What is the cause of fever and recommended antibiotic regimen in a patient with gouty arthritis, post double-j (DJ) stenting for ureteric stones, presenting with low-grade fever, leukocytosis (elevated white blood cell count) and elevated procalcitonin (PCT) levels while on steroids?

Fever in a Patient with Gouty Arthritis Post DJ Stenting: Cause and Antibiotic Management

Cause of Fever

The fever in this patient is most likely due to urinary tract infection associated with the double-J stent, which requires prompt antibiotic treatment targeting common uropathogens. 1, 2

The combination of:

• Low-grade fever
• Leukocytosis (WBC 16,500)
• Elevated procalcitonin (PCT 1.7)

Strongly suggests an infectious process, specifically a urinary tract infection related to the DJ stent.

Risk Factors in This Patient:

• Recent urological procedure (DJ stent placement)
• Ureteric stones (underlying condition)
• Steroid therapy (immunosuppression)

Antibiotic Management

First-Line Antibiotic Therapy:

• Empiric treatment with a fluoroquinolone (ciprofloxacin) or a third-generation cephalosporin (ceftriaxone) should be initiated immediately. 1, 2

For Severe Infection/Sepsis:

• Intravenous antibiotics with broader coverage:
  • Piperacillin-tazobactam OR
  • Carbapenem (meropenem/imipenem) + vancomycin if MRSA is suspected

Duration:

• 7-14 days depending on clinical response
• Consider longer duration due to presence of foreign body (DJ stent)

Diagnostic Steps

1. Urine Culture: Obtain urine culture before starting antibiotics if possible, but don't delay treatment 1
2. Blood Cultures: Recommended due to elevated PCT and risk of urosepsis
3. Imaging: Consider ultrasound or CT to assess for hydronephrosis or perinephric collections

Management Algorithm

1. Assess Severity:

   • If hemodynamically stable: Oral or IV antibiotics
   • If unstable or signs of sepsis: IV antibiotics + fluid resuscitation + ICU consideration

2. Consider Stent Management:

   • If severe infection: Replace the DJ stent after starting antibiotics 1
   • If mild-moderate infection: Complete antibiotic course first, then reassess stent

3. Adjust Antibiotics:

   • Narrow spectrum once culture results are available
   • Consider local antibiogram for empiric therapy

Important Considerations

Microbiology

The most common pathogens in DJ stent-associated infections are 2, 3:

• Escherichia coli
• Enterococcus species
• Pseudomonas aeruginosa
• Staphylococcus species
• Candida species (especially with prolonged stenting)

Risk Factors for Stent-Associated Infection

• Female gender (higher colonization rates of 64.3% vs 34.7% in males) 3
• Duration of stent placement (>6 weeks significantly increases risk) 4
• Comorbidities (diabetes, chronic renal failure) 3
• Immunosuppression (steroids in this case)

Pitfalls to Avoid

1. Don't delay antibiotics while waiting for cultures in a patient with elevated PCT and leukocytosis
2. Don't assume sterile urine means no stent colonization - up to 60% of patients with positive stent cultures may have sterile urine 2
3. Don't continue steroids without addressing the infection first
4. Don't forget to reassess stent necessity - remove as soon as clinically appropriate 1

Steroid Considerations

• The patient's steroid therapy for gout may be masking some inflammatory symptoms
• Consider temporarily adjusting steroid dosage but don't abruptly discontinue
• Monitor closely for adrenal insufficiency during infection

The combination of fever, leukocytosis, and elevated PCT in a patient with a DJ stent strongly points to a urinary tract infection as the cause, requiring prompt antibiotic therapy targeting common uropathogens while considering the patient's steroid therapy.