How would you treat a patient with a complicated urinary tract infection (UTI) after extracorporeal shock wave lithotripsy (ESWL)?

Treatment of Complicated UTI After ESWL

For a patient with a complicated UTI after extracorporeal shock wave lithotripsy (ESWL), treatment should include immediate antibiotic therapy with levofloxacin 750 mg once daily for 5 days, along with establishing appropriate drainage if purulence is encountered during any endoscopic intervention.

Initial Management

When managing a complicated UTI after ESWL, the following approach is essential:

1. Immediate assessment of infection severity:

   • Evaluate for signs of systemic infection/sepsis (fever, tachycardia, hypotension)
   • Obtain urine culture before starting antibiotics
   • Consider blood cultures if patient appears septic

2. Establish appropriate drainage if needed:

   • If purulent urine is encountered during any endoscopic procedure, the American Urological Association strongly recommends aborting the procedure and establishing drainage 1
   • Place a ureteral stent or nephrostomy tube to ensure adequate drainage
   • Culture the purulent urine to guide targeted therapy

Antibiotic Therapy

First-line Treatment:

• Levofloxacin 750 mg orally once daily for 5 days is recommended for complicated UTIs 2
• This higher-dose, shorter-course regimen has demonstrated efficacy against common uropathogens including E. coli, Klebsiella pneumoniae, and Proteus mirabilis 2

Alternative Regimens:

• If fluoroquinolones are contraindicated:
  • Amoxicillin-clavulanate 500mg/125mg twice daily for 7-14 days 3
  • For patients with risk factors for resistant organisms: consider hospitalization for IV therapy with agents like ceftazidime-avibactam or meropenem-vaborbactam 3

Duration of Therapy:

• 5 days for levofloxacin 750 mg daily regimen 2
• 7-14 days for complicated UTIs with other antibiotic regimens 3

Special Considerations

Risk Factors for Treatment Failure:

• Female gender (higher risk of post-ESWL UTI) 4
• Larger stone size 4
• Higher number of delivered shocks during ESWL 4
• Presence of urinary tract abnormalities or obstruction 1

Monitoring and Follow-up:

• Assess clinical response within 48-72 hours of initiating therapy 3
• Adjust antibiotics based on culture and sensitivity results when available
• Consider imaging to evaluate for residual stones or obstruction if symptoms persist

Prevention of Future Episodes

While routine antibiotic prophylaxis is not universally recommended for all ESWL procedures 4, the AUA guidelines state that antibiotic prophylaxis should be administered prior to stone intervention based on:

• Prior urine culture results
• Local antibiogram
• Current Best Practice Policy Statement on Urologic Surgery Antibiotic Prophylaxis 1

Common Pitfalls to Avoid

1. Failing to establish drainage: In the presence of purulent urine or obstruction, drainage must be established before definitive stone management 1

2. Continuing with stone removal when infection is present: The AUA strongly recommends aborting stone removal procedures if purulent urine is encountered, establishing drainage, and continuing antibiotics until the infection is appropriately treated 1

3. Inadequate antibiotic coverage: Ensure coverage against both gram-positive and gram-negative uropathogens, particularly E. coli, Klebsiella, and Proteus species, which are common in post-ESWL infections 3, 2

4. Overlooking the need for repeat intervention: If initial ESWL fails, endoscopic therapy (URS or PCNL) should be offered as the next treatment option 1

By following this approach, you can effectively manage complicated UTIs after ESWL while minimizing the risk of progression to more severe infections or sepsis.