A 40-year-old diabetic woman complaints of 3 days of fever, chills, dysuria, and flank pain. This morning, she noted some dizziness with standing and vomited once. In the ED, her rectal temperature is 38.8°C. You note her to be thin with dry lips. The remainder of the examination is unremarkable except for right costovertebral angle tenderness. Urinalysis shows trace ketones, numerous WBCs in clumps and casts, and 4+ bacteria. Her peripheral white blood cell count is 9.5 and her blood glucose is 220. She has no prior history of urinary infection. Your most appropriate treatment is to:
Infuse 2000 mL normal saline, administer a dose of intravenous ceftriaxone, and discharge home on oral antibiotics.
Infuse 2000 mL normal saline, administer a dose of intravenous ceftriaxone, and admit to the hospital.
Obtain renal ultrasound; if negative, proceed as in choice b.
Give 4 units of regular insulin now, 2000 mL intravenous normal saline, administer a dose of intravenous ceftriaxone, order blood and urine cultures, and admit to the hospital.
Insert a central venous catheter for central venous pressure monitoring, begin presumptive treatment with fluids, give intravenous steroids, start empiric antibiotics, and admit to the intensive care unit.
This patient has acute pyelonephritis. In general, young patients with uncomplicated urinary tract infections or simple acute pyelonephritis do not require admission and can be treated as outpatients with oral antibiotics, antipyretics, and pain medications. However, patients with the following complicating conditions are at higher risk of severe complication and should be admitted: pregnancy, diabetes, cancer, immunosuppression, sickle cell anemia, organ transplant recipients, comorbid obstructing renal calculi, intractable nausea and vomiting, and azotemia. Debilitated patients or those unable to care for themselves should also be admitted. Complications of pyelonephritis include urosepsis and septic shock, emphysematous pyelonephritis, perinephric abscess, papillary necrosis, and renal failure. Because of her diabetes, this patient is also at risk of developing diabetic ketoacidosis and adequate fluid replacement and insulin therapy are particularly important.