title: Recommended Initial Antimicrobial Therapy for Emphysematous Pyelonephritis: 51 Cases and 14-Year-Experience of a Tertiary Referral Center.
abstract: The aim of this study was to investigate the profiles of pathogens and patterns of antibiotic resistance of emphysematous pyelonephritis (EPN), offering recommendations for initial antibiotic treatment.Between January, 2001, and November, 2014, demographic data, presenting clinical features, management strategies, and treatment outcomes of 51 patients with EPN were retrospectively reviewed, analyzing microbiological characteristics of causative pathogens and patterns of antibiotic resistance.Overall survival rate was 90.2% (46/51). Pathogens isolated most frequently were Escherichia coli (49.0%), Klebsiella pneumoniae (19.6%), and Proteus mirabilis (17.7%). Approximately 24% of E coli isolates and 22% K pneumoniae isolates were resistant to fluoroquinolones. Improper empiric antibiotic use (P = 0.02) and third-generation cephalosporin-resistant pathogens (G3CRP) (P = 0.01) were significantly more common in cases of patient fatality. Prior hospitalization and antibiotic use within past year (P = 0.03), need for emergency hemodialysis (P = 0.03), and development of disseminated intravascular coagulation (DIC) (P = 0.03) were factors correlating significantly with microbial resistance to third-generation cephalosporins. The area under the receiver operating characteristic curve was 0.91. The cut-off point determined by the maximum Youden index for 2 of these 3 factors yielded a sensitivity of 0.8 and specificity of 0.93.Third-generation cephalosporins are recommended as initial treatment of EPN. In patients with histories of prior hospitalization and antibiotic use and in those needing emergency hemodialysis or developing DIC, carbapenem is the empiric antibiotic of choice. Patients presenting with 2 or more factors carry the highest risk of G3CRP involvement. Fluoroquinolone and gentamicin should be avoided.
authors.affiliation: From the Department of Urology (Y-CL), National Taiwan University Hospital, Yunlin Branch ; Department of Urology (J-HH, B-JC, Y-HP, C-YH, Y-SP), National Taiwan University Hospital; Departments of Laboratory Medicine and Internal Medicine (P-RH), National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Yu-Chuan
authors.initials: YC
authors.lastname: Lu
authors.forename: Jian-Hua
authors.initials: JH
authors.lastname: Hong
authors.forename: Bing-Juin
authors.initials: BJ
authors.lastname: Chiang
authors.forename: Yuan-Hung
authors.initials: YH
authors.lastname: Pong
authors.forename: Po-Ren
authors.initials: PR
authors.lastname: Hsueh
authors.forename: Chao-Yuan
authors.initials: CY
authors.lastname: Huang
authors.forename: Yeong-Shiau
authors.initials: YS
authors.lastname: Pu
mesh_terms: D000208:Acute Disease; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000494:pharmacology* / Q000627:therapeutic use*; D002511:Cephalosporins / Q000494:pharmacology / Q000627:therapeutic use; D004352:Drug Resistance, Microbial; D005260:Female; D024841:Fluoroquinolones / Q000494:pharmacology / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D011704:Pyelonephritis / Q000188:drug therapy* / Q000382:microbiology* / Q000401:mortality; D012189:Retrospective Studies; D012737:Sex Factors
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D024841:Fluoroquinolones