Upper Urinary Tract Infection: Chronic Pyelonephritis

UPPER URINARY TRACT INFECTION: CHRONIC PYELONEPHRITIS

Repeated bouts of acute pyelonephritis may lead to chronic pyelone-phritis. Recent evidence suggests that chronic pyelonephritis is decreasing as a common cause of end-stage renal disease (ESRD), while renovascular disease is increasing as one of the most common causes for ESRD (Fatica, Port & Young, 2001).

Clinical Manifestations

The patient with chronic pyelonephritis usually has no symptoms of infection unless an acute exacerbation occurs. Noticeable signs and symptoms may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss. Persistent and recurring infection may produce progressive scarring of the kidney, with renal failure the end result.

Assessment and Diagnostic Findings

The extent of the disease is assessed by an intravenous urogram and measurements of creatinine clearance and BUN and creatinine lev-els. Bacteria, if detected in the urine, are eradicated if possible.

Complications

Complications of chronic pyelonephritis include ESRD (from progressive loss of nephrons secondary to chronic inflammation and scarring), hypertension, and formation of kidney stones (from chronic infection with urea-splitting organisms).

Medical Management

The choice of antimicrobial agent is based on which pathogen is identified through urine culture. If the urine cannot be made bacteria-free, nitrofurantoin or TMP-SMZ may be used to sup-press bacterial growth. Impaired renal function alters the excre-tion of antimicrobial agents and necessitates careful monitoring of renal function, especially if the medications are potentially toxic to the kidneys.

Nursing Management

The patient may require hospitalization or may be treated as an outpatient. When the patient is hospitalized, fluid intake and out-put are carefully measured and recorded. Unless contraindicated, fluids are encouraged (3 to 4 L/day) to dilute the urine, decrease burning on urination, and prevent dehydration. The nurse assesses the patient’s temperature every 4 hours and administers anti-pyretic and antibiotic agents as prescribed. Often the patient is more comfortable on bed rest during the acute phase of the illness.

Patient teaching focuses on prevention of UTIs by consuming adequate fluids, emptying the bladder regularly, and performing recommended perineal hygiene. The importance of taking anti-microbial medications exactly as prescribed is stressed to the pa-tient, as is the need for keeping follow-up appointments.