From the Guidelines
For a patient with costovertebral angle (CVA) tenderness, you should initiate empiric antibiotic therapy first, then obtain imaging. Start with an antibiotic that covers common urinary pathogens such as ceftriaxone 1-2g IV daily, ciprofloxacin 400mg IV twice daily, or levofloxacin 750mg IV daily, as recommended by the European Association of Urology guidelines on urological infections 1. While waiting for antibiotics to take effect, order a urinalysis, urine culture, and blood cultures. After initiating treatment, arrange for a CT scan of the abdomen and pelvis with contrast to evaluate for complications like abscess formation, obstruction, or renal stones.
This approach is recommended because CVA tenderness often indicates pyelonephritis, which can rapidly progress to sepsis if treatment is delayed, as noted in the ACR Appropriateness Criteria for acute pyelonephritis 1. The clinical priority is to control the infection quickly, as waiting for imaging results before starting antibiotics could allow the infection to worsen. Once culture results return in 48-72 hours, narrow antibiotic therapy based on susceptibilities and continue treatment for 7-14 days depending on clinical response and any complications identified. Key considerations include:
- Initiating antibiotic therapy promptly to prevent progression to sepsis
- Using antibiotics that cover common urinary pathogens
- Obtaining a CT scan after starting antibiotics to evaluate for complications
- Adjusting antibiotic therapy based on culture results and clinical response
The European Association of Urology guidelines on urological infections 1 provide the most recent and highest quality evidence for managing patients with CVA tenderness, supporting the approach of initiating empiric antibiotic therapy first, then obtaining imaging.
From the Research
Patient with Costovertebral Angle (CVA) Tenderness
In a patient presenting with costovertebral angle (CVA) tenderness, the clinical approach involves considering the potential for acute pyelonephritis or other urinary tract infections. The decision to order a computed tomography (CT) scan immediately or to initiate antibiotic therapy first depends on several factors, including the severity of symptoms, the presence of complications, and the patient's overall health status.
Initiating Antibiotic Therapy
- Antibiotic therapy should be initiated promptly in patients with suspected acute pyelonephritis to prevent serious complications, as indicated by studies such as 2 and 3.
- The choice of empirical antibiotic therapy should be based on local resistance patterns, patient characteristics, and the severity of the infection.
- Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) and injectable third-generation cephalosporins (e.g., ceftriaxone) are commonly recommended for the treatment of acute uncomplicated pyelonephritis, as per 2.
Role of CT Scan
- A CT scan may be ordered in certain situations, such as when complications are suspected (e.g., emphysematous pyelonephritis), as seen in the case report 4.
- CT scans can help in diagnosing the extent of the infection and guiding the treatment, especially in cases where the patient does not respond to initial antibiotic therapy or when there are signs of severe infection.
Treatment Approach
- The treatment approach should be individualized based on the patient's clinical presentation, laboratory results, and imaging findings.
- In patients with severe symptoms or signs of complications, both antibiotic therapy and diagnostic imaging (including CT scans) may be initiated concurrently, as suggested by 5.
- The duration of antibiotic therapy can vary depending on the severity of the infection, the patient's response to treatment, and the presence of any complications, with studies like 6 highlighting the importance of balancing treatment duration with the risk of resistance and adverse effects.