From the Guidelines
No, a patient with hydronephrosis caused by a urinary stone and flank pain who has a negative urinalysis for infection should not be empirically treated with antibiotics. According to the most recent guidelines from the European Association of Urology 1, antibiotics are only indicated when there is evidence of infection, such as positive nitrites, leukocyte esterase, or bacteria in the urinalysis, or if the patient has signs of systemic infection like fever or elevated white blood cell count. The European Urology guidelines also recommend managing any urological abnormality and/or underlying complicating factors, which in this case would involve addressing the hydronephrosis caused by the stone 1.
The appropriate management for uncomplicated urolithiasis with hydronephrosis includes:
- Pain control with NSAIDs like ketorolac (30mg IV or 10mg oral) or acetaminophen
- Adequate hydration
- Medical expulsive therapy with tamsulosin 0.4mg daily if the stone is <10mm and located in the distal ureter The patient should be monitored for signs of infection or worsening obstruction, which would require immediate medical attention. Antibiotics should be reserved for cases where there is clear evidence of infection or if the patient develops signs of infection during the course of treatment, as recommended by the European Association of Urology guidelines 1.
From the Research
Empirical Antibiotic Treatment for Hydronephrosis
- The decision to empirically treat a patient with hydronephrosis caused by a stone and flank pain, but a negative Urinalysis (UA) for infection, with antibiotics is complex and should be based on individual patient assessment 2, 3.
- According to the study on acute pyelonephritis, a positive urinalysis confirms the diagnosis in patients with a compatible history and physical examination, but it does not directly address the scenario of a negative UA with hydronephrosis caused by a stone 2.
- The study on the impact of time to antibiotic therapy on clinical outcome in patients with bacterial infections suggests that withholding antibiotic therapy until diagnostic results are available and a diagnosis has been established seems acceptable in most cases unless septic shock or bacterial meningitis are suspected 3.
- In the context of hydronephrosis, the absence of infection signs does not necessarily preclude the possibility of infection, especially if the patient has a stone causing obstruction, which can lead to infection 4, 5.
- However, there is no clear evidence to support empirical antibiotic treatment in this specific scenario, and the decision should be guided by clinical judgment and consideration of individual patient factors, such as the presence of symptoms suggestive of infection, the severity of hydronephrosis, and the patient's overall health status 3, 6.
- It is essential to note that the studies provided do not directly address the question of empirical antibiotic treatment for hydronephrosis caused by a stone with a negative UA, and more research is needed to provide definitive guidance on this topic.