BERKELEY, CA (UroToday.com) - Community-onset acute pyelonephritis (CO-APN) is a common bacterial infection. Although most CO-APN cases are readily treated with antimicrobial agents, it is important to consider complicating factors such as urinary tract abnormalities and underlying diseases when making decisions about treatment and patient care. In clinical practice, patients who have risk factors for mortality or poor clinical response after treatment must be hospitalized. Furthermore, patients who are at risk of clinical failure after 72 hours of treatment (early clinical failure) also need hospitalization because radiologic imaging of the urinary tract, investigation of other complicating factors, or modification of the initial antimicrobial regimen in line with antibiotic susceptibility results are usually required. In order to help physicians determine whether hospitalization is needed in a CO-APN patient, we assessed risk factors for early clinical failure using demographic and clinical factors such as age, underlying diseases, and simple laboratory test results at the initial presentation and established whether early clinical failure had an effect on mortality and final treatment outcomes by a prospective multicenter observational study.
A total of 1 062 women with CO-APN were enrolled, and 784 (73.8%) of 1 062 gave positive urine and/or blood cultures. Clinical significance of early clinical failure was verified; final clinical failure and mortality were higher in the early clinical failure group than the early clinical success group (14.9% vs. 2.3%, P < 0.001; 6.8% vs. 0.1%, P=0.001, respectively). We found that the variables predictive of early clinical failure fell into 3 categories: the first were underlying diseases such as chronic liver disease (OR 3.3; 95% CI 1.6-6.7), malignancy (OR 2.2; 95% CI 1.1-4.4) and diabetes (OR 1.5; 95% CI 1.1-2.1); the second consisted of parameters reflecting the severity of infection such as Pitt’s score ≥ 2 (OR 2.5; 95% CI 1.6-3.8), presence of azotemia (OR 1.8; 95% CI 1.2-2.7), serum CRP level ≥ 20 mg/dL (OR 1.7; 95% CI 1.2-2.4) and white blood cell count ≥ 20,000/mm3 (OR 2.5; 95% CI 1.6-4.0), while the third category consisted of history of antibiotic usage within 1 year (OR 1.5; 95% CI 1.1-2.2). In subgroup analysis with culture-positive patients, fluoroquinolone resistance of the uropathogen was also independently associated with early clinical failure (OR 1.7; 95% CI 1.1-2.5).
This study clearly indicated that patients with CO-APN showing a poor clinical response after 72 hours of treatment are more likely to suffer subsequent clinical failure and mortality. We propose that simple variables such as underlying diseases, a history of antibiotic usage, and laboratory test outcomes, easily obtainable at initial presentation, can be used to decide on the direction of treatment in CO-APN patients.
Hyunjoo Pai, MD, PhD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea