What antibiotic is recommended for a patient with an injected ureteral stent?

Antibiotic Selection for Ureteral Stent Infection

For patients with infected ureteral stents, a single dose of intravenous third-generation cephalosporin (such as ceftriaxone) or ampicillin/sulbactam is recommended as the first-line antibiotic therapy. 1

First-Line Antibiotic Options

• A single dose of intravenous ceftriaxone is recommended as the primary antibiotic for infected ureteral stents, as it has been shown to decrease serious post-procedural sepsis-related complications from 50% to 9% in high-risk patients 1
• Ampicillin/sulbactam is an effective alternative first-line option that provides similar coverage against expected uropathogens 1
• For patients undergoing ureteral stent procedures, antimicrobial prophylaxis is strongly recommended according to the American Urological Association guidelines 1

Antibiotic Selection Based on Patient Risk Factors

High-Risk Patients

For patients considered at high risk for infection (immunocompromised, history of recurrent UTIs, uncontrolled diabetes, or history of infected renal stones):

• Ciprofloxacin or trimethoprim-sulfamethoxazole prophylaxis is recommended 1
• Intravenous antimicrobials should be administered for complex procedures requiring extensive instrumentation under general anesthesia 1
• Consider targeted prophylactic approach based on urine culture obtained a few days before scheduled stent exchange 1

Standard Risk Patients

• A single oral or IV dose of an antibiotic that covers both gram-positive and gram-negative uropathogens is recommended 1
• Oral ciprofloxacin has shown similar efficacy to intravenous cefazolin in preventing UTI and sepsis in patients undergoing endourologic procedures including ureteral stent placement 1

Common Pathogens to Consider

• The most common pathogens in ureteral stent infections include Pseudomonas, Escherichia coli, Stenotrophomonas, Klebsiella, and Enterococcus species 1
• Up to 50% of infections may be polymicrobial or involve normal skin flora at the percutaneous nephrostomy tube exit site 1
• Bacterial biofilms can form on stents, making infections more resistant to treatment 1, 2

Important Clinical Considerations

• If purulent urine is encountered during the procedure, abort the procedure, establish appropriate drainage with a stent or nephrostomy tube, culture the purulent urine, and continue broad-spectrum antibiotics pending culture results 1
• The procedure can be resumed once the infection is appropriately treated 1
• Long-term antibiotic prophylaxis during the entire stent indwelling time has not been shown to significantly reduce UTI rates compared to perioperative prophylaxis alone 3
• Fluoroquinolones (ciprofloxacin) have been shown to adsorb onto ureteral stents, potentially providing ongoing antibacterial activity 4, 5

Special Situations

• For complicated UTIs with systemic symptoms, consider combination therapy with amoxicillin plus an aminoglycoside, a second-generation cephalosporin plus an aminoglycoside, or an intravenous third-generation cephalosporin 1
• Only use ciprofloxacin if local resistance rates are <10% and when the patient does not require hospitalization or has anaphylaxis to β-lactam antimicrobials 1
• Avoid fluoroquinolones for empirical treatment if the patient has used them in the last 6 months 1

Duration of Treatment

• For infected ureteral stents, treatment duration should be 7-14 days (14 days for men when prostatitis cannot be excluded) 1
• When the patient is hemodynamically stable and has been afebrile for at least 48 hours, a shorter treatment duration (7 days) may be considered 1

Prevention of Recurrent Infections

• Periodically reassess the need for ureteral stents to determine whether removal is possible, as the main risk factor for infection is the length of time the device remains in place 1
• Maintain a clean exit site area with antiseptic use and regular dressing exchange 1
• Avoid concomitant use of Foley catheters with ureteral stents when feasible 1
• For patients with frequent exit site infections, consider using chlorhexidine-impregnated dressings and exchanging them weekly 1

Remember that proper antimicrobial selection and timing are crucial for preventing serious infectious complications in patients with ureteral stents.