When should patients with pyelonephritis be sent to the Emergency Room (ER)?

From the Guidelines

Patients with pyelonephritis should be sent to the Emergency Room if they have severe symptoms, complications, or risk factors that make outpatient management unsafe, as indicated by the most recent guidelines from the European Association of Urology in 2024 1. These include high fever, severe pain, inability to maintain oral hydration, persistent vomiting, signs of sepsis, pregnancy, significant comorbidities, anatomical abnormalities of the urinary tract, or failure to improve after 48-72 hours of appropriate oral antibiotics. Some key points to consider when deciding to send a patient to the ER include:

• Severe symptoms such as high fever (>103°F/39.5°C), severe pain, or signs of sepsis (rapid heart rate, low blood pressure, confusion) 1
• Complications such as kidney stones obstructing urine flow, or failure to improve after 48-72 hours of appropriate oral antibiotics 1
• Risk factors that make outpatient management unsafe, such as pregnancy, significant comorbidities (diabetes, immunosuppression, kidney disease), or anatomical abnormalities of the urinary tract 1
• Elderly patients or those with underlying health conditions that may worsen with pyelonephritis should also be evaluated in the ER 1 Prompt hospitalization allows for intravenous antibiotics, adequate hydration, pain management, and monitoring for complications such as abscess formation or septic shock, which is crucial for preventing permanent kidney damage, bloodstream infection, and even death 1. It is essential to follow the most recent guidelines and consider the individual patient's risk factors and symptoms when deciding to send them to the ER. In general, the treatment of pyelonephritis involves the use of antibiotics, with fluoroquinolones and cephalosporins being the recommended choices for oral empiric treatment 1. However, the specific treatment regimen should be tailored to the individual patient's needs and the local resistance patterns. Overall, recognizing the warning signs of severe pyelonephritis and seeking immediate medical attention is crucial for preventing serious complications and improving patient outcomes.

From the Research

Criteria for Sending Patients to the ER

When considering sending patients with pyelonephritis to the Emergency Room (ER), several factors should be taken into account:

• Severity of symptoms: Patients with severe symptoms such as high fever, chills, flank pain, nausea, and vomiting may require immediate attention in the ER 2.
• Presence of complications: Patients with complicated pyelonephritis, such as those with urinary tract obstruction, sepsis, or risk of infection with a multidrug-resistant organism, should be sent to the ER for prompt treatment 3.
• Ability to tolerate oral therapy: Patients who are unable to tolerate oral antibiotics may require intravenous therapy in the ER 3.
• Pregnancy: Pregnant patients with pyelonephritis are at increased risk of severe complications and should be sent to the ER for close monitoring and treatment 3.
• Age and comorbidities: Older patients or those with underlying comorbidities may require closer monitoring and more aggressive treatment in the ER 4.

Management in the ER

In the ER, patients with pyelonephritis should receive:

• Prompt antibiotic therapy: Patients should be started on empiric antibiotic therapy, with adjustments made based on culture and susceptibility results 2, 3.
• Bacteriological samples: Urine cultures and blood cultures should be collected before initiating antibiotic therapy to guide treatment 2, 3.
• Imaging and other tests: Imaging studies and other tests may be ordered to rule out complications or alternative diagnoses 3.
• Close monitoring: Patients should be closely monitored for signs of improvement or deterioration, with adjustments made to their treatment plan as needed 3, 4.