Which feature more strongly suggests acute pyelonephritis rather than acute cystitis?

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The key idea is distinguishing upper urinary tract infection from a bladder infection by looking at systemic signs and where the pain is felt. Fever with flank pain points to kidney involvement (acute pyelonephritis) because it reflects inflammation of the renal parenchyma and pelvis along with a systemic response. In acute cystitis, the problem is confined to the bladder and symptoms are local to lower urinary tract comfort—dysuria, frequency, urgency, and often suprapubic pain—without fever or flank pain. So fever with flank pain best signals pyelonephritis.

Dysuria, frequency, and urgency without fever align with cystitis. Suprapubic pain without systemic symptoms also suggests bladder irritation rather than kidney infection. Cloudy urine with no other symptoms is nonspecific and doesn’t point clearly to kidney involvement.