What is the management of a 69-year-old patient on Rinvoq (upadacitinib) who developed fever and chills 72 hours after a urology procedure to remove stones with a catheter left in place?

Management of Catheter-Associated Urinary Tract Infection in a Patient on Rinvoq

The patient with fever and chills 72 hours after urological stone removal with indwelling catheter should have the catheter removed immediately, blood and urine cultures obtained, and empiric broad-spectrum antibiotics started with vancomycin plus a third-generation cephalosporin or carbapenem. 1

Clinical Assessment and Diagnosis

This 69-year-old patient on Rinvoq (upadacitinib) who developed fever and chills 72 hours after a urological procedure with an indwelling catheter is presenting with classic signs of catheter-associated urinary tract infection (CA-UTI) that has likely progressed to urosepsis. Key considerations include:

• Immunosuppression from Rinvoq (JAK inhibitor) increases infection risk 2
• Indwelling catheter is a major risk factor for UTI (3-8% risk per day) 1
• Fever and chills 72 hours post-procedure strongly suggest infectious etiology

Immediate Management Steps

1. Remove the urinary catheter - This is essential as the catheter is the source of infection 1

2. Obtain cultures before starting antibiotics:

   • Blood cultures (at least 2 sets)
   • Urine culture from the catheter before removal
   • If purulent drainage is present at insertion site, culture it as well 1

3. Start empiric broad-spectrum antibiotic therapy immediately:

   • First-line combination: Vancomycin PLUS one of the following: 1

     • Third-generation cephalosporin (e.g., ceftazidime)
     • Carbapenem (e.g., meropenem)
     • β-lactam/β-lactamase inhibitor combination

   • This regimen covers both gram-positive organisms (including MRSA) and gram-negative pathogens commonly associated with CA-UTI 1

4. Temporarily discontinue Rinvoq - The FDA label specifically states: "If a patient develops a serious infection, including serious opportunistic infection, interrupt RINVOQ treatment until the infection is controlled" 2

5. Assess for signs of severe sepsis or septic shock:

   • Monitor vital signs, respiratory rate, mental status, and blood pressure
   • If qSOFA score ≥2 (respiratory rate ≥22, altered mental status, or systolic BP ≤100 mmHg), manage as severe sepsis 1

Further Management

• Imaging: Consider renal ultrasound or CT to rule out obstruction, abscess, or residual stones if fever persists after 48-72 hours of appropriate therapy 1

• Antibiotic adjustment: Tailor antibiotics based on culture results and clinical response within 48-72 hours 1

• Duration of therapy:

  • 7-14 days for uncomplicated CA-UTI 1
  • Extended therapy (4-6 weeks) if there is persistent bacteremia >72 hours after catheter removal, or if endocarditis or suppurative thrombophlebitis develops 1

Special Considerations with Rinvoq

• Rinvoq increases risk of serious infections including opportunistic infections 2
• Monitor closely for clinical improvement before considering restarting Rinvoq
• Resume Rinvoq only after the infection is fully controlled 2

Monitoring and Follow-up

• Daily assessment of clinical response (temperature, white blood cell count, symptoms)
• If no improvement within 72 hours, consider:
  • Resistant organisms
  • Inadequate source control
  • Complications (abscess, obstruction)
  • Alternative diagnoses

Common Pitfalls to Avoid

1. Delaying catheter removal - The catheter is the source of infection and should be removed promptly 1

2. Inadequate empiric coverage - Given the patient's immunosuppression with Rinvoq, broad-spectrum coverage is essential 1, 2

3. Continuing Rinvoq during active infection - JAK inhibitors should be interrupted during serious infections 2

4. Insufficient treatment duration - Immunocompromised patients may require longer courses of antibiotics 1

5. Missing complications - Failure to investigate persistent fever may miss complications requiring additional interventions