More Than Just Air

Abstract Extended-spectrum beta-lactamase (ESBL) Escherichia coli emphysematous pyelonephritis with urosepsis is a rare yet severe urogenital infection primarily observed in health care settings. Those at elevated risk include the elderly and individuals with diabetes, prior antibiotic exposure, and anatomical abnormalities of the urogenital tract. In this case report, we present a 92-year-old male with chronic comorbidities and recent urologic surgery who was admitted to the intensive care unit (ICU) with septic shock secondary to ESBL E. coli emphysematous pyelonephritis. The infection was initially managed with meropenem and later transitioned to ertapenem to complete a 2-week course. Despite appropriate therapy, blood cultures remained positive for 8 days. Computed tomography (CT) imaging revealed emphysematous pyelitis and pyelonephritis with air in the renal parenchyma. The case highlights the diagnostic distinction and prognostic implications of emphysematous pyelitis versus pyelonephritis, both of which coexisted in this patient.