Patient Presentation--Acute Pyelonephritis

At the end of my first week, my preceptor had me present a patient to her and the pharmacist assigned to the Family Medicine service.  The case a chose was among the patients I had been following throughout the week.  

ID: 55 year old female

CC: Fever x 6 days

HPI: 

Date	Note
Before 8/5	Patient visited outpatient clinic for lower abdominal pain and dysuria. She was given an oral antibiotic for a suspected UTI
8/5	Patient developed a subjective fever.
8/7	She went to the ER, WBC 18650 with left shift (Seg 91.2%), UA:  pyuria (WBC >100), sent home on cephalexin
8/9	She returned to the ER, WBC 11070 with left shift (Seg 89.7), UA: pyuria (WBC 20-35).  Renal ECHO revealed parenchymal renal disease.  Admitted for further evaluation and management.

PMH:

  

Hyperlipidemia

Medication List (8/15):

Acetaminophen 500 mg 1 Tablet PO q6h PRN

Cefuroxime Sodium 1500 mg IV q8h                  

NaCl 500 mL IF QD

Acyclovir Cream 5% 

Magnesium Oxide 250 mg 2 Tablets PO TID

Bisacodyl 10 mg 2 pills qod PRN

sennoside A+B calcium 12.5 mg 2 Tablets PO PRN

Allergies: NKDA

Physical Exam:

Unremarkable

VS:  BP: 126/76    T: 36.6     P: 68   RR: 19       Ht : 156cm   Wt : 67kg       BMI:27.5kg/m2

Labs:     WBC 8.18   RBC 4.92        Hgb 10.2         Hct 31.6      Plts 378           BUN 15.6     

SCr 0.7        AST 47            ALT 52            Na 137        K 5.0                LDL 115           

Tg 146         HDL 26           T. Chol 174     

Problem List:

1.     UTI

2.     Hyperlipidemia

1.  Acute pyelonephritis
S/O	Subjective	Dysuria and frequent urination for several days
	Objective	1.      Febrile since 8/5 2.      Left CVA tenderness 3.      Leukocytosis (WBC 11070)+left shift (Seg: 89.7%) 4.      UA:  pyuria WBC 20-35, proteinuria (200), WBC esterase, bacteria (3+) 5.      Urine culture:  Enterococcus species, colony count 1000/ml
A	1.      Likely pathogens for pyelonephritis:  Escherichia coli (75 to 95 %), with occasional other species of Enterobacteriaceae, such as Proteus mirabilis and Klebsiella pneumoniae, and Staphylococcus saprophyticus. 2.     Women with pyelonephritis requiring hospitalization should be initially treated with IV antimicrobial therapy:  ·         Fluoroquinolone ·          aminoglycoside ±ampicillin ·         extended-spectrum cephalosporin or extended-spectrum penicillin ± aminoglycoside ·         carbapenem Regimen should be based on local resistance data and susceptibility results. -Cefuroxime 1500 mg IV q8h (8/11—) 3.      Antibiotics should be administered for at least 10 to 14 days. 4.      Standard definition of positive urine culture is ≥105CFU/ml together with pyuria. 5.      Though guidelines recommend the usage of extended-spectrum cephalosporins, given that the colony count is low and patient is clinically improving ie UA, the antimicrobial therapy is adequate.
P	Goal	·         Clear infection ·         Relieve dysuria, frequency of urination ·          Restore WBC to normal ·          Restore UA to normal
	Monitoring	·       Urine analysis ·       Signs and symptoms of infection:  leukocytosis, fever ·       Side effects of medications ·       Renal function

2.  Hyperlipidemia
S/O	Subjective	Nil
	Objective	8/11/2011:  LDL-C:  135 8/13/2012: ·        TG: 146 ·        T-CHO:  174 ·        LDL-C:  115 ·        HDL-C:  26
A	·          Previously on Mevalotin 40 mg PO qHS ·          10-Year Risk by Total Framingham Point Score:  2% ·          ATP III LDL goal is <130 mg/dL ·          Initiation of treatment now is not necessary
P	Monitoring	·        Lipid panel
	Goal	LDL-C<130 mg/dL

Case Discussion

At first, I felt the approach to the treatment of UTI's in Taiwan, and infections in general, was very similar to that of the U.S. However, as I looked at more patients and spoke with my preceptor, I found that the treatment strategies are actually different.  In the case of pyelonephritis, this patient would be classified as a complicated UTI and would require a broad spectrum cephalosporin ie at least a 3rd generation to treat the likely pathogens.  However, I've seen many cases similar to this where they have treated with 1st and 2nd generation cephalosporins.  My preceptor noted that the physicians are, for the most part, aware of the IDSA guidelines and recommendations, however they utilize it literally as a guideline and do not follow it as closely as the U.S. does.  In addition, I noticed many cases where antibiotic changes are made without any rhyme or reason, except that the patient spiked a fever.  The scenario is usually a patient spiking a fever while on an antibiotic regimen.  The antibiotic is switched to another class without regard for whether there was any additional microorganism coverage.  I feel that in the area of infectious diseases, pharmacists have many opportunities to make interventions.