Case Study: Acute Pyelonephritis in a Third-Trimester Pregnancy Caused by Klebsiella variicola

Case at a Glance

A 30-year-old female at 34 weeks gestation presented with symptoms of a urinary tract infection (UTI) that rapidly progressed to acute pyelonephritis despite initial oral antibiotic therapy. The causative agent was identified as Klebsiella variicola, highlighting the challenges of managing complicated UTIs during pregnancy.

Patient's Story

The patient, a 30-year-old female in her 34th week of pregnancy, presented to her hospital's obstetric triage unit on a Friday. She was experiencing uterine contractions and severe back pain. She had a history of UTIs in the past but had never been diagnosed with this particular type of bacterial infection before. The clinical team initiated an evaluation to determine the cause of her symptoms.

Initial Assessment

Upon arrival, the patient was in noticeable distress due to back pain and contractions. A urine sample was collected, and a urinalysis revealed significant hematuria (blood in the urine). An ultrasound was performed to rule out nephrolithiasis (kidney stones) and assess fetal well-being. With no evidence of kidney stones, a presumptive diagnosis of a UTI was made. The patient was discharged with a prescription for a 7-day course of an empiric oral antibiotic, and her urine sample was sent for culture and sensitivity testing.

The Diagnostic Journey

Over the subsequent 48 hours, the patient's condition worsened at home. The day after discharge, she developed a low-grade fever. By the second day, her fever had spiked to 101°F (her baseline temperature is 97.7°F), and she began experiencing nausea, vomiting, and profound malaise. This clinical deterioration suggested that the infection had ascended from the bladder to the kidneys, resulting in acute pyelonephritis. Concurrently, the results from her urine culture became available, identifying the pathogen as Klebsiella variicola.

Final Diagnosis

Acute Pyelonephritis secondary to a Klebsiella variicola urinary tract infection in a patient at 34 weeks gestation.

Treatment Plan

Given the patient's failure to respond to oral antibiotics and the development of systemic symptoms (fever, vomiting), a change in management was required. The clinical suspicion was that the Klebsiella variicola strain was resistant to the initial empiric antibiotic. The patient was advised to return to the hospital for admission. The plan included:

1. Hospitalization: Admission for inpatient management and monitoring of both maternal and fetal status.
2. Intravenous (IV) Antibiotics: Discontinuation of the oral antibiotic and initiation of broad-spectrum IV antibiotics appropriate for use in pregnancy. The choice of antibiotic would be tailored once the full sensitivity profile from the urine culture was available.
3. Supportive Care: Administration of IV fluids for hydration, antipyretics to manage fever, and antiemetics to control nausea and vomiting.
4. Monitoring: Continuous fetal monitoring and regular assessment of maternal vital signs.

Outcome and Follow-up

The patient was admitted and commenced on IV antibiotic therapy. She showed significant clinical improvement within 48 hours, with resolution of fever and a decrease in symptoms. After completing a course of IV therapy, she was transitioned to an appropriate oral antibiotic based on the culture's sensitivity report to complete a 10-14 day total course. She was discharged home with instructions for close obstetric follow-up. A repeat urine culture was scheduled for 1-2 weeks post-treatment to ensure complete eradication of the infection and prevent recurrence.