Urinary Tract Infections in Pregnant Individuals, p. 8).
Supportive Treatment
- IV fluids (0.9% normal saline) — rehydration
- Acetaminophen — antipyresis and analgesia
- Encouraged increased oral fluid intake
Clinical Course
- Symptoms improved within 48 hours — fever resolved, pain decreased, oral intake resumed
- Completed 7-day IV ceftriaxone course
- Discharged in stable condition on oral cefixime
Follow-Up Plan
| Timeframe | Action |
|---|---|
| 2 weeks post-discharge | Control urinalysis |
| 1 month post-discharge | Repeat renal ultrasound |
| Ongoing | Evaluate for chronic infectious foci (dental, tonsillar) |
Patient Education
- Maintain adequate hydration
- Avoid hypothermia
- Complete the full antibiotic course without interruption
- Seek early medical attention if symptoms recur
Key Teaching Points
- Classic triad of acute pyelonephritis: fever + flank pain + CVA tenderness
- Pasternatsky's sign (percussion over CVA reproduces pain) is a useful bedside test for upper UTI
- Urine culture is essential — guides de-escalation and confirms the causative organism
- Normal procalcitonin helps distinguish uncomplicated pyelonephritis from urosepsis/bacteremia
- Renal ultrasound is the first-line imaging — used to exclude obstruction, abscess, and calculi
- Empiric cephalosporins (ceftriaxone, cefepime) are first-line IV therapy; always tailor once culture returns
- IV-to-oral step-down is safe once the patient is afebrile and tolerating oral intake
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