1/5/2020 1/10 Pharmacotherapy Casebook: A Patient-Focused Approach, 10eChapter 133: Pyelonephritis: Resistant Rod Level II Elizabeth A. Coyle Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email User Services ([email protected]) for more information. LEARNING OBJECTIVES Aer completing this case study, the reader should be able to: Dierentiate the signs, symptoms, and laboratory findings associated with pyelonephritis from those seen in lower urinary tract infections. Recommend appropriate empiric antimicrobial and symptomatic pharmacotherapy for a patient with suspected pyelonephritis. Make appropriate adjustments in pharmacotherapy based on patient response and culture results, recognizing the prevalence of Escherichia coli and the risk of resistance. Design a monitoring plan for a patient with pyelonephritis that allows objective assessment of the response to therapy. PATIENT PRESENTATION Chief Complaint “I am freezing and my back is killing me.” HPI Isabella Toms is a 22-year-old college student with type 1 diabetes, who presents to the ER complaining that she has had pain in her right flank region over the last 24 hours, as well as pain in her abdomen. She complains of some nausea and reports that she woke up this morning with severe stomach and back pain, but has not vomited. The patient states she has not eaten for 24 hours, but has been able to drink water and non–diet soda, and has continued to keep her insulin pump on, but has not given any additional regular insulin. The patient reports she recently started treatment for a urinary tract infection about 2 days ago with trimethoprim/sulfamethoxazole. She states that she has been feeling feverish and has the chills. She reports no substernal chest pain, shortness of breath, cough, or sputum production. She denies any diarrhea or rash.
Transcript
1/5/2020
1/10
Pharmacotherapy Casebook: A Patient-Focused Approach, 10e
Chapter 133: Pyelonephritis: Resistant Rod Level II Elizabeth A. Coyle
Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email User Services([email protected]) for more information.
LEARNING OBJECTIVES
A�er completing this case study, the reader should be able to:
Di�erentiate the signs, symptoms, and laboratory findings associated with pyelonephritis from those seenin lower urinary tract infections.
Recommend appropriate empiric antimicrobial and symptomatic pharmacotherapy for a patient withsuspected pyelonephritis.
Make appropriate adjustments in pharmacotherapy based on patient response and culture results,recognizing the prevalence of Escherichia coli and the risk of resistance.
Design a monitoring plan for a patient with pyelonephritis that allows objective assessment of theresponse to therapy.
PATIENT PRESENTATION
Chief Complaint
“I am freezing and my back is killing me.”
HPI
Isabella Toms is a 22-year-old college student with type 1 diabetes, who presents to the ER complainingthat she has had pain in her right flank region over the last 24 hours, as well as pain in her abdomen. Shecomplains of some nausea and reports that she woke up this morning with severe stomach and back pain,but has not vomited. The patient states she has not eaten for 24 hours, but has been able to drink waterand non–diet soda, and has continued to keep her insulin pump on, but has not given any additionalregular insulin. The patient reports she recently started treatment for a urinary tract infection about 2 daysago with trimethoprim/sulfamethoxazole. She states that she has been feeling feverish and has the chills.She reports no substernal chest pain, shortness of breath, cough, or sputum production. She denies anydiarrhea or rash.
Type 1 diabetes, diagnosed at age 11; has an insulin pump
FH
Mother and father are in their 40s and healthy; one sister with asthma, and an older brother with Crohndisease
SH
Nonsmoker, no IVDA, drinks alcohol socially. Single, but has a steady boyfriend and is sexually active.Currently is a first-year law student at the local university.
Meds
Ortho-Novum 7/7/7 one tablet daily
Insulin pump; regular insulin basal rate of 28 units per day
Regular insulin 2 units with breakfast, lunch, and supper
Trimethoprim/sulfamethoxazole one double strength tablet twice daily for 3 days (she has completed 2days of therapy)
All
Penicillin (develops an itchy rash)
ROS
She has a history of UTIs and has had two UTIs in the past year, the most recent 2 days ago
Physical Examination
Gen
Conscious, alert, and oriented young Caucasian woman in mild distress
VS
BP 112/68, P 65, RR 16, T 39.0°C, O2 sat 98% room air; Wt 63 kg (IBW 61.1 kg), Ht 5′7″
EOMI; funduscopic examination WNL; pharynx clear and dry
Neck
Supple, no JVD
Chest
CTA
CV
RRR
Abd
So� with suprapubic tenderness to deep palpation; no rebound or guarding; active bowel sounds. There isno hepatosplenomegaly or masses.
Back
No paraspinal or spinal tenderness
Genit/Rect
Normal female genitalia; no abnormal vaginal discharge; normal sphincter tone; last menstrual period 1week ago
Ext
No CCE; pulses 2+ bilaterally
Neuro
A & O × 3; CN II–XII intact; sensory and perception intact
Labs and UA on Admission
See Table 133-1
1/5/2020
4/10
TABLE 133-1
Laboratory Tests and Urinalyses on Days 1–3 of Hospitalization
Parameter (Units) Day 1 Day 2 Day 3
Serum chemistry
Na (mEq/L) 141 139 141
K (mEq/L) 3.9 4.0 4.1
Cl (mEq/L) 99 101 102
CO2 (mEq/L) 27 28 28
BUN (mg/dL) 19 14 12
SCr (mg/dL) 1.1 1.0 1.0
Glucose (mg/dL) 65 92 89
Hematology
Hgb (g/dL) 13.9 13.8 13.6
Hct (%) 40.6 40.3 40.5
Plt (×103/mm3) 275 276 276
WBC (×103/mm3) 26.3 20.4 12.5
PMN/B/L/M (%) 80/13/7/0 85/10/5/0 86/6/7/1
Urinalysis
Appearance Hazy
Color Amber
pH 5.0
Specific gravity 1.017
Blood 2+
1/5/2020
5/10
B, bands; L, lymphocytes; M, monocytes; PMN, polymorphonuclear leukocytes.
