Abstract
Background and Aims
Emphysematous pyelonephritis (EPN) is a rare but life-threatening acute suppurative infection of the kidney.60-70% are associated with uncontrolled diabetes mellitus (DM) with or without obstructive uropathy and superimposed with infection caused by gas-forming organisms. Conventional treatment of EPN is parenteral antibiotics with percutaneous or open surgical drainage and/or nephrectomy. There is no current consensus on management of EPN as to whether present day antibiotics alone good enough or is surgical intervention necessary and if surgical intervention required when should one go for nephrectomy.
Method
A prospective observational study was conducted at Tertiary care hospital, Lucknow from 2015-2018 to look for clinical, microbial profile and treatment outcome of diabetic patients with emphysematous pyelonephritis.The clinical features and laboratory data at the initial presentation, management and outcomes were analyzed .Contrast enhanced computerized tomography (CECT) was performed in case of suspected renal abscess and nonrecovering pyelonephritis
Results
A total of 76 Diabetic patients diagnosed with pyelonephritis were identified, of which 15 patients were diagnosed with EPN (26.3%) Renal papillary necrosis and renal abscess was seen in 1 and 3 patients, respectively. The mean age of the patients was 58.4 ± 6.5 years (age range 22-79 years). Pyelonephritis was more common among males. Duration of symptoms prior to hospitalization ranged from 16.34 ± 7.32 (range 8-32) days. Renal dysfunction at presentation was seen in 15 (100%) patients. Bilateral involvement was seen in 5 (33.3%) patients. Fever was the most common presenting symptom followed by dysuria. Urine and blood cultures were positive in 13 (88.3%) and 3 (20 %) patients respectively. Gram-negative bacilli were the most frequent organisms isolated, Escherichia coli in 11 (73.3%), Klebsiella sp. in 1 (6.6%), Pseudomonas in 1 (6.6%), and 1 each with polymicrobial and fungal UTI respectively. The fungus included Candida albicans managed with fluconazole. Good, moderate, and poor glycemic control was seen in 13 (12.3%), 16 (15.2%) and 76 (72.3%), respectively.Of 15 EPN patients, 13 (86.6 %) survived and 2 (13.3%) expired. 2 of them underwent Nephrectomy both survived.All patients with Stage I, II and IIIa EPN (n = 12) were managed with antibiotics with or without PCD. In EPN Stage IIIb/IV (n = 3), all the 3 (20 %) patients were managed with antibiotics and PCD and later 2 (13.3%) needed nephrectomy.Of different variable only altered sensorium and shock at presentation were associated with poor outcome in EPN patients (P < 0.05)
Conclusion
EPN in diabetics needs good multidisciplinary approach with adequate antibiotics and surgical management as and well required for better patient outcomes.
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