What is the treatment for a UTI (Urinary Tract Infection) with suspected kidney stone, hematuria, and leukocyturia?

Management of UTI with Suspected Kidney Stone, Hematuria, and Leukocyturia

The treatment for a UTI with suspected kidney stone requires both antimicrobial therapy for the infection and appropriate management of the kidney stone, with complete stone removal being essential for cure in cases of infection stones. 1, 2

Initial Assessment and Management

• Obtain urine culture before starting antibiotics to guide targeted therapy, as screening with dipsticks might be sufficient only in uncomplicated cases 1
• Start empiric antibiotic therapy with agents effective against gram-positive and gram-negative uropathogens while awaiting culture results 1, 3
• For adults with uncomplicated UTI, trimethoprim-sulfamethoxazole is recommended at a dosage of 4 teaspoonfuls (20 mL) every 12 hours for 10-14 days 3
• If purulent urine is encountered during any procedure, abort the procedure, establish drainage, continue antibiotics, and obtain cultures 1

Stone Management Approach

• Complete stone removal is essential, especially for infection stones, to prevent recurrent UTIs and renal damage 1, 2
• Stone material should be sent for analysis to determine composition and guide further management 1
• For calcium oxalate stones (as noted in the urinalysis), treatment approach depends on stone size and location 1
• If obstruction is present with infection, urgent drainage of the affected kidney is required to prevent permanent renal damage 4

Procedural Considerations

• Ureteroscopy (URS) is recommended as first-line therapy for most patients requiring stone intervention 1
• Antimicrobial prophylaxis should be administered prior to any stone intervention procedure based on prior urine culture results and local antibiogram 1
• Avoid blind basketing of stones; stone extraction should always be performed under direct ureteroscopic vision 1
• For stones <10mm, observation with periodic evaluation may be an initial option if symptoms are controlled 1

Special Considerations for Infection Stones

• Infection stones form due to urease-producing bacteria that create alkaline urine, while most other stone types require different pH environments for dissolution 5, 6
• Struvite stones require acidification for dissolution, while uric acid stones require alkaline urine (pH 6.0-7.0) 5
• Long-term antibiotic therapy may be necessary for patients with infection stones to prevent recurrence 7
• Risk factors for infection stones include urinary tract obstruction, neurogenic bladder, voiding dysfunction, and temporary or indwelling urinary catheters 6

Follow-up Care

• For patients with residual stone fragments, offer endoscopic procedures to render them stone-free, especially if infection stones are suspected 1
• Monitor for recurrent UTIs as they may indicate residual stone fragments or incomplete stone clearance 1, 4
• In cases of recurrent UTIs, investigate for underlying predispositions including anatomical abnormalities 1
• Obtain follow-up imaging to confirm complete stone clearance and resolution of obstruction 1

Complications to Watch For

• Sepsis remains the most serious complication of treatment despite antibiotic prophylaxis 4
• Urosepsis risk factors include patient conditions, history of recurrent infections, stone characteristics, and urinary tract anatomy 7
• If fever, acute abdominal or flank pain, and increased white blood cell count occur, workup for kidney infection is needed 1
• Patients with complex stones or anatomy may require additional contrast imaging for better definition of the collecting system 1