What is the treatment for pericarditis (inflammation of the pericardium) following a urinary tract infection (UTI)?

Treatment of Pericarditis Following Urinary Tract Infection

Pericarditis following a urinary tract infection should be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, along with colchicine as adjunctive therapy, while addressing the underlying UTI with appropriate antibiotics. 1, 2

Pathophysiology and Classification

Pericarditis following a UTI likely represents either:

1. Immune-mediated inflammation triggered by the infection
2. Direct bacterial seeding (purulent pericarditis) - less common but more serious

Treatment Algorithm

Step 1: Assess Severity and Type

• Evaluate for hemodynamic compromise: Hypotension, tachycardia, jugular venous distention
• Check for purulent pericarditis: Fever >38°C, sepsis signs, frankly purulent fluid on pericardiocentesis 1
• Laboratory evaluation: Blood cultures, CRP, CBC, renal function

Step 2: Initial Treatment Based on Type

For Non-Purulent (Immune-Mediated) Pericarditis:

1. First-line therapy:

   • NSAIDs: Ibuprofen 600mg every 8 hours or Aspirin 750-1000mg every 8 hours with gastroprotection 1, 2
   • Continue for 1-2 weeks until symptoms resolve and CRP normalizes
   • Gradually taper dose afterward

2. Adjunctive therapy:

   • Colchicine: 0.5mg once daily if <70kg or 0.5mg twice daily if ≥70kg 1, 2
   • Continue for 3 months to prevent recurrence
   • Note: Adjust dose in renal impairment; contraindicated in severe renal failure 1

3. For severe or refractory cases:

   • Prednisone (0.5-1.0 mg/kg daily, maximum 80mg) in tapering doses over 1-2 weeks 1
   • Only if NSAIDs/colchicine fail or are contraindicated
   • If corticosteroids are used, add itraconazole (200mg 3 times daily for 3 days, then once or twice daily for 6-12 weeks) to prevent progression of any occult infection 1

For Purulent Pericarditis:

1. Urgent management required (mortality approaches 100% if untreated) 1, 3:

   • Immediate pericardiocentesis for diagnosis and drainage 1
   • Send fluid for bacterial, fungal, and tuberculous studies 1
   • Empiric broad-spectrum antibiotics based on likely organisms 1, 3

2. Surgical intervention:

   • Consider subxiphoid pericardiostomy for complete drainage 1
   • Intrapericardial thrombolysis may help with loculated effusions 1

Step 3: Manage the Underlying UTI

• Appropriate antibiotics based on urine culture and sensitivity
• Ensure adequate duration of therapy

Step 4: Monitoring and Follow-up

• Monitor CRP to guide treatment duration 1, 2
• Follow-up echocardiogram to assess for resolution of effusion
• Initial follow-up 1-2 weeks after starting treatment 2
• Subsequent follow-up every 1-2 months until treatment completion 2

Special Considerations

• Activity restriction: Until symptoms resolve and CRP, ECG, and echocardiogram normalize 1, 2
• Risk of recurrence: 15-30% without colchicine, reduced to 8-15% with colchicine 2
• Risk of constrictive pericarditis: <1% for idiopathic/viral pericarditis, higher for bacterial causes (20-30%) 1
• Renal impairment: Adjust NSAID and colchicine doses; may need alternative therapy 1, 2

Pitfalls to Avoid

1. Premature discontinuation of therapy: Continue until complete resolution of symptoms and normalization of inflammatory markers
2. Early corticosteroid use: Increases risk of recurrence; reserve as second-line therapy 1, 2
3. Failure to drain purulent effusions: Mortality approaches 100% without drainage 1, 3
4. Overlooking cardiac tamponade: Monitor for signs of hemodynamic compromise
5. Inadequate treatment of underlying UTI: Ensure appropriate antibiotic coverage and duration

By following this treatment approach, most patients with pericarditis following UTI will experience resolution of symptoms and reduced risk of complications such as recurrence or constrictive pericarditis.