Management of Ureteral Stents in PCN-Related Infections
When a percutaneous nephrostomy (PCN) tube becomes infected, any concurrent ureteral stent should also be exchanged, ideally within 4 days of infection diagnosis once appropriate antimicrobials are initiated. 1
Primary Management Strategy
The fundamental approach to PCN-related infections involves both antimicrobial therapy and device management:
- Start empiric antibiotics immediately with ceftriaxone or ampicillin/sulbactam to cover expected uropathogens, which reduces serious sepsis-related complications from 50% to 9% in high-risk patients 2, 3
- Obtain blood and urine cultures before initiating antibiotics, then adjust therapy based on sensitivities 3
- Exchange the infected PCN catheter within 4 days once concordant antimicrobials are confirmed, as this significantly reduces recurrent infections (OR 0.1; p = 0.048) 1
When Ureteral Stents Must Be Exchanged
If a ureteral stent is present alongside an infected PCN, the stent requires exchange in these situations:
- Persistent bacteremia or fungemia despite 48-72 hours of appropriate antimicrobial therapy 3
- Hemodynamic instability or septic shock, where prompt device exchange is critical 3
- When the PCN is being exchanged for infection, as both devices share the same infected urinary tract and can serve as persistent sources of infection 2, 4
The rationale is straightforward: both PCN tubes and ureteral stents become colonized by the same uropathogens (Pseudomonas, E. coli, Klebsiella, Enterococcus species), with up to 50% of infections being polymicrobial 2. Leaving an infected stent in place while only exchanging the PCN creates a persistent nidus for reinfection.
Timing and Technique Considerations
Critical timing window: Exchange both devices within 4 days of infection diagnosis once appropriate antimicrobials are started 1. This timing is supported by research showing:
- Concordant antibiotic use combined with early catheter exchange (within 4 days) independently reduces recurrent PCN infections (OR 0.04 for concordant antibiotics; OR 0.1 for early exchange) 1
- The infection rate for newly placed PCNs is 14%, with median time to infection of 44 days, emphasizing that device colonization occurs rapidly 2
Device-specific considerations:
- Internal double-J ureteral stents are particularly prone to infection, with reported rates of 11% 2
- In patients with urinary diversions (ileal conduits), double-J stents occlude quickly from mucous plugging and should be avoided in favor of percutaneous nephroureteral catheters 2
- Severe infection and bleeding after PCN placement may temporarily contraindicate stent insertion until adequate drainage is established 5
Common Pitfalls to Avoid
Do not attempt device salvage with antibiotics alone when there is persistent fever, bacteremia, or clinical deterioration beyond 48-72 hours 3. The biofilm on indwelling devices makes eradication with antimicrobials alone extremely difficult.
Do not delay exchange waiting for "complete" antibiotic courses - once concordant therapy is confirmed and the patient is clinically stable, proceed with exchange within the 4-day window 1
Monitor for multidrug-resistant organisms: 38.54% of double-J stent infections and 37.75% of PCN infections involve MDR pathogens, particularly in patients with prior UTIs, prolonged catheterization, or extended hospital stays 4. This necessitates culture-directed therapy rather than empiric treatment alone.
Prevention Strategy
The most effective prevention is periodic reassessment of device necessity with removal when no longer required, as infection risk correlates directly with duration of placement 2, 3. For planned exchanges:
- Use preprocedural antimicrobial prophylaxis with ceftriaxone or ampicillin/sulbactam 2, 3
- Consider targeted prophylaxis based on colonizing organisms from urine culture obtained days before scheduled exchange 2
- Regular surveillance with scheduled exchanges is mandatory to prevent infectious complications 5