Ramakrishnan Kalyanakrishnan, Scheid Dewey C
Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104, USA.
Am Fam Physician. 2005 Mar 1;71(5):933-42.
There are approximately 250,000 cases of acute pyelonephritis each year, resulting in more than 100,000 hospitalizations. The most common etiologic cause is infection with Escherichia coli. The combination of the leukocyte esterase test and the nitrite test (with either test proving positive) has a sensitivity of 75 to 84 percent and a specificity of 82 to 98 percent for urinary tract infection. Urine cultures are positive in 90 percent of patients with acute pyelonephritis, and cultures should be obtained before antibiotic therapy is initiated. The use of blood cultures should be reserved for patients with an uncertain diagnosis, those who are immunocompromised, and those who are suspected of having hematogenous infections. Outpatient oral antibiotic therapy with a fluoroquinolone is successful in most patients with mild uncomplicated pyelonephritis. Other effective alternatives include extended-spectrum penicillins, amoxicillin-clavulanate potassium, cephalosporins, and trimethoprim-sulfamethoxazole. Indications for inpatient treatment include complicated infections, sepsis, persistent vomiting, failed outpatient treatment, or extremes of age. In hospitalized patients, intravenous treatment is recommended with a fluoroquinolone, aminoglycoside with or without ampicillin, or a third-generation cephalosporin. The standard duration of therapy is seven to 14 days. Urine culture should be repeated one to two weeks after completion of antibiotic therapy. Treatment failure may be caused by resistant organisms, underlying anatomic/functional abnormalities, or immunosuppressed states. Lack of response should prompt repeat blood and urine cultures and, possibly, imaging studies. A change in antibiotics or surgical intervention may be required.
每年约有25万例急性肾盂肾炎病例，导致超过10万次住院治疗。最常见的病因是大肠杆菌感染。白细胞酯酶试验和亚硝酸盐试验（任一试验呈阳性）联合使用对尿路感染的敏感性为75%至84%，特异性为82%至98%。90%的急性肾盂肾炎患者尿培养呈阳性，应在开始抗生素治疗前进行培养。血培养适用于诊断不明确、免疫功能低下以及怀疑有血行感染的患者。大多数轻度非复杂性肾盂肾炎患者采用氟喹诺酮类药物门诊口服抗生素治疗是成功的。其他有效的替代药物包括广谱青霉素、阿莫西林克拉维酸钾、头孢菌素和甲氧苄啶磺胺甲恶唑。住院治疗指征包括复杂性感染、脓毒症、持续呕吐、门诊治疗失败或年龄极端情况。对于住院患者，建议静脉使用氟喹诺酮类药物、氨基糖苷类药物（可加用或不加用氨苄西林）或第三代头孢菌素。标准治疗疗程为7至14天。抗生素治疗结束后1至2周应复查尿培养。治疗失败可能由耐药菌、潜在的解剖/功能异常或免疫抑制状态引起。治疗无反应应促使复查血培养和尿培养，可能还需要进行影像学检查。可能需要更换抗生素或进行手术干预。
