What is the next best step in managing a febrile urinary tract infection (UTI) in a patient 18 months post-cystectomy and orthotopic neobladder, with no hydronephrosis on computed tomography (CT) scan?

Management of Febrile UTI in Post-Cystectomy Patient with Orthotopic Neobladder

For a patient with a febrile UTI 18 months after cystectomy and orthotopic neobladder construction, with no hydronephrosis on CT scan, the next best step is to obtain urine cultures and initiate empiric antibiotic therapy with a fluoroquinolone or cephalosporin while awaiting culture results.

Initial Assessment and Diagnostic Approach

• Obtain urine cultures before starting antimicrobial therapy to identify the causative pathogen and guide subsequent treatment 1
• Bacterial colonization is common in neobladder patients, but treatment should focus on symptomatic infections, particularly when fever is present 2
• The most common pathogens in neobladder UTIs are Escherichia coli (40%) and Enterococcus species, with the latter being particularly common in the early postoperative period 3

Antimicrobial Therapy Selection

• Initiate empiric antimicrobial therapy with agents that achieve adequate tissue penetration:
  • Fluoroquinolones (e.g., ciprofloxacin) are appropriate first-line options for febrile UTIs in patients with orthotopic neobladders 1, 4
  • Cephalosporins are alternative options if fluoroquinolones are contraindicated 1
• Avoid nitrofurantoin as it does not achieve therapeutic concentrations in the bloodstream and is inadequate for treating pyelonephritis or urosepsis 1
• Duration of therapy should be 7-14 days based on clinical response and culture results 1

Additional Evaluation

• Since CT has already ruled out hydronephrosis, evaluate for other potential complications:
  • Assess for potential intestinal neobladder fistula, which can present with recurrent UTIs and fever 5
  • Consider evaluating residual urine volume, as increased residual urine is associated with higher risk of febrile UTI in neobladder patients 3
• Assess for other risk factors for UTI in neobladder patients:
  • Ureteral stricture (independent risk factor for febrile UTI) 3
  • Vesicoureteral reflux 3

Follow-up Considerations

• Schedule close follow-up to ensure clinical improvement within 48-72 hours of initiating therapy 1
• If fever persists beyond 72 hours of appropriate antimicrobial therapy, consider additional imaging to evaluate for complications such as abscess or fistula 1
• Prophylactic antibiotics should only be considered for patients with recurrent UTIs, not for isolated episodes 2

Important Caveats

• UTIs are among the most common complications after radical cystectomy and orthotopic neobladder reconstruction, with an incidence of approximately 90.4 per 1,000 person-years 6
• Patients with orthotopic neobladders have a higher risk of UTI compared to those with ileal conduits (HR: 1.21) 6
• Treating asymptomatic bacteriuria in neobladder patients is not recommended, as bacterial colonization is common due to the use of intestinal tissue 2
• The risk of febrile UTI is highest within the first 6 months after surgery, but patients require lifelong monitoring for complications 3, 6