What is the workup and treatment for a urinary tract infection (UTI) associated with a double J (DJ) stent?

Management of UTI Associated with DJ Stent

For UTIs associated with double J (DJ) ureteral stents, obtain urine culture before starting empirical broad-spectrum antibiotic therapy against Enterobacteriaceae and Enterococci, and adjust treatment based on culture results. 1

Diagnostic Workup

• CT urography with both nephrographic and excretory phases is the gold standard diagnostic exam for suspected urinary tract complications related to DJ stents 1
• Obtain urine culture before initiating antibiotics to guide targeted therapy 1, 2
• Serum inflammatory markers (e.g., C-reactive protein), renal function tests, and peritoneal fluid analysis (if applicable) may be useful diagnostic tools when CT urography is unavailable 1
• Consider stent culture at removal, as stent colonization can occur even with negative urine cultures 3, 4

Microbiology Considerations

• The most common pathogens in DJ stent-associated UTIs are Escherichia coli, Enterococcus species, Staphylococcus species, Pseudomonas, and Candida species 3, 5
• Bacterial colonization of DJ stents increases significantly with indwelling time - from 2.2% when in place <4 weeks to 25% when in place >6 weeks 6
• Stent isolates often show higher antibiotic resistance compared to organisms isolated before stent insertion 3

Treatment Approach

Empiric Antibiotic Therapy

• Start empirical broad-spectrum antibiotic therapy as soon as possible in patients with signs of infection, sepsis, or septic shock 1
• For complicated UTIs with systemic symptoms, consider:
  • Third-generation cephalosporins (e.g., ceftriaxone 1-2g daily) 2
  • Fluoroquinolones (e.g., ciprofloxacin 500-750mg twice daily) if local resistance rates are below 10% 2, 7
  • Aminoglycosides for severe infections or suspected resistant organisms 2, 3

Treatment Duration

• Short-course antibiotic therapy (3-5 days) is recommended in cases with adequate source control 1
• For complicated UTIs, 7-14 days of treatment may be necessary, with early re-evaluation based on clinical course and laboratory parameters 2

Source Control

• Consider stent removal or replacement if infection persists despite appropriate antibiotic therapy 3, 8
• If the stent has been in place for ≥2 weeks when UTI is diagnosed, replacing it before initiating antibiotics may improve outcomes 2

Special Considerations

• Adjust antibiotic dose and timing based on patient's weight, renal clearance, and liver function 1
• Empirical antifungal therapy is not recommended for stent-associated UTIs unless fungal infection is documented 1
• In patients with diabetes mellitus, chronic renal failure, or diabetic nephropathy, there is a higher risk of bacteriuria with DJ stents (57-78% vs. 28% in patients without these conditions) 3

Prevention Strategies

• Antibiotic prophylaxis at the time of stent insertion may reduce the risk of subsequent UTI (8.1% UTI rate without prophylaxis vs. 1.4% with prophylaxis) 8
• Consider norfloxacin or ciprofloxacin as prophylaxis prior to stent insertion 3
• Minimize stent dwell time when possible, as bacterial colonization increases significantly after 6 weeks 5, 6

Common Pitfalls to Avoid

• Failing to obtain urine culture before starting antibiotics 2
• Using fluoroquinolones empirically when local resistance rates are high 2
• Inadequate treatment duration, especially in complicated infections 2
• Not replacing long-term catheters before initiating treatment 2
• Relying solely on urine culture to rule out stent colonization (60% of patients with positive stent cultures may have sterile urine) 3