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After completing this case study, the reader should be able to:

  • Differentiate the signs, symptoms, and laboratory findings associated with pyelonephritis from those seen in lower urinary tract infections.

  • Recommend appropriate empiric antimicrobial and symptomatic pharmacotherapy for a patient with suspected pyelonephritis.

  • Make appropriate adjustments in pharmacotherapy based on patient response and culture results, recognizing the prevalence of Escherichia coli and the risk of resistance.

  • Design a monitoring plan for a patient with pyelonephritis that allows objective assessment of the response to therapy.


Chief Complaint

“I am freezing and my back is killing me.”


Isabella Toms is a 22-year-old college student with type 1 diabetes, who presents to the ER complaining that she has had pain in her right flank region over the last 24 hours, as well as pain in her abdomen. She complains of some nausea and reports that she woke up this morning with severe stomach and back pain, but has not vomited. The patient states she has not eaten for 24 hours, but has been able to drink water and non–diet soda, and has continued to keep her insulin pump on, but has not given any additional regular insulin. The patient reports she recently started treatment for a urinary tract infection about 2 days ago with trimethoprim/sulfamethoxazole. She states that she has been feeling feverish and has the chills. She reports no substernal chest pain, shortness of breath, cough, or sputum production. She denies any diarrhea or rash.


Type 1 diabetes, diagnosed at age 11; has an insulin pump


Mother and father are in their 40s and healthy; one sister with asthma, and an older brother with Crohn disease


Nonsmoker, no IVDA, drinks alcohol socially. Single, but has a steady boyfriend and is sexually active. Currently is a first-year law student at the local university.


  • Ortho-Novum 7/7/7 one tablet daily

  • Insulin pump; regular insulin basal rate of 28 units per day

  • Regular insulin 2 units with breakfast, lunch, and supper

  • Trimethoprim/sulfamethoxazole one double strength tablet twice daily for 3 days (she has completed 2 days of therapy)


Penicillin (develops an itchy rash)


She has a history of UTIs and has had two UTIs in the past year, the most recent 2 days ago

Physical Examination


Conscious, alert, and oriented ...

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