How to manage a post-ureteroscopy patient on Rinvoq (upadacitinib) with signs of infection?

Management of Post-Ureteroscopy Infection in a Patient on Rinvoq

For a 69-year-old female with rheumatoid arthritis on Rinvoq who develops fever, chills, elevated WBC on day 3 after ureteroscopy with laser lithotripsy and stent placement, immediate empirical broad-spectrum antibiotic therapy targeting Enterobacteriaceae and Enterococci should be initiated, along with urine and blood cultures to guide subsequent treatment. 1

Initial Management

1. Obtain cultures immediately:

   • Collect urine culture (before starting antibiotics if possible)
   • Obtain two sets of blood cultures
   • Consider stent culture if stent removal is indicated

2. Initiate empiric antibiotic therapy:

   • First-line options 1:

     • Combination of amoxicillin plus an aminoglycoside
     • Second-generation cephalosporin plus an aminoglycoside
     • Intravenous third-generation cephalosporin

   • Avoid fluoroquinolones if local resistance rates are >10% or if the patient has used fluoroquinolones in the last 6 months 1

3. Source control:

   • Consider stent removal or exchange if it's the suspected source of infection
   • Evaluate for any urinary tract obstruction that may require drainage 1

Special Considerations for Rinvoq (Upadacitinib)

Rinvoq is a JAK1 inhibitor that increases infection risk:

• Clinical trials show higher rates of infections in patients on upadacitinib compared to placebo:

  • 29-32% of patients on upadacitinib experienced infections vs. 21% on placebo 2
  • Urinary tract infections specifically occurred in 9% of patients on 15mg dose 3

• Temporary discontinuation of Rinvoq should be considered during the acute infection period, especially with systemic symptoms, as it may impair immune response to infection

Antibiotic Duration and Follow-up

• Short-course therapy (3-5 days) is recommended if adequate source control is achieved 1
• Early re-evaluation based on clinical course and laboratory parameters is essential 1
• Adjust antibiotics based on culture results and clinical response 1

Monitoring and Additional Management

• Monitor vital signs, WBC count, and inflammatory markers (CRP, procalcitonin)
• Assess for signs of sepsis using qSOFA criteria (respiratory rate ≥22/min, altered mental status, systolic BP ≤100 mmHg) 1
• Consider imaging (ultrasound or CT) if there's concern for abscess formation or persistent obstruction

Common Pitfalls to Avoid

1. Delayed initiation of antibiotics - This can lead to progression to urosepsis with increased morbidity and mortality

2. Failure to obtain cultures before antibiotics - This reduces the chance of identifying the causative organism

3. Inadequate source control - Persistent obstruction or infected stent material can lead to treatment failure

4. Not considering immunosuppression - Rinvoq increases infection risk and may mask typical inflammatory responses

5. Prolonged antibiotic therapy - Extending antibiotics beyond 5 days without clear indication increases risk of resistance and adverse effects 1

Follow-up Plan

• Daily assessment of clinical response during acute phase
• Repeat urine culture after completion of antibiotics to ensure clearance
• Consider urological follow-up to assess stent function and plan for eventual removal
• Discuss with rheumatologist regarding optimal timing for Rinvoq resumption

This patient's presentation with fever, chills, and elevated WBC count on day 3 post-ureteroscopy strongly suggests a urinary tract infection related to the procedure, which requires prompt and aggressive management to prevent progression to more severe infection, especially given the patient's immunocompromised state due to Rinvoq therapy.