From the Guidelines
Suppressive antibiotics should be given if a staghorn calculus cannot be removed to prevent recurrent urinary tract infections and potential kidney damage. The management of patients with staghorn calculi is crucial, even after attempted removal, as these patients are at risk for stone recurrence and associated infections 1. When a staghorn calculus cannot be removed, the risk of infection persists, and suppressive antibiotics can help mitigate this risk.
The recommended approach typically involves long-term, low-dose antibiotics, and the choice of antibiotic should be guided by urine culture results and local resistance patterns. Regular urine cultures every 3-6 months are essential to monitor for breakthrough infections and changes in bacterial resistance patterns, which may necessitate adjusting the antibiotic regimen. Patients should also increase fluid intake to maintain dilute urine and consider taking urinary antiseptics if appropriate.
Staghorn calculi, often composed of struvite stones associated with urease-producing bacteria, serve as a persistent reservoir for infection 1. Without intervention, patients face significant risks, including recurrent urinary tract infections, pyelonephritis, urosepsis, and progressive kidney damage. While definitive surgical removal remains the gold standard treatment, suppressive antibiotics are a critical component of management when surgery is not possible due to patient comorbidities, surgical contraindications, or patient preference.
Key considerations in the management of staghorn calculi include:
- Long-term, low-dose antibiotic therapy to suppress infection
- Regular urine cultures to monitor for infection and resistance
- Increased fluid intake to maintain dilute urine
- Consideration of urinary antiseptics
- Close monitoring for signs of infection or kidney damage, as the primary goal is to prevent morbidity, mortality, and reduce the impact on quality of life.
From the Research
Management of Staghorn Calculi
- Staghorn calculi are complex renal stones that can lead to high morbidity and mortality if left untreated 2, 3, 4, 5
- The ideal treatment for staghorn calculi is maximal surgical removal, but some patients may be unwilling or unable to undergo surgery 3, 5
Role of Suppressive Antibiotics
- There is no direct evidence to support the use of suppressive antibiotics in patients with staghorn calculi that cannot be removed 2, 3, 4, 6, 5
- However, patients with staghorn calculi are at risk of developing urinary tract infections and urosepsis, and antibiotics may be necessary to manage these complications 2, 3, 4, 5
Alternative Management Options
- Metabolic evaluation and medical management may be recommended for patients with staghorn calculi, especially if the stones are metabolic in etiology 3
- Conservative management may be considered for high-risk patients who are unable to undergo surgery, but this approach is associated with a higher risk of complications and deterioration of renal function 5
- Extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotripsy (PCNL) are alternative treatment options for staghorn calculi, and the choice of treatment depends on the size and location of the stone, as well as the patient's overall health 6, 5