Emergency Medicine Forum

A 22 y/o female presents with fever and weakness.  She also has right sided abdominal pain.  She has been sick for 2 days. 

ROS:  Fever, x 2 days.  Vomited once yesterday.  Today feels nauseous, but no vomiting.  She has a mild cough. No sore throat, neck pain, chest pain, shortness of reath, problems with bowels, or rashes.  She denies vaginal discharge, or pain with urination, but does note that her urine feels ‘hot’ when she has a fever.  She has a younger sister with a bad ‘cold.’

PMH/ FH/SH: All negative.
PE:  WDWN obese female, lying on cot. She is slightly diaphoretic (she got Tylenol at triage).
VS:  130/78, HR=110, RR=20, Temp=102 PO
HEENT:   PERRL, pharynx normal, MM slightly dry, neck supple, TM normal.
Heart: Tachycardia, no murmurs
Lungs:  Clear bilaterally, no rales
Abd:  Obese, soft, minimal tenderness to deep palpation in Right upper quadrant laterally.
NSVK:  R CVA tenderness
Ext:  Negative, skin no rashes
Neuro:  normal.

U/A sent at triage is back:  SG:  1.030, Positive Leukocyte esterase, positive nitrite, many bacteria, WBC=280, RBC=28, squamous epithelial cells = 4

Answers:

1. What is the 2 by 2 rule for treatment of pyelonephritis?

I first read about this in the Tintinalli Emergency Medicine Textbook when I was a resident. (1) I always found it easy to remember.  Basically, for pyelonephritis patients, you treat with
a. 2 liters of hydration IV (2L NS)
b. Drop the temp by 2 degrees F (Its an old rule so degrees F is used instead of degrees centigrade)
c. Treat with 2 grams of IV Ceftriaxone (Rocephin)
d. Make sure the patient can tolerate 2 glasses of fluids (water or juice)
e. If the patient is a candidate for outpatient management, then give antibiotics twice a day (Trimethoprim Sulfamethoxazole, Cipro, Augmentin, etc.) for 2 weeks, and follow up in 2 days.

Patients eligible for outpatient management are those with normal renal function, no immunocomprimising state, no foreign body (urethral stone), no severe chronic diseases, and they must be non-toxic and not at the extremes of age.  Clearly it depends on multiple host issues. 

2. Should you send a urine culture?

Urine cultures are not routinely used because of the predictable nature of the causative bacteria ecoli (75-95% of all infections), staphylococcus saprophyitcus (5-20%). (2)  Other enterobacteriaceae (Klebsiella, Proteus) occasionally contribute.   I will send cultures on admitted patients (because I’m admitting because of some issue), and those with foley’s, or other confounders for the causative organism.

3. How would your management change if she was pregnant?

Untreated pyelonephritis in pregnancy is associated with low birth weight, prematurity, premature labor, hypertension, preeclampsia, and amnionitis. (3) For antibiotics, penicillins and cephalosporins are safe (considered category B).  (3)

Unfortunately, fluroquinolones and tetracyclines are known teratogens and clearly contraindicated.  (3). Nitrofurantoin is also used in pregnancy, as is keflex.  (3)  Because the antibiotic choices are limited, I always consider culturing any pregnant female with a UTI.  The disposition is also more challenging.  Most experts recommend hospitalization for pregnant women with pyelonephritis, however a few studies support outpatient management in selected populations (4).  In this study, the outpatient management included daily IM shots of Ceftriaxone until the fever and flank tenderness resolved.  Other studies also support the option of outpatient treatment in selected pregnant populations. (5) I would only consider out patient management after personal discussions with the OB/GYN attending, as most pregnant females with pyelonephritis are usually admitted.

4. Besides Bactrim or Cipro, what other antibiotics can be used?

There are lots of other choices.   Oral Bactrim or fluroquinolones have been mentioned.  Other antibiotics that are effective include Amoxicillin-clavulanate.  In pregnancy, penicillins and cephalosporins are safe.

Outcome: 
I applied the 2 x 2 rules, and the temp came down to 99, HR normalized, she got 2 L NS, 2 Gm Rocephin, drank 2 glasses of water, and appeared reliable for outpatient management.  She did not look toxic, and at the time of our last conversation, she was laughing on her cell phone when I walked into the room.  She did not meet any admission criteria, and therefore was discharged on antibiotics with follow-up in 2 days.

References: 
1. Howes DS.  Urinary Tract Infection, Female: Treatment and Medication.  EMedicine. Nov 20, 2009. Accessed at: http://emedicine.medscape.com/article/778670-treatment
2. Mehnert-Kay SA. Diagnosis and Management of Uncomplicated Urinary Tract Infections.  Amer Fam Phy 2005 Aug. Available on line at: http://www.aafp.org/afp/2005/0801/p451.html
3. Loynd AM, Rosh AJ.  Pregnancy, Urinary Tract Infections: EMedicine.  Aug 2009. Accessed at: http://emedicine.medscape.com/article/797066-diagnosis
4. Brooks AM, Garite TJ.  Pyelonephritis in Pregnancy.  Infect Dis in Obstet and Gynecol 1995 3(2):50-55 Accessed at: http://www.ncbi.nlm.nih.gov:80/pmc/articles/PMC2364416/pdf/IDOG-03-050.pdf
5. Isaacs L.  Outpatient treatment evolves for pyelonephritis in Pregnancy: Not every pregnant woman with pyelonephritis can be discharged, but some can with strict patient selection and good follow-up. Emergency Medicine News 2002 Dec 24(12) 6. Accessed at: http://journals.lww.com/em-news/Fulltext/2002/12000/Outpatient_Treatment_Evolves_for_Pyelonephritis_in.10.aspx