Do you need to replace a nephrostomy (percutaneous catheter used to divert urine away from the kidneys) tube if it's associated with an infection?

Management of Infected Nephrostomy Tubes

Yes, nephrostomy tubes should be replaced when associated with an infection to reduce morbidity and mortality and improve outcomes. 1

Rationale for Nephrostomy Tube Exchange

Nephrostomy tubes can become readily colonized and infected by urinary tract pathogens, with infection rates reported between 1-19% 1. These infections typically occur early, with a median time from placement to infection of 44 days, and are often polymicrobial, involving organisms such as Pseudomonas, Escherichia, Stenotrophomonas, Klebsiella, and Enterococcus species 1.

Evidence-Based Approach to Management

Timing of Nephrostomy Tube Exchange

• Early exchange is critical: Exchanging the nephrostomy catheter within 4 days of infection diagnosis significantly reduces the risk of recurrent infection (OR 0.1; p=0.048) 2
• This should be done once antimicrobial susceptibility results are available and the patient is receiving appropriate antibiotics 2

Antimicrobial Therapy

• Concordant antibiotic therapy (active against all identified organisms) is independently associated with decreased recurrent infections (OR 0.04; p=0.008) 2
• For fungal infections:
  • Irrigation through nephrostomy tubes with amphotericin B deoxycholate (25-50 mg in 200-500 mL sterile water) is strongly recommended 1
  • Systemic antifungal therapy should be administered concurrently 1

Special Considerations

For Fungal Infections

Percutaneous nephrostomy management of fungal infections allows for:

• Prompt microbiologic diagnosis
• Urinary diversion with improvement in renal function
• Local irrigation with antifungal agents
• Guidewire fragmentation of fungus balls if present 3

Prevention Strategies

To minimize infection risk:

• Periodically reassess the need for the nephrostomy tube 1
• Maintain a clean exit site with antiseptic use
• Regular dressing exchange
• Place urinary drainage collection bag below the insertion site
• Avoid concomitant use of Foley catheters when possible 1
• Consider chlorhexidine-impregnated dressings with weekly exchange for patients with frequent exit site infections 1

Common Pitfalls to Avoid

1. Delayed exchange: Waiting too long to exchange an infected nephrostomy tube increases the risk of recurrent infection and sepsis 2

2. Inappropriate antibiotic selection: Using antibiotics that don't cover all identified organisms significantly increases recurrence risk 2

3. Surveillance cultures without symptoms: Discourage surveillance urinary cultures and treatment of asymptomatic patients to avoid development of multidrug-resistant organisms 1

4. Ignoring risk factors: Patients with prior urinary tract infections and neutropenia are at significantly higher risk for nephrostomy tube-related pyelonephritis (p=0.047 and p=0.03, respectively) and may need more aggressive management 4

By promptly exchanging infected nephrostomy tubes and providing appropriate antimicrobial therapy, the high rate of recurrent infections can be significantly reduced, along with associated costs and potential delays in further treatment for underlying conditions 2.