What is the management plan for a patient with left pyelonephritis and a possible 10mm ureteric stone causing mild pelvic fullness and upper ureter dilation?

From the Guidelines

The management plan for a patient with left pyelonephritis and a possible 10mm ureteric stone causing mild pelvic fullness and upper ureter dilation requires prompt intervention with antibiotics and pain management, followed by stone treatment. Initially, empiric broad-spectrum antibiotics such as ceftriaxone 1-2g IV daily or piperacillin-tazobactam 3.375g IV every 6 hours should be started immediately after obtaining blood and urine cultures, as recommended by the European Association of Urology guidelines on urological infections 1. Once culture results return, therapy should be tailored to the specific pathogen for a total of 10-14 days. Pain control with NSAIDs like ketorolac 30mg IV or ibuprofen 600mg orally every 6 hours is recommended, supplemented with opioids if needed. Adequate hydration should be maintained with IV fluids initially, transitioning to oral intake of 2-3 liters daily. For the 10mm stone, which is unlikely to pass spontaneously, urological intervention is necessary after the infection is controlled. Options include extracorporeal shock wave lithotripsy (ESWL), ureteroscopy with laser lithotripsy, or percutaneous nephrolithotomy, with the specific approach determined by stone characteristics and patient factors, as outlined in the American Urological Association/Endourological Society guideline on surgical management of stones 1. A ureteral stent may be placed temporarily to relieve obstruction. Close monitoring of vital signs, urine output, renal function, and infection markers is essential, with follow-up imaging (typically CT scan) after resolution of the acute infection to assess stone status and any residual hydronephrosis. The choice between ESWL and URS should be based on local resistance patterns and optimized, with URS being associated with significantly higher stone-free rates in a single procedure compared to SWL, as noted in the 2007 guideline for the management of ureteral calculi 1. However, the most recent and highest quality study, the European Association of Urology guidelines on urological infections 1, should guide the management plan, prioritizing the patient's morbidity, mortality, and quality of life. Key considerations include:

• Prompt differentiation between uncomplicated and potentially obstructive pyelonephritis to prevent progression to urosepsis
• Use of fluoroquinolones and cephalosporins as the only recommended antimicrobial agents for oral empiric treatment of uncomplicated pyelonephritis
• Evaluation of the upper urinary tract via ultrasound to rule out urinary tract obstruction or renal stone disease
• Consideration of additional investigations, such as a contrast-enhanced computed tomography scan, if the patient remains febrile after 72 hours of treatment or if there is a deterioration in clinical status. Given the potential for ureteral stone disease, the American Urological Association/Endourological Society guideline on surgical management of stones 1 recommends that patients be informed about the existing active treatment modalities, including the relative benefits and risks associated with each modality, and that both SWL and URS be discussed as initial treatment options for the majority of cases. Ultimately, the management plan should prioritize the patient's morbidity, mortality, and quality of life, with a focus on prompt and effective treatment of the infection and the ureteric stone.

From the FDA Drug Label

Dosing and initial route of therapy (i.e., I.V. or oral) for complicated urinary tract infection or pyelonephritis should be determined by the severity of the infection. Complicated Urinary Tract or Pyelonephritis Intravenous 6 to 10 mg/kg(maximum 400 mgper dose; not to be exceeded even in patients weighing > 51 kg) Every 8 hours 10-21 days* (patients from 1 to 17 years of age) Oral 10 mg/kg to 20 mg/kg (maximum 750 mg per dose; not to be exceeded even in patients weighing > 51 kg) Every 12 hours

The management plan for a patient with left pyelonephritis and a possible 10mm ureteric stone causing mild pelvic fullness and upper ureter dilation may involve the use of ciprofloxacin.

• The dosing of ciprofloxacin for complicated urinary tract infection or pyelonephritis should be determined by the severity of the infection.
• The initial route of therapy (I.V. or oral) should also be determined by the severity of the infection.
• For patients with complicated urinary tract infection or pyelonephritis, the recommended oral dose is 10 mg/kg to 20 mg/kg (maximum 750 mg per dose) every 12 hours 2.

From the Research

Management Plan for Left Pyelonephritis and Possible Ureteric Stone

• The patient's condition involves left pyelonephritis and a possible 10mm ureteric stone causing mild pelvic fullness and upper ureter dilation, as indicated by the CT KUB results.
• The management plan should include antibiotic therapy to treat the pyelonephritis, as well as further evaluation and possible treatment for the ureteric stone.

Antibiotic Therapy

• According to 3, acute pyelonephritis is typically treated with antibiotics, and the choice of antibiotic should be guided by the results of urine culture and susceptibility testing.
• 4 suggests that a 10- to 20-day course of antibiotic therapy is usually effective in treating pyelonephritis, and that the choice of antibiotic should depend on the severity of the infection and the presence of any underlying medical conditions.
• 5 recommends that empirical antibiotic therapy should be initiated promptly to prevent serious complications, and that oral fluoroquinolones such as ciprofloxacin or levofloxacin are effective in treating acute uncomplicated pyelonephritis.
• 6 found that a 7-day course of ciprofloxacin was non-inferior to a 14-day course in treating acute pyelonephritis in women.

Evaluation and Treatment of Ureteric Stone

• The presence of a ureteric stone should be further evaluated with imaging studies such as CT or ultrasound to determine the size and location of the stone.
• According to 7, patients with urinary tract abnormalities such as renal stone disease are at increased risk of developing urinary tract infections, and should be treated with antibiotics that are effective against the causative organism.
• The treatment of the ureteric stone will depend on its size and location, and may involve surgical intervention or other procedures to remove the stone.

Monitoring and Follow-up

• The patient should be closely monitored for signs of improvement or worsening of their condition, and should be followed up with repeat imaging studies and urine cultures to ensure that the infection is resolving and that the ureteric stone is being effectively treated.
• 3 recommends that patients with pyelonephritis should be followed up with urine cultures and imaging studies to ensure that the infection is resolving, and that any underlying urinary tract abnormalities are being effectively treated.