From the Guidelines
The patient should be switched to a different antibiotic, such as a fluoroquinolone, due to persistent symptoms and sensitivity to cefdinir.
Next Course of Action
- The patient's symptoms, including fever and pain, 10 days after lithotripsy for a 5mm kidney stone, suggest a possible urinary tract infection (UTI) or pyelonephritis that has not been adequately treated with cefdinir.
- According to the European Association of Urology guidelines 1, fluoroquinolones and cephalosporins are recommended for oral empiric treatment of uncomplicated pyelonephritis.
- Given the patient's sensitivity to cefdinir, a fluoroquinolone such as ciprofloxacin or levofloxacin could be considered as an alternative treatment option.
- The choice of antibiotic should be based on local resistance patterns and the patient's specific clinical presentation.
- It is also important to consider the possibility of a complicating factor, such as a urinary tract obstruction or renal stone disease, and to perform additional investigations, such as a contrast-enhanced computed tomography scan, if the patient remains febrile after 72 hours of treatment.
- The Infectious Diseases Society of America and European Society for Microbiology and Infectious Diseases guidelines 1 also recommend fluoroquinolones as a first-line treatment option for acute pyelonephritis.
- The World Health Organization's Essential Medicines and Aware recommendations 1 suggest that ciprofloxacin can be used as a first-choice option for empiric treatment of mild-to-moderate pyelonephritis, if local/national data on antimicrobial resistance patterns allow its use.
- The International Clinical Practice Guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women 1 recommend that women with pyelonephritis requiring hospitalization should be initially treated with an intravenous antimicrobial regimen, such as a fluoroquinolone, and that the choice of antibiotic should be based on local resistance data and tailored on the basis of susceptibility results.
From the Research
Patient Situation
The patient has persistent fevers and pain 10 days after lithotripsy for a 5mm kidney stone and is sensitive to cefdinir for a urinary tract infection (UTI).
Relevant Studies
- A study from 2018 2 found that febrile UTI after ureteroscopic lithotripsy occurred in 14.1% of patients, and the operation time was an independent predictive factor for this complication.
- A 2021 study 3 identified risk factors for urinary infection after retrograde upper urinary lithotripsy, including female gender, age >50 years, diabetes, stone diameter ≥2cm, duration of urinary tube insertion ≥3 days, and duration of surgery ≥90 minutes.
- Research from 2020 4 showed that diabetic patients are at a higher risk of developing postoperative UTI after ureteroscopic lithotripsy, with UTI history and HbA1c level being independent risk factors.
- A 2010 study 5 found that risk factors for fever after shockwave lithotripsy include positive urine culture, indwelling nephrostomy tube or stent, lithotripsy of kidney or upper ureteral stones, and preoperative symptomatic UTI or sepsis.
- A 2013 study 6 found that targeted antibiotic prophylaxis can effectively prevent urinary tract infections after shock wave lithotripsy, with a low incidence of UTI and asymptomatic bacteriuria.
Possible Next Steps
- Consider alternative antibiotic treatments, as the patient is sensitive to cefdinir 2, 3.
- Monitor the patient's condition closely, as the risk of febrile UTI is higher in certain patient populations, such as diabetics 4.
- Evaluate the patient's risk factors for urinary infection, including stone size, duration of urinary tube insertion, and duration of surgery 3.
- Consider the use of targeted antibiotic prophylaxis to prevent further complications 6.