Emphysematous urinary tract infections
- Amy C Weintrob, MD
Amy C Weintrob, MD
- Associate Professor of Medicine
- The George Washington University and Veterans Affairs Medical Center
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
Emphysematous urinary tract infections (UTIs) are infections of the lower or upper urinary tract associated with gas formation. They may manifest as cystitis, pyelitis, or pyelonephritis.
Issues related to emphysematous UTIs will be reviewed here. Diabetes mellitus is a major risk factor for these infections and is also associated with an increased risk of asymptomatic bacteriuria and certain symptomatic UTIs such as cystitis, renal and perinephric abscess, and Candida infections [1-3]. (See "Asymptomatic bacteriuria in patients with diabetes mellitus" and "Acute uncomplicated cystitis and pyelonephritis in women" and "Renal and perinephric abscess" and "Candida infections of the bladder and kidneys" and "Susceptibility to infections in persons with diabetes mellitus" and "Acute complicated cystitis and pyelonephritis".)
The pathogenesis of emphysematous UTIs is poorly understood. Elevated tissue glucose levels in diabetic patients may provide a more favorable microenvironment for gas-forming microbes. However, bacterial gas production does not fully explain the pathologic and clinical manifestations of emphysematous UTIs [4,5].
Diabetes mellitus and urinary tract obstruction are the major risk factors for emphysematous urinary tract infections (UTIs). In different series, diabetes was present in more than 80 percent of patients with emphysematous pyelonephritis [4,6-9], at least 50 percent of patients with emphysematous pyelitis, and 60 to 70 percent of patients with emphysematous cystitis [5,10]. In addition, most patients were women, similar to the predominance of women in acute uncomplicated cystitis and pyelonephritis [4,5,10], and most patients were over age 60 [4,5,10].
One of the largest published experiences comes from a retrospective study of 48 patients in Taiwan who were diagnosed with either emphysematous pyelonephritis or emphysematous pyelitis . Diabetes was present in 96 percent and urinary tract obstruction in 22 percent. The mean patient age was 60 years (range 37 to 83 years) and women outnumbered men 6:1. Similar findings were noted in a literature review of 135 patients with emphysematous cystitis: diabetes was present in 67 percent, the mean age was 66 years, and women accounted for 64 percent of cases .
- Ronald A, Ludwig E. Urinary tract infections in adults with diabetes. Int J Antimicrob Agents 2001; 17:287.
- Geerlings SE, Stolk RP, Camps MJ, et al. Risk factors for symptomatic urinary tract infection in women with diabetes. Diabetes Care 2000; 23:1737.
- Boyko EJ, Fihn SD, Scholes D, et al. Diabetes and the risk of acute urinary tract infection among postmenopausal women. Diabetes Care 2002; 25:1778.
- Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000; 160:797.
- Grupper M, Kravtsov A, Potasman I. Emphysematous cystitis: illustrative case report and review of the literature. Medicine (Baltimore) 2007; 86:47.
- Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med 1987; 83:149.
- Chen MT, Huang CN, Chou YH, et al. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. J Urol 1997; 157:1569.
- Pontin AR, Barnes RD, Joffe J, Kahn D. Emphysematous pyelonephritis in diabetic patients. Br J Urol 1995; 75:71.
- Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology 1997; 49:343.
- Thomas AA, Lane BR, Thomas AZ, et al. Emphysematous cystitis: a review of 135 cases. BJU Int 2007; 100:17.
- Kumar A, Turney JH, Brownjohn AM, McMahon MJ. Unusual bacterial infections of the urinary tract in diabetic patients--rare but frequently lethal. Nephrol Dial Transplant 2001; 16:1062.
- Mokabberi R, Ravakhah K. Emphysematous urinary tract infections: diagnosis, treatment and survival (case review series). Am J Med Sci 2007; 333:111.
- Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int 2011; 107:1474.
- Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology 1996; 198:433.
- Chang SW, Yen DH, Fung CP, et al. Klebsiella pneumoniae renal abscess. Zhonghua Yi Xue Za Zhi (Taipei) 2000; 63:721.
- Johnson JR, Ireton RC, Lipsky BA. Emphysematous pyelonephritis caused by Candida albicans. J Urol 1986; 136:80.
- Hildebrand TS, Nibbe L, Frei U, Schindler R. Bilateral emphysematous pyelonephritis caused by Candida infection. Am J Kidney Dis 1999; 33:E10.
- Yao J, Gutierrez OM, Reiser J. Emphysematous pyelonephritis. Kidney Int 2007; 71:462.
- Ahlering TE, Boyd SD, Hamilton CL, et al. Emphysematous pyelonephritis: a 5-year experience with 13 patients. J Urol 1985; 134:1086.
- Park BS, Lee SJ, Kim YW, et al. Outcome of nephrectomy and kidney-preserving procedures for the treatment of emphysematous pyelonephritis. Scand J Urol Nephrol 2006; 40:332.
- Roy C, Pfleger DD, Tuchmann CM, et al. Emphysematous pyelitis: findings in five patients. Radiology 2001; 218:647.
- Mydlo JH, Maybee GJ, Ali-Khan MM. Percutaneous drainage and/or nephrectomy in the treatment of emphysematous pyelonephritis. Urol Int 2003; 70:147.
- Somani BK, Nabi G, Thorpe P, et al. Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review. J Urol 2008; 179:1844.
- Falagas ME, Alexiou VG, Giannopoulou KP, Siempos II. Risk factors for mortality in patients with emphysematous pyelonephritis: a meta-analysis. J Urol 2007; 178:880.
- Kapoor R, Muruganandham K, Gulia AK, et al. Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis. BJU Int 2010; 105:986.
- Lu YC, Chiang BJ, Pong YH, et al. Predictors of failure of conservative treatment among patients with emphysematous pyelonephritis. BMC Infect Dis 2014; 14:418.
- Aswathaman K, Gopalakrishnan G, Gnanaraj L, et al. Emphysematous pyelonephritis: outcome of conservative management. Urology 2008; 71:1007.
- RISK FACTORS
- EMPHYSEMATOUS PYELONEPHRITIS AND PYELITIS
- Clinical features
- Differential Diagnosis
- - Prognostic classification
- - Risk factors for adverse outcomes
- - Suggested approach
- EMPHYSEMATOUS CYSTITIS
- Clinical presentation
- Differential Diagnosis
- SUMMARY AND RECOMMENDATIONS