급성 신우신염, 항생제

20대/여자

일주일 전 왼쪽 옆구리 통증, 식은땀, 오한

**병원 ER에서 abdomen enhanced CT 촬영함

'신우신염까지는 아니고 요로감염인 것 같다'는 말 듣고

ciprofloxacin 500 mg bid X3일 처방 받음.

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이후 진통소염제를 복용함에도 밤마다 오한이 있어 내원하였습니다.

항생제는 3일 복용하고 중단한 상태

다시 의료기관 방문하지 않음.

Lt. Knocking Td는 저명하지 않음.

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Q.

1. 신우신염은 아닌데 열이 났었다면 ureteritis 정도였을까?

2. 왼쪽 옆구리 통증이 있었으므로 신우신염이었지 않았을까?

3. 병소는 다른 곳이고 우연히 검사결과가 요로감염 소견이지 않았을까?

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plan) blood test and urine test

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Rx) amoxicillin 375 mg tid + doxycycline 100 mg bid

acetaminophen 650 mg, 2T tid

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DDx

1. Pyelonephritis? Liver enzyme은 secondary change?
2. Liver abscess? 요로감염은 incidental finding?

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Q.

신우신염은 아닌데 열이 났었다면 ureteritis 정도였을까?

왼쪽 옆구리 통증이 있었으므로 신우신염이었지 않았을까?

병소는 다른 곳이고 우연히 요로감염 소견이 있지 않았을까?

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• CT를 최근에 찍었지만 **병원이 멀리 있어서 CT 가져 오기도 쉽지 않고
• 현재 일주일 넘게 해열제 복용에도 불구하고 오한이 지속되며 (WBC, CRP 증가가 많이 되어 있고)
• 일주일 전 CT에서 신우신염까지는 아니었다고 하였음에도 pyuria, bacteriuria 소견 보이고
• liver abscess 등 다른 발열 원인 감별도 필요하므로 복부 CT 다시 찍기로 함.

 

Plan) abdomen CT, enhanced

 

 

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Dx ) Acute pyelonephritis, Lt

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Plan) Doxycycline stop

Amoxicillin/Clavulanate 유지 (ciprofloxacin 3일 사용 후 중단된 상태이고 기왕 amoxicillin/clavulanate 2일 복용 중이면서 증상 호전이 있으므로)

 

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Empiric antimicrobial agent selection for acute complicated urinary tract infection

Patient population	Risk for MDR?*	Empiric regimens	Comments
Hospitalized with: Critical illness warranting intensive care (eg, severe sepsis) or Urinary tract obstruction	N/A	An antipseudomonal carbapenem: Imipenem 500 mg IV every 6 hours infused over 3 hours or Meropenem 1 g IV every 8 hours infused over 3 hours PLUS Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours with or without a loading dose	The rationale for broad coverage is the high risk of adverse outcomes with insufficient antimicrobial therapy. In regions with low community prevalence of ESBL-producing organisms, it is reasonable to select a regimen based on individual MDR risk, as listed for "Other hospitalized patients."
Other hospitalized patients	No	Ceftriaxone 1 g IV once daily or Piperacillin-tazobactam 3.375 g IV every 6 hours or Alternatives: Levofloxacin 750 mg IV or orally daily Ciprofloxacin 400 mg IV twice daily Ciprofloxacin 500 mg orally twice daily Ciprofloxacin extended-release 1000 mg orally once daily	If Enterococcus or Staphylococcus species are suspected (eg, based on prior isolates), piperacillin-tazobactam is preferred. If Pseudomonas is suspected (based on prior isolates), piperacillin-tazobactam or a fluoroquinolone is preferred.
	Yes	Piperacillin-tazobactam 3.375 g IV every 6 hours or Cefepime 2 g IV every 12 hours (not for ESBL risk) or An antipseudomonal carbapenem (if recent ESBL isolate): Imipenem 500 mg IV every 6 hours infused over 3 hours or Meropenem 1 g IV every 8 hours infused over 3 hours	If VRE or MRSA are suspected (eg, based on prior isolates), vancomycin (for MRSA) or daptomycin or linezolid (for VRE) is added.
Outpatients	No, and no concerns with fluoroquinolones (eg, at low risk for adverse effects)	For patients with low risk of fluoroquinolone resistance/toxicity: Ciprofloxacin 500 mg orally twice daily for 5 to 7 days or Ciprofloxacin extended-release 1000 mg orally once daily for 5 to 7 days or Levofloxacin 750 mg orally once daily for 5 to 7 days	If the community prevalence of fluoroquinolone resistance in Escherichia coli is known to be >10%, give one dose of a long-acting parenteral agent prior to the fluoroquinolone: Ceftriaxone 1 g IV or IM once Ertapenem 1 g IV or IM once Gentamicin 5 mg/kg IV or IM once Tobramycin 5 mg/kg IV or IM once
	No, but with concerns with fluoroquinolones (eg, at risk for adverse effects)	For patients who cannot use a fluoroquinolone: One dose of a long-acting parenteral agent: Ceftriaxone 1 g IV or IM once or Ertapenem 1 g IV or IM once or Gentamicin 5 mg/kg IV or IM once or Tobramycin 5 mg/kg IV or IM once Followed by one of the following: TMP-SMX one double-strength tablet orally twice daily for 7 to 10 days or Amoxicillin-clavulanate 875 mg orally twice daily for 7 to 10 days or Cefpodoxime 200 mg orally twice daily for 7 to 10 days or Cefdinir 300 mg orally twice daily for 7 to 10 days or Cefadroxil 1 g orally twice daily for 7 to 10 days	In outpatients who are systemically ill or are at risk for more severe illness, we favor continuing the parenteral agent until culture and susceptibility testing results can guide selection of an appropriate oral agent.
	Yes	Ertapenem 1g IV or IM once Followed by: Ciprofloxacin 500 mg orally twice daily for 5 to 7 days or Ciprofloxacin extended-release 1000 mg orally once daily for 5 to 7 days or Levofloxacin 750 mg orally daily for 5 to 7 days	If the patient cannot take a fluoroquinolone or has high risk for fluoroquinolone resistance (fluoroquinolone-resistant isolate or fluoroquinolone use in prior three months): Ertapenem 1 g IV or IM once daily until cultures and susceptibility testing return

These antibiotic regimens represent our approach to empiric treatment for acute complicated UTI. Once culture and susceptibility testing results are available, the regimen should be tailored to those results. If feasible, an antibiotic with a narrow spectrum of activity should be chosen to complete the antibiotic course.

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MDR: multidrug resistance; IV: intravenous; VRE: vancomycin-resistant Enterococcus; MRSA: methicillin-resistant Staphylococcus aureus; IM: intramuscular; TMP-SMX: trimethoprim-sulfamethoxazole; UTI: urinary tract infection.

* Risk factors for MDR gram-negative UTIs include any one of the following in the prior three months:

• An MDR, gram-negative urinary isolate, including a fluoroquinolone-resistant Pseudomonas urinary isolate
• Inpatient stay at a health care facility (eg, hospital, nursing home, long-term acute care facility)
• Use of a fluoroquinolone, TMP-SMX, or broad-spectrum beta-lactam (eg, third- or later-generation cephalosporin)
• Travel to parts of the world with high rates of MDR organisms

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Ref. UpToDate 2023.01.05