From the Guidelines
Costovertebral tenderness is a clinical finding that warrants prompt evaluation for pyelonephritis, and patients with this symptom should undergo urinalysis, including assessment of white and red blood cells and nitrite, as well as urine culture and antimicrobial susceptibility testing, as recommended by the European Association of Urology guidelines 1. To assess for costovertebral tenderness, a healthcare provider places one hand over the costovertebral angle and taps it with the other hand; pain with this maneuver suggests kidney inflammation. Patients with pyelonephritis typically present with flank pain, fever, chills, nausea, vomiting, and urinary symptoms like frequency, urgency, and dysuria. Some key points to consider in the evaluation and management of costovertebral tenderness include:
- The use of fluoroquinolones and cephalosporins as the only antimicrobial agents recommended for oral empiric treatment of uncomplicated pyelonephritis 1
- The importance of prompt differentiation between uncomplicated and potentially obstructive pyelonephritis, as the latter can swiftly progress to urosepsis 1
- The need for additional investigations, such as a contrast-enhanced computed tomography scan, or excretory urography, if the patient remains febrile after 72 h of treatment, or immediately if there is a deterioration in clinical status 1
- The recommendation for ultrasound or magnetic resonance imaging (MRI) to be used preferentially in pregnant women to avoid radiation risk to the foetus 1 The tenderness occurs because the inflamed kidney capsule stretches, stimulating pain receptors, and percussion transmits pressure waves through tissues to the inflamed kidney. Other conditions that can cause costovertebral tenderness include kidney stones, renal abscess, and perinephric abscess, making proper diagnosis essential for appropriate treatment.
From the Research
Costovertebral Tenderness
- Costovertebral tenderness is a symptom that can be associated with pyelonephritis, which is a bacterial infection of the kidney and renal pelvis 2.
- The diagnosis of pyelonephritis is typically made based on a combination of clinical symptoms, such as flank pain and laboratory evidence of urinary tract infection 2.
- The treatment of pyelonephritis typically involves the use of antibiotics, with fluoroquinolones and trimethoprim/sulfamethoxazole being effective oral antibiotics in most cases 2.
- However, increasing resistance to these antibiotics makes empiric use problematic, and alternative treatments such as cephalosporins may be considered 3.
- Cephalosporins have been shown to be effective in the treatment of uncomplicated pyelonephritis, with no trials reporting inferiority of clinical treatment outcomes compared to fluoroquinolones or trimethoprim/sulfamethoxazole 3.
Antibiotic Treatment
- The choice of antibiotic treatment for pyelonephritis depends on various factors, including the severity of the infection, the presence of underlying medical conditions, and the susceptibility of the causative organism to different antibiotics 4, 5.
- A 7-day course of ciprofloxacin has been shown to be as effective as a 14-day course of trimethoprim/sulfamethoxazole for the treatment of pyelonephritis 4.
- However, the increasing resistance to trimethoprim/sulfamethoxazole makes it less effective in some cases, and alternative treatments such as ciprofloxacin or cephalosporins may be considered 5, 6.
- The use of oral antibiotics for the treatment of pyelonephritis is generally recommended for uncomplicated cases, while parenteral antibiotic therapy is recommended for more severe cases or for patients who are unable to tolerate oral therapy 2.