From the Guidelines
For a urinary tract infection (UTI) with costovertebral angle (CVA) tenderness, immediate evaluation and treatment with empiric antibiotic therapy using fluoroquinolones or cephalosporins is necessary, as recommended by the European Association of Urology guidelines 1. The patient should undergo urinalysis, including assessment of white and red blood cells and nitrite, and a urine culture with antimicrobial susceptibility testing should be performed to guide therapy adjustments 1. Evaluation of the upper urinary tract via ultrasound is recommended to rule out urinary tract obstruction or renal stone disease, especially in patients with a history of urolithiasis, renal function disturbances, or a high urine pH 1. Key considerations for management include:
- Empiric antibiotic therapy with fluoroquinolones, such as ciprofloxacin or levofloxacin, or cephalosporins, for 7-14 days 1
- Obtaining a urine culture before starting antibiotics to guide therapy adjustments if needed
- Ordering a complete blood count, basic metabolic panel, and blood cultures if the patient appears systemically ill with fever, chills, or signs of sepsis
- Considering outpatient management for mild to moderate cases with good oral intake and no vomiting, but hospitalization is recommended for severe illness, pregnancy, immunocompromise, inability to tolerate oral medications, or concern for urinary obstruction 1
- Imaging with renal ultrasound or CT scan is indicated if there's concern for complications like abscess, obstruction, or if symptoms don't improve within 48-72 hours of appropriate antibiotic therapy 1 Adequate hydration and pain management with acetaminophen or NSAIDs are important supportive measures. Prompt differentiation between uncomplicated and potentially obstructive pyelonephritis is crucial, as the latter can swiftly progress to urosepsis, and this delineation should be established promptly using appropriate imaging techniques 1.
From the Research
UTI with CVA Tenderness Workup
- The diagnosis of urinary tract infections (UTIs), including pyelonephritis, is typically made based on clinical presentation, with symptoms such as dysuria, frequency, and costovertebral angle (CVA) tenderness being highly predictive of the condition 2.
- Urine culture is recommended for the diagnosis and management of pyelonephritis, recurrent UTI, and complicated UTIs 3.
- The presence of pyuria is usually indicative of a UTI, and its absence may suggest another condition is causing the patient's symptoms 2.
- Laboratory tests, such as urine dipstick for nitrites and leukocyte esterase, can aid in diagnosis, but a negative result does not exclude pyelonephritis 4.
Diagnostic Approach
- A thorough history and physical examination are essential in diagnosing acute pyelonephritis, with symptoms such as fever, flank pain, and CVA tenderness being suggestive of the condition 4, 5.
- Urine culture with antimicrobial susceptibility testing should be performed in all patients to direct therapy 5.
- Imaging, blood cultures, and measurement of serum inflammatory markers are not necessary in uncomplicated cases 5.
Treatment
- Antibiotic therapy should be initiated without delay, with the choice of antibiotic depending on the severity of the infection and local resistance patterns 4, 5.
- Fluoroquinolones and trimethoprim/sulfamethoxazole are effective oral antibiotics in most cases, but increasing resistance makes empiric use problematic 5.
- Parenteral antibiotic therapy is recommended for patients admitted to the hospital or those with sepsis or risk of infection with a multidrug-resistant organism 5.