Treatment, outcomes, and management strategy for purulent pyelonephritis: a systematic review and meta-analysis. Part II
This article presents the second part of a systematic review and meta-analysis addressing the problem of purulent pyelonephritis.Pavlov V.N., Vorobev V.A., Ananyev V.A.
Objective. To summarize the available literature on treatment approaches for purulent pyelonephritis, its immediate and long-term outcomes, as well as the results of a meta-analysis on key therapeutic issues.
A total of 46 clinical studies (1981–2024) focused on the management of complicated pyelonephritis were analyzed. The review considered therapeutic modalities (conservative antibiotic therapy, drainage procedures, nephrectomy), intensive care for sepsis, and the incidence and predictors of adverse outcomes (mortality, renal loss, progression to chronic disease). Quantitative synthesis of mortality and surgical treatment rates was performed using a random-effects model.
All patients with purulent pyelonephritis received antibiotic therapy; the optimal strategy was the earliest possible initiation of a broad-spectrum bactericidal antibiotic, ideally within the first hours after hospitalization. Empirical regimens included third-generation cephalosporins (ceftriaxone) in hemodynamically stable patients, fluoroquinolones as an alternative, and β-lactam/β-lactamase inhibitor combinations or carbapenems when resistant pathogens were suspected. Delayed initiation of antibiotics (>24 hours) was associated with prolonged fever and an increased risk of sepsis. Approximately 30% of patients required intensive care (shock correction with fluids and vasopressors, mechanical ventilation in 5%). In cases of urinary tract obstruction, urgent decompression with nephrostomy or ureteral stenting was mandatory and led to improvement in >90% of cases. Large renal abscesses (>3–5 cm) were effectively managed with percutaneous drainage under US/CT guidance, avoiding open surgery in 80–90% of patients. Radical nephrectomy was required in 6% of patients with purulent pyelonephritis, including 25–40% of those with emphysematous pyelonephritis. Modern management approaches achieved relatively low overall mortality—5.8% (342/5912); however, in patients with septic shock, mortality reached 20–30%. Factors associated with death included septic shock, pre-existing chronic kidney disease, severe thrombocytopenia, and the need for dialysis. Renal preservation was achieved in 94% of patients; chronic kidney disease developed in 9% of survivors (often de novo after purulent pyelonephritis). Recurrence within 6 months was observed in 14% of patients, most frequently in the presence of unresolved predisposing factors (e.g., diabetes).
Conclusions. The combination of intensive antibiotic therapy and timely minimally invasive procedures (decompression of obstruction, abscess drainage) allows successful treatment of most patients with purulent pyelonephritis while preserving renal function. Nevertheless, mortality in complicated pyelonephritis remains approximately 5–10%, highlighting the need for further improvements in management strategies (development of prognostic scoring systems, optimization of therapy duration, and introduction of novel agents).
Keywords
pyelonephritis
complications
antibiotic therapy
drainage
nephrectomy
outcomes
meta-analysis
About the Authors
Corresponding author: V.A. Ananyev – Ph.D., MD, Bashkir State Medical University, Ministry of Health of the Russian Federation, Ufa, Russia; Regional Clinical Hospital (KGBUZ KKB), Barnaul, Russia; е-mail: urologkkb@mail.ruSimilar Articles
