What is the best course of treatment for a 24-year-old woman with a urinary tract infection, severe right flank pain, fever, and a 5mm stone in the right ureter at the ureteropelvic (UPJ) junction with mild hydronephrosis?

Management of Urinary Tract Infection with Ureteral Stone

A urological consultation is urgently needed for this patient with pyelonephritis and an obstructing ureteral stone, as drainage of the collecting system is mandatory to prevent urosepsis and significant morbidity or mortality. 1

Clinical Assessment

This 24-year-old woman presents with:

• Acute onset severe right flank pain
• Fever (38.3°C)
• Dysuria
• Tachycardia (102 bpm)
• Tachypnea (22 respirations/min)
• Hypertension (160/x mmHg)
• Leukocytosis (14,000 WBC)
• Pyuria (100 WBCs in urinalysis)
• Hematuria (10 RBCs in urinalysis)
• 5mm stone at the right ureteropelvic junction with mild hydronephrosis

These findings are consistent with pyelonephritis complicated by an obstructing ureteral stone, which represents a urological emergency.

Management Algorithm

Step 1: Immediate Management

• Continue intravenous fluids and antibiotics (ceftriaxone already initiated)
• Urgent urological consultation for drainage of the collecting system 1
• The patient requires prompt drainage of the collecting system with a ureteral stent or percutaneous nephrostomy tube to prevent progression to urosepsis 1

Step 2: Antibiotic Therapy

• Complete a 7-14 day course of antibiotics based on culture results 2
• For complicated UTIs with systemic symptoms, the European Association of Urology recommends:
  • Amoxicillin plus an aminoglycoside, OR
  • A second-generation cephalosporin plus an aminoglycoside, OR
  • An intravenous third-generation cephalosporin 2
• Fluoroquinolones (like levofloxacin) should be used only if local resistance is <10% and the patient has not used fluoroquinolones in the last 6 months 2

Step 3: Definitive Stone Management

• Delay definitive stone treatment until the infection is controlled 1
• For a 5mm stone at the UPJ, options include:
  • Ureteroscopy with laser lithotripsy (URS)
  • Shock Wave Lithotripsy (SWL)
• URS is preferred due to higher single-procedure stone-free rates 1

Rationale for Urological Consultation

The combination of pyelonephritis and an obstructing ureteral stone creates a high-risk situation:

1. Obstruction prevents adequate antibiotic penetration to the infected collecting system 3
2. Bacteria trapped behind the obstruction can lead to rapid progression to urosepsis 4
3. Urgent decompression is necessary to allow drainage of infected urine and improve antibiotic efficacy 1, 4

Common Pitfalls to Avoid

1. Delaying drainage: Attempting to treat with antibiotics alone without addressing the obstruction can lead to sepsis and permanent renal damage 4
2. Premature definitive stone treatment: Performing definitive stone removal before controlling the infection increases risk of septic complications 1
3. Inadequate antibiotic coverage: Given the patient's presentation with systemic symptoms, broad-spectrum coverage is needed until culture results are available 2
4. Inadequate follow-up: This patient needs close urological follow-up after the acute episode to prevent recurrence 1

Follow-up Plan

1. Complete the full antibiotic course (7-14 days) 2
2. Definitive stone management once infection is controlled
3. Metabolic evaluation to identify risk factors for stone formation
4. Increase fluid intake to achieve urine volume of at least 2.5 liters daily 1

In conclusion, while antibiotics are essential for treating the infection, the presence of an obstructing stone necessitates urgent urological intervention for drainage of the collecting system. Therefore, option C (consult with urologist) is the most appropriate next step.