What should I do next for a patient with fever after ureteral stent (stent) placement?

Management of Fever After Ureteral Stent Placement

Initial Assessment and Management

For a patient with fever after recent ureteral stent placement, the most appropriate next step is to obtain blood cultures and urine cultures, replace the urinary catheter if present, and initiate empiric antibiotic therapy targeting common uropathogens while awaiting culture results. 1, 2

Immediate Evaluation

• Assess vital signs (temperature, heart rate, blood pressure, respiratory rate)
• Examine the surgical site for signs of infection
• Evaluate for signs of sepsis or systemic inflammatory response syndrome
• Check for flank pain, which may indicate stent-related complications or obstruction

Diagnostic Workup

1. Blood cultures: Obtain at least two sets (60 mL total) from different sites 1
2. Urine studies:
   • Replace urinary catheter if present before obtaining urine specimen 1
   • Urinalysis and urine culture from newly placed catheter 1
   • Look for pyuria, bacteriuria, and leukocyte esterase/nitrites

Understanding the Risk

Fever following ureteral stent placement is a common complication, occurring in up to 25% of patients who undergo urgent stent placement 3. Risk factors include:

• Urgent (versus elective) stent insertion 3
• Positive pre-procedure urine culture 4, 5
• Female gender 5
• History of recent urinary tract infection 5
• Presence of indwelling nephrostomy tube during procedure 4
• Higher Charlson comorbidity index 5

Treatment Approach

Antimicrobial Therapy

• Initiate empiric antibiotics effective against common uropathogens based on local sensitivity patterns
• Consider coverage for both gram-negative and gram-positive organisms
• Adjust therapy based on culture results and clinical response

Monitoring and Follow-up

• Monitor vital signs frequently to assess for worsening infection or development of sepsis
• Follow clinical response to antibiotics (temperature trends, white blood cell count)
• Consider imaging if fever persists despite appropriate antibiotics

When to Consider Stent Removal or Exchange

Consider stent removal or exchange if:

• Persistent fever despite appropriate antibiotic therapy
• Signs of septic shock
• Evidence of stent obstruction or migration on imaging
• Positive blood cultures with the same organism as urine culture 1

Special Considerations

Timing of Fever

• Fever appearing within 48 hours of stent placement may represent inflammatory response to the procedure 2
• Fever after 48-96 hours is more likely to represent infection requiring antibiotic treatment 2
• After 96 hours, infectious etiology is highly probable and requires complete evaluation 2

Potential Complications to Monitor

• Stent obstruction (occurs in up to 34% of cases) 6
• Stent migration (9.5%) 7
• Stent encrustation (21.6%) 7
• Urosepsis (occurs in approximately 20% of patients with febrile UTI) 5

Prevention Strategies for Future Stent Placements

• Appropriate pre-procedure antibiotic prophylaxis
• Shorter stent dwell time when possible
• Consider selective prophylactic treatment in high-risk patients 4
• Ensure sterile technique during stent placement

Common Pitfalls to Avoid

1. Delaying antibiotic therapy in patients with signs of infection after stent placement
2. Attributing fever to atelectasis without excluding infectious causes
3. Failing to replace urinary catheter before obtaining urine culture
4. Inadequate blood cultures (obtain at least two sets)
5. Overlooking stent complications such as migration or obstruction as potential causes of persistent fever

Remember that ureteral stent-associated UTIs can lead to serious complications including sepsis in approximately 20% of cases 5, making prompt evaluation and treatment essential.