Management of Antibiotics in a Patient with Sepsis due to UTI and Negative Cultures
Antibiotics should be discontinued in this patient with a history of MDRO who presented with sepsis due to UTI, has shown clinical improvement, and has negative cultures while on antibiotics.
Rationale for Discontinuing Antibiotics
Assessment of Current Status
- Patient has clinically improved from sepsis due to UTI
- Cultures obtained while on antibiotics are negative
- Patient has a ureteral stent in place
- Patient has history of multidrug-resistant organisms (MDRO)
Evidence-Based Decision Making
The Surviving Sepsis Campaign guidelines recommend that "antimicrobial therapy is narrowed once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted" 1. In this case, the patient has shown clinical improvement and cultures are negative, supporting antibiotic discontinuation.
The World Society of Emergency Surgery (WSES) guidelines similarly state that "empirical antimicrobial therapy should be reassessed daily for potential de-escalation" to prevent development of resistance, reduce toxicity, and reduce costs 1.
Decision Algorithm for Antibiotic Discontinuation
Assess clinical improvement
- Patient shows resolution of sepsis symptoms
- Vital signs have normalized
- Laboratory markers of infection have improved
Evaluate culture results
- Negative cultures while on antibiotics
- No identified pathogen requiring continued treatment
Consider source control status
- Ureteral stent is in place, providing adequate drainage
- Source control has been achieved
Make antibiotic decision
- Discontinue antibiotics if clinical improvement + negative cultures + adequate source control
- Continue targeted therapy only if specific pathogen identified requiring treatment
Important Considerations
Source Control
Source control through the placement of a ureteral stent is critical in preventing sepsis development in complicated UTIs 2. With the stent in place and clinical improvement achieved, the primary intervention for infection management has been accomplished.
Antimicrobial Stewardship
Continuing antibiotics without evidence of ongoing infection contributes to antimicrobial resistance. The WSES guidelines emphasize that "previous antimicrobial therapy is one of the most important risk factors for resistant pathogens" 1. Given the patient's history of MDRO, limiting unnecessary antibiotic exposure is particularly important.
Risk of Prolonged Therapy
Prolonged antibiotic therapy in culture-negative sepsis has not been shown to improve outcomes. Recent research suggests that shorter courses of antibiotics for culture-negative sepsis are not associated with worse outcomes and may result in shorter hospital stays 3.
Special Considerations for MDRO History
While the patient has a history of MDRO, continuing antibiotics without an identified pathogen may:
- Increase risk of selecting for additional resistant organisms
- Lead to adverse drug effects
- Disrupt normal microbiome
Monitoring After Discontinuation
After discontinuing antibiotics:
- Monitor closely for 24-48 hours for any signs of clinical deterioration
- Be prepared to restart antibiotics if symptoms recur
- Ensure proper function of the ureteral stent
Conclusion
Based on current guidelines and the patient's clinical improvement with negative cultures, discontinuing antibiotics is the appropriate management strategy. This approach aligns with antimicrobial stewardship principles while ensuring adequate treatment of the initial septic episode has been achieved.