Parameter (Units) Day 1 Day 2 Day 3
Ketones Negative
Leukocyte esterase 3+
Nitrites 2+
Urine protein, qualitative Trace
Urine glucose, qualitative Trace
WBC/hpf 487
RBC/hpf 102
Bacteria Many
WBC casts 2+
Chest X-Ray
No infiltrates, no consolidation seen
CT Abdomen with Contrast
Findings: Liver, gallbladder, pancreas, spleen, and adrenals are unremarkable. No evidence of ascites orfocal areas of fluid collection. The le� kidney is unremarkable. A hypoattenuating lesion is seen involvingthe right kidney from mid- to lower pole.
Impression: Hypoattenuating lesion in right kidney consistent with pyelonephritis; correlate with clinicalpicture.
Abdominal Ultrasound
Findings: There is a hypoechoic region within the lateral cortex of the right kidney, which does not displaythrough transmission.
Impression: Focal cortical thickening with decreased echogenicity involving the mid right renal cortex,similar to the recent CT scan, most likely representing focal pyelonephritis. No renal abscess identified. Nohydronephrosis.
Urine Gram Stain
1/5/2020
6/10
Many gram-negative rods.
Blood Culture
Many gram-negative rods.
Vaginal Swab
Negative
Assessment
Pyelonephritis
Bacteremia
Type 1 diabetes
QUESTIONS
Problem Identification
1.a. Create a list of the patient’s drug therapy problems.
1.b. What information (signs, symptoms, laboratory tests) indicates the presence and severity ofpyelonephritis in this patient?
1.c. List any potential contributing factors that may have predisposed this patient to developingpyelonephritis.
1.d. What additional information is needed to fully assess the patient?
Desired Outcome
2. What are the goals of pharmacotherapy in this patient?
Therapeutic Alternatives
3.a. What nondrug therapies might be useful for this patient?
3.b. What organisms are commonly associated with pyelonephritis?
3.c. How o�en is antimicrobial resistance to E. coli seen in the community?
3.d. What feasible pharmacotherapeutic alternatives are available for the empiric treatment ofpyelonephritis?
Optimal Plan
1/5/2020
7/10
4. Outline an antimicrobial regimen that will provide appropriate empiric therapy for pyelonephritis in thispatient.
Outcome Evaluation
5.a. What clinical and laboratory parameters are necessary to evaluate the antibiotic therapy forachievement of the desired therapeutic outcomes and to detect or prevent adverse e�ects?
CLINICAL COURSE
The patient was started on the empiric antimicrobial regimen you recommended. She requiredacetaminophen Q 6 H for pain. Her fevers subsided with the initiation of acetaminophen and antibiotics. Onday 3 of hospitalization, she was much improved and was ready for discharge. Laboratory tests for days 2and 3 are included in Table 133-1. Culture results from admission were finalized on day 3 (late in the day)and are shown in Table 133-2.
1/5/2020
8/10
TABLE 133-2
Culture Results of Urine and Blood Samples Taken on Day 1 and Reported on Day 3
5.b. What recommendations, if any, do you have for changes in the initial drug regimen?
Patient Education
6. What information should be provided to the patient on discharge to enhance adherence, ensuresuccessful therapy, and minimize adverse e�ects?
SELF-STUDY ASSIGNMENTS
1. Develop a protocol for switching patients from IV to oral therapy when treating pyelonephritis.
2. Perform a literature search to find clinical trials comparing drug therapy in pyelonephritis, and compareinclusion criteria, drug regimens, outcomes, and costs of therapy.
3. Develop a clinical pathway that could be used for the management of suspected pyelonephritis.
CLINICAL PEARL
Pyelonephritis can be managed with many di�erent drugs; choose drugs that are bactericidal and clearedin the active form by the kidney. Drugs suitable for once-daily therapy help to reduce treatment costs.
REFERENCES
Filiatrault L, McKay RM, Patrick DM, et al. Antibiotic resistance in isolates recovered from women withcommunity-acquired urinary tract infections presenting to tertiary care emergency department. CJEM2012;14(5):295–305. [PubMed: 22967697]
Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment ofacute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious DiseasesSociety of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis2011;52(5):e103–e120. [PubMed: 21292654]
Colgan R, Williams M. Diagnosis and treatment of acute pyelonephritis in women. Am Fam Physician2011;84(5):519–526. [PubMed: 21888302]
Eliakim-Raz N, Yahar D, Paul M, Leibovici L. Duration of antibiotic treatment for acute pyelonephritisand septic urinary tract infection–7 days versus longer treatment: systemic review and meta-analysis ofrandomized controlled trials. J Antimcrob Chemother 2013;68:2183–2191.
Peterson J, Kaul S, Khashab M, Fisher AC, Kahn JB. A double-blind, randomized comparison oflevofloxacin 750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for thetreatment of complicated urinary tract infections and acute pyelonephritis. Urology 2008;71(1):17–22. [PubMed: 18242357]
