Pyelonephritis in older adult — RACGP Fellowship MCQ

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HardGeriatricsPyelonephritis in older adultRACGP Fellowship

An 83-year-old woman in residential aged care presents with dysuria, fever and flank pain. Temperature is 38.6°C, BP is 102/62 mmHg, pulse is 112/min and eGFR is 34 mL/min/1.73 m². She is allergic to trimethoprim-sulfamethoxazole. What is the most appropriate management?

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Correct answer: C — Arrange hospital assessment for suspected pyelonephritis or urosepsis

This patient presents with acute pyelonephritis (fever, dysuria, flank pain) with systemic inflammatory signs (fever 38.6°C, tachycardia 112, hypotension 102/62) and significant renal impairment (eGFR 34). Hospital assessment is mandatory to: (1) confirm pyelonephritis and rule out urosepsis; (2) initiate IV antibiotics (nitrofurantoin is oral, ineffective for pyelonephritis, and poorly tolerated at eGFR <60); (3) assess need for imaging (ultrasound to exclude obstruction); (4) monitor for acute kidney injury or septic shock. Option D fails because nitrofurantoin is contraindicated in eGFR <60 and is not appropriate for pyelonephritis. Option B delays essential empiric antibiotic therapy in a septic patient. Option A misclassifies symptomatic infection as asymptomatic bacteriuria. Option E lacks evidence and delays treatment. Option C is correct: RACGP guidance and Therapeutic Guidelines recommend hospital-level assessment for suspected pyelonephritis with systemic signs, especially in frail older adults with comorbidities.

Reference: Therapeutic Guidelines (eTG) – Antibiotic: Acute pyelonephritis in adults, 2024; RACGP – UTIs in residential aged care facilities, AJGP 2024. https://www1.racgp.org.au/getattachment/d140bdeb-d0ae-475b-a2ff-27c7f9584064/UTIs-in-residential-aged-care-facilities.aspx