Approach

No specific treatment is available. Renal damage incurred is not reversible and management options are limited. Eliminating recurrent urinary tract infections (UTIs) and identifying and correcting any underlying anatomic or functional urinary problems (e.g., obstruction, urolithiasis) can prevent further renal damage. However, unless ongoing infection is documented, antibiotic treatment in these patients is generally not helpful.[45] It is recommended that patients are referred for specialist nephrology/urologic consult. Xanthogranulomatous pyelonephritis (XGP) and emphysematous pyelonephritis (EPN) are uncommon subsets of chronic pyelonephritis, and are managed surgically.

Xanthogranulomatous pyelonephritis (XGP)

Nephrectomy is usually the treatment of choice; however, a partial nephrectomy may be performed in patients with focal disease.

Antibiotics for the treatment of infection should be given both before and following surgery, to cover gram-negative organisms. Antibiotic treatment includes third-generation cephalosporins, fluoroquinolones, extended-spectrum penicillins, aminoglycosides, and carbapenem antibiotics.

In the setting of increasing drug resistance in uropathogens, the following newer antibiotics are approved in some countries for use in adults with complicated UTI caused by susceptible organisms who have limited or no alternative options: meropenem/vaborbactam, plazomicin, cefiderocol, and imipenem/cilastatin/relebactam.[46][47][48]​​

The disease rarely involves both kidneys and has not been shown to progress serially from one kidney to the other, and surgical resection is curative.[16]

Emphysematous pyelonephritis (EPN)

Most patients are acutely ill, and stabilization in the emergency department with adequate fluid resuscitation and tissue oxygenation has been shown to decrease morbidity and improve mortality.[26] Most patients with EPN are diabetic. Extremely tight glucose control has been shown to improve outcomes in experimental models of sepsis and in diabetic patients with severe infections.[49][50]

Depending on the severity of the disease, EPN may be treated with percutaneous drainage, antibiotics, or, if the patient is severely ill with worsening sepsis, nephrectomy.[1][18][51]​ Antibiotic treatment for the gas-forming organisms includes third-generation cephalosporins, fluoroquinolones, extended-spectrum penicillins, aminoglycosides, and carbapenem antibiotics. Empiric treatment depends in part on local bacterial susceptibility patterns.[52]

In the setting of increasing drug resistance in uropathogens, the following newer antibiotics are approved in some countries for use in adults with complicated UTI caused by susceptible organisms who have limited or no alternative options: meropenem/vaborbactam, plazomicin, cefiderocol, and imipenem/cilastatin/relebactam.[46][47][48]​​

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