How to manage recurrent febrile UTIs (urinary tract infections) in a patient with CKD (chronic kidney disease) and an ileal conduit after radical cystectomy?

Management of Recurrent Febrile UTIs in a Patient with CKD and Ileal Conduit

For a 75-year-old man with chronic kidney disease experiencing recurrent febrile UTIs after radical cystectomy with ileal conduit, comprehensive evaluation of the upper and lower urinary tracts with imaging and cystoscopy is strongly recommended, followed by targeted antibiotic therapy based on culture results. 1

Diagnostic Evaluation

• Obtain urinalysis and urine culture during each symptomatic episode to guide antimicrobial therapy 1
• Collect urine specimens properly by changing the catheter and allowing for urine accumulation while plugging the catheter; never obtain specimens from extension tubing or collection bag 1
• Perform upper tract imaging (ultrasound or CT) to evaluate for potential complications such as stones, hydronephrosis, or other anatomic abnormalities 1
• Consider cystoscopic examination of the ileal conduit to identify potential sources of infection such as retained sutures, stones, or other foreign bodies 1

Treatment Approach

• Treat symptomatic UTIs with appropriate antibiotics based on culture results and local resistance patterns 1
• Consider trimethoprim-sulfamethoxazole as first-line therapy if local resistance patterns permit (E. coli resistance <20%) 1, 2
• Be aware that common pathogens in post-cystectomy patients with ileal conduit include Escherichia coli, Enterococcus faecalis, Klebsiella pneumoniae, and Pseudomonas species 3, 4
• Adjust antibiotic dosing based on the patient's renal function (CKD with creatinine of 2.2) 1

Prevention Strategies

• Do not use daily antibiotic prophylaxis routinely as this may increase bacterial resistance without significantly reducing symptomatic infections 1
• Consider methenamine hippurate for UTI prevention in patients without urinary tract abnormalities, though evidence in ileal conduit patients is limited 1
• Evaluate for and address potential risk factors such as ureteral stricture, which is independently associated with febrile UTIs (OR 5.93) 5
• Assess for significant residual urine in the ileal conduit, as larger residual volumes are associated with increased UTI risk 5

Special Considerations for Ileal Conduit Patients

• Female sex is a significant risk factor for immediate post-operative UTIs in ileal conduit patients 3, 4
• The type of ureteral anastomosis (Wallace technique) may influence UTI risk 31-90 days post-discharge 3
• Consider evaluation for vesicoureteral reflux, though its presence is not consistently associated with febrile UTI risk 5
• Be aware that gram-positive organisms (particularly Enterococcus species) are common pathogens in the early post-operative period, while gram-negative organisms become more prevalent later 4, 5

Follow-up Recommendations

• Schedule regular follow-up with upper tract imaging to monitor for complications, especially given the patient's CKD 1
• Instruct the patient to seek prompt medical evaluation (within 48 hours) for future febrile episodes 1
• Do not perform surveillance/screening urine cultures in asymptomatic patients, as this may lead to unnecessary antibiotic treatment 1
• Consider urodynamic evaluation if recurrent UTIs persist despite an unremarkable evaluation of the upper and lower urinary tract 1

Pitfalls and Caveats

• Avoid treating asymptomatic bacteriuria, as this promotes antimicrobial resistance without clinical benefit 1
• Be aware that patients with ileal neobladder have higher UTI rates (52.9%) compared to those with ileal conduit (18.8%) 4
• Consider internalization of nephroureteral stents in patients with recurrent UTIs and ureteral strictures 6
• Remember that the cumulative incidence of post-operative UTIs after radical cystectomy is approximately 14%, with varying risk factors at different time points 3