Relevance in the emergency department of a decisional algorithm for outpatient care of women with acute pyelonephritis

Abstract

The outcome of three types of management for patients with acute pyelonephritis, in an emergency department is assessed. This was carried out by a prospective enrolment of patients with acute pyelonephritis. Through a decisional algorithm, doctors were encouraged to discharge female patients under 60 years with acute uncomplicated pyelonephritis, either directly from the emergency ward or after a short stay in the observation unit. All received a single intravenous dose of pefloxacin, after urine and blood cultures were obtained; before discharge a normal ultrasonography of the abdomen and the pelvis was required. Conversely, hospitalization was advised for patients who did not fit the criteria of uncomplicated pyelonephritis. Only females with positive urine cultures qualified. Of 83 patients enrolled, 70 were females with positive urine cultures, 60 of whom had uncomplicated pyelonephritis. At 3 weeks, two of 70 patients were lost to follow-up. In the remaining 68, favourable outcome was observed in 98% of 48 patients discharged from the observation unit (95% CI: [94%; 100%]), 90% of 10 discharged from the emergency ward (95% CI: [73%; 100%]) and 70% of 10 hospitalized (95% CI: [50%; 93%]). A decisional algorithm was useful in determining that over 85% of women who present to our emergency department with pyelonephritis have an uncomplicated form and may be safely treated as outpatients, if necessary after a brief stay in the observation unit. Prospective controlled trials are needed to determine duration of antimicrobial therapy, length of follow-up and finally, to compare tolerance and cost-effectiveness of outpatient vs. inpatient care of acute uncomplicated pyelonephritis.