Pyelonephritis

Patient Presentation:
B.M., a 29 year old woman, presented to her OBGYN’s office complaining of fever, bilateral flank pain, nausea, aches, chills, dysuria, hematuria, and urinary frequency.  B.M. is a G1P1 who delivered a healthy, term baby girl five days earlier.  She had an uneventful pregnancy and normal prenatal labs.  One hour prior to her arrival, B.M. had taken 675mg of Tylenol® PO for her fever.   Her BP was 128/82, pulse was 100, SaO2 was 99% on room air, and temperature was 38.7 degrees Celsius.  She rated her bilateral flank pain as 8/10.  She reported experiencing urinary frequency with dysuria and hematuria for the past 24 hours and reported nausea, but denied vomiting.  B.M. was transferred to the postpartum unit for inpatient admission.

Differential List:
B.M. had a CT scan of her abdomen and pelvis in order to rule out kidney stones or an obstruction.  Bilateral blood cultures from B.M.’s arms and a clean catch urine culture were obtained.

Diagnosis:
A urinalysis was positive for leukocyte esterase.  A CBC showed that B.M.’s white blood cell count was 10.7 and neutrophil count was high, with 84.8% neutrophils and an absolute neutrophil count of 9.1.  She was diagnosed with pyelonephritis (a urinary tract infection that affects the kidney[s]).

Treatment:
B.M. was started on continuous IV fluids for hydration.  She began an antibiotic treatment of IV Rocephin® (ceftriaxone sodium) 1 gram daily.  For pain relief, B.M. was given IV Dilaudid® 2mg every 4 hours PRN.  For nausea relief, she received IV Zofran® 4mg every 8 hours.  She was also ordered for PO Tylenol® 1 gram every 8 hours for fever and pain relief.

Outcome:
Three days later, B.M.’s temperature had decreased to 36.6 degrees Celsius and she had been afebrile for 24 hours.  Her vital signs were stable and WNL, with a BP of 108/68, pulse 74, respiratory rate 18, and SaO2 99% on room air.  Her bilateral flank pain had decreased to 2/10 and she reported that it was well controlled with Tylenol®.  By day 3, both blood cultures and the urine culture showed no growth.  B.M. was discharged home and given prescriptions to continue on PO Macrobid® 100mg BID for two weeks.  She was instructed to return to her OBGYN’s office or the ER if she experienced fever, dysuria, urinary frequency, or uncontrolled bilateral flank pain again.
Case created by Brittany Moore, 2012.