What is the appropriate management for a patient with a urinary tract infection and obstructing nephrolithiasis, presenting with hematuria and bacteriuria?

Management of UTI with Obstructing Nephrolithiasis

In cases of UTI with obstructing nephrolithiasis, urgent decompression of the collecting system via either percutaneous nephrostomy or ureteral stenting is strongly recommended, along with immediate antibiotic therapy. 1

Initial Assessment and Management

• The urinalysis findings (large hemoglobin, 6-9 WBCs, 21-50 RBCs, and 1+ bacteria) in the setting of obstructing nephrolithiasis indicate a urinary tract infection that requires prompt intervention 1
• Obstructive pyelonephritis is a urologic emergency as it can result in sepsis and even death 2
• Urine culture should be obtained before initiating antibiotics, but treatment should not be delayed while awaiting results 1

Urgent Decompression

• Urgent decompression of the obstructed kidney is necessary to prevent progression to urosepsis 1
• Two primary options for decompression:
  1. Percutaneous nephrostomy (PCN): May have higher technical success rate in relieving obstruction, especially with severe obstruction 1
  2. Retrograde ureteral stenting: Equally effective option that may be better tolerated by patients 1
• The choice between PCN and ureteral stenting may depend on local expertise, patient factors, and severity of infection 1
• In a retrospective analysis, patient survival was 92% when PCN was used, compared with 88% for open surgical decompression and 60% for medical therapy without decompression 1

Antibiotic Therapy

• Antibiotics should be administered immediately after obtaining urine culture 1
• Initial empiric therapy should cover common uropathogens:
  • Fluoroquinolones or third-generation cephalosporins are recommended as first-line options 1, 3
  • A recent study demonstrated superiority of third-generation cephalosporin ceftazidime versus fluoroquinolone ciprofloxacin in both clinical and microbiological cure rates 1
• Antibiotic regimen should be re-evaluated and adjusted based on culture and sensitivity results 1
• Duration of therapy typically ranges from 7-14 days depending on clinical response 1, 3

Definitive Stone Management

• Definitive treatment of the stone should be delayed until sepsis is resolved 1
• Options for definitive stone management after resolution of infection include:
  1. Extracorporeal shock wave lithotripsy (ESWL)
  2. Ureteroscopy with laser lithotripsy
  3. Percutaneous nephrolithotomy (PCNL)
• The choice depends on stone size, location, composition, and patient factors 1

Follow-up Care

• Follow-up imaging to confirm complete stone removal is essential 1
• For patients with infection stones (struvite), complete stone removal is critical to prevent recurrence 2, 4
• Consider metabolic evaluation to identify risk factors for stone formation 1
• Long-term antibiotic prophylaxis may be considered in patients with recurrent UTIs and stone disease 4

Important Caveats

• Antibiotics alone are insufficient in treating acute obstructive pyelonephritis; drainage is essential 1
• Delaying decompression in the setting of obstructive pyelonephritis can lead to urosepsis, septic shock, and death 2, 5
• PCN can yield important bacteriological information and may alter antibiotic treatment regimens by correctly identifying the offending pathogen 1
• The choice of antibiotic prophylaxis should be tailored to institutional or regional antimicrobial susceptibility patterns 1