What is the recommended management for a patient with nephrolithiasis (kidney stones) who also has a fever?

Management of Nephrolithiasis with Fever

In cases of nephrolithiasis with fever, urgent decompression of the collecting system via either percutaneous nephrostomy or ureteral stenting is strongly recommended, along with immediate antibiotic therapy. 1, 2

Initial Assessment and Management

• Fever in a patient with nephrolithiasis indicates urinary tract infection with obstruction, which is a urologic emergency requiring immediate intervention to prevent progression to urosepsis 2
• Urine culture should be obtained before starting antibiotics, but treatment should not be delayed while awaiting results 1, 2
• Antibiotics should be administered immediately after obtaining urine culture 1, 2
• Initial empiric therapy should cover common uropathogens, with fluoroquinolones or third-generation cephalosporins recommended as first-line options 2

Urgent Decompression

• The presence of both nephrolithiasis and fever necessitates urgent decompression of the obstructed collecting system 1, 2
• Two main options for decompression exist:
  • Percutaneous nephrostomy (PCN) - may have higher technical success rate in severe obstruction 2
  • Retrograde ureteral stenting - equally effective and may be better tolerated by patients 2
• Patient survival is significantly higher with decompression (92% with PCN) compared to medical therapy without decompression (60%) 2

Antibiotic Management

• Antibiotics should be given immediately, and the regimen should be re-evaluated following antibiogram findings 1
• The choice of antibiotic prophylaxis should be tailored to institutional or regional antimicrobial susceptibility patterns 1
• A recent study demonstrated superiority of third-generation cephalosporin ceftazidime versus fluoroquinolone ciprofloxacin in both clinical and microbiological cure rates 2
• Intensive care might become necessary in cases of severe sepsis 1

Definitive Stone Management

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

Common Pitfalls to Avoid

• Treating with antibiotics alone without drainage is insufficient and dangerous in acute obstructive pyelonephritis 2
• Delaying decompression while waiting for culture results can lead to rapid clinical deterioration 2
• Attempting definitive stone treatment before resolution of infection increases risk of septic complications 1, 2
• Failure to obtain stone analysis after removal prevents identification of stone type and targeted prevention strategies 1

Follow-up Care

• Follow-up imaging to confirm complete stone removal is essential 2
• Consider metabolic evaluation to identify risk factors for stone formation 2
• For prevention of recurrence, increased fluid intake to achieve at least 2 liters of urine output daily is recommended 3