A Clinical Risk Case Study- Delay in Diagnosis of Acute Pyelonephritis

A Clinical Risk Case Study- Delay in Diagnosis of Acute Pyelonephritis

Setting the Scene

The patient attended an out of hours service with flu-like symptoms of backache and headache. The patient also had raised temperature, fast pulse and loin tenderness. The patient was referred to the local hospital with suspicion of pyelonephritis (Inflammation of the Kidney).

The patient also had increased urinary frequency, and urine tests showed blood, ketone and protein, but was negative for leucocyte or nitrite. Blood results revealed a high CRP and they diagnosed a viral infection, gastroenteritis and haematuria. Once the symptoms settled with analgesia, they were discharged home.

The patient reattended hospital and was diagnosed with pyelonephritis in addition to the possibility of a renal stone. An ultrasound showed slight obstruction in the left ureter but no stone. The patient was subsequently discharged with oral antibiotics and referred to the urology outpatient’s department for further treatment.

The main learning points from this review stem from the following events:

  • The clinician needed to be able to identify and diagnose pyelonephritis by understanding all the steps needed for a full assessment. This would include identifying if the patient is tachycardic and also excluding sepsis

  • When clinically indicated the clinicians did not start the patient on antibiotics

  • Ultrasound imaging was not used to rule out urinary tract obstruction or renal stone disease at the first presentation

  • The clinicians did not fully assess the patient and take into account all factors to prevent misdiagnosing pyelonephritis and instead diagnosing a viral infection, gastroenteritis and haematuria

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:

  • Consider all symptoms and signs in conjunction with one another in order to make correct diagnoses. Bacterial infection was most probable in this scenario and the treating clinician did not account for all the patient’s symptoms when confirming their diagnosis. This ultimately led to a delay in achieving the correct diagnosis and providing treatment thereafter.

  • Ensure patients with suspected infections and signs of systemic effect such as tachycardia have a comprehensive clinical assessment, and when appropriate, initiation of antibiotics at the earliest opportunity. This is crucial to preventing the worsening of infection and complications associated with more severe infection. In this case, there was no clinical reason to delay the start of antibiotics.

  • In patients with complicated UTIs, it is strongly advisable to undertake ultrasound imaging to rule out urinary tract obstruction or renal stone disease, as outlined in European Association of Urology guidelines1. The colicky nature of the patient’s loin pain in this case could have indicated a renal stone, which would need to be confirmed through use of ultrasound imaging.

  • Be aware of the presenting symptoms of acute pyelonephritis and investigate this if patients present with back pain, increased infection markers and haematuria. In this case, it was more likely for all the patient’s symptoms to be due to one single presenting condition than for them to have both a viral infection and gastroenteritis presenting with blood in the urine.

  • Provide a timely diagnosis of pyelonephritis to ensure prompt treatment. Diagnosis should be made using clinical symptoms and infection markers, along with ultrasound imaging if complicated UTI is suspected. A delay in diagnosis can lead to subsequent delay in treatment, which can have life-threatening consequences.

To Summarise

This is a case where a patient’s pyelonephritis was not correctly diagnosed, and they were not started on antibiotics until they reattended the hospital after further referral from their GP. The patient therefore suffered with their symptoms of pain, fever, urinary frequency for an extended period of time and was left open to potentially life-threatening consequences. Awareness of the symptoms of pyelonephritis should be provided to Clinicians to ensure full assessments are undertaken.

TMLEP would like to highlight the importance of diagnosing acute pyelonephritis in a timely manner and undertaking ultrasound imaging in cases of complicated UTI, to facilitate swift treatment to provide patients with the best chance of optimal outcome.

References

  • European Association of Urology guidelines - https://uroweb.org/guideline/urological-infections/
  • Shields J, Maxwell AP; Acute pyelonephritis can have serious complications; The Practitioner 2010; 254 (1728): 19-24
  • Keenan, Declan & O'Rourke, Declan & Courtney, Aisling; Pyelonephritis can lead to life-threatening complications; The Practitioner (2017); 261; 17-20.
  • Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group, Maximilian Macdonald, TMLEP Analyst and Dr Richard Hull, Consultant Nephrologist. (2020). A Clinical Risk Case Study- Delay in Diagnosis of Acute Pyelonephritis. TMLEP Clinical Risk Case Studies. 3 (6), 1.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0) 203 355 9796.