What is the best course of action for an elderly patient with a ureteral stent (indwelling ureteric catheter) in place for an infected kidney stone who continues to experience fevers (pyrexia)?

Immediate Stent Removal is Required

For an elderly patient with a ureteral stent placed for an infected stone who continues spiking fevers, the stent must be removed immediately and replaced at a different site or exchanged over a guidewire, followed by appropriate antimicrobial therapy. This persistent fever indicates ongoing catheter-related infection that cannot be adequately treated with the device in place.

Why the Stent Must Come Out

The continued fever despite stent placement strongly suggests catheter-related bloodstream infection (CRBSI) or persistent obstruction with ongoing infection. 1 Ureteral stents develop bacterial biofilms that are exceedingly difficult to eradicate with antibiotics alone, and these biofilms serve as a nidus for persistent bacteremia and potential urosepsis, which carries mortality rates up to 50% in severely infected patients. 1

The stent should be removed immediately if the patient has:

• Persistent fever >72 hours after stent placement 2
• Signs of sepsis or hemodynamic instability 3
• No clinical improvement despite appropriate antibiotics 4

Immediate Management Algorithm

Step 1: Obtain Cultures Before Antibiotics

• Draw at least 2 sets of blood cultures (one peripheral, one from any other catheter if present) 2
• Obtain urine culture from the stent or bladder 2
• Do NOT delay antibiotic initiation if patient is septic 3

Step 2: Remove and Replace the Stent

For patients with severe illness or persistent fever:

• Remove the infected stent and culture the tip 2
• Insert a new stent at a different anatomical site if possible 2
• If no alternative site exists, exchange over a guidewire 2
• Do not attempt definitive stone removal if purulent urine is encountered - establish drainage only 5

Step 3: Initiate Broad-Spectrum Antibiotics

Start empirical therapy immediately after cultures are obtained:

• Vancomycin PLUS a fluoroquinolone or third-generation cephalosporin for coverage of both gram-positive and gram-negative organisms 2, 5
• Third-generation cephalosporins may be superior to fluoroquinolones for upper tract infections 5
• Adjust antibiotics within 48-72 hours based on culture sensitivities 2

Step 4: Assess for Complications

Order urgent imaging if not already done:

• CT scan or renal ultrasound to evaluate for persistent obstruction, hydronephrosis, or perinephric abscess 5, 3
• If obstruction persists despite stent, consider percutaneous nephrostomy 5

Duration of Antibiotic Therapy

The duration depends on clinical response and complications:

• 7 days if prompt resolution of symptoms after stent removal 2
• 10-14 days if delayed response 2
• 4-6 weeks if complicated by bacteremia >72 hours, endocarditis, or suppurative thrombophlebitis 2
• Use lipid-soluble antibiotics (fluoroquinolones) for prolonged upper tract infections 5

Critical Pitfalls to Avoid

Do not retain the stent hoping antibiotics alone will work. 2, 1 Unlike coagulase-negative staphylococcal infections of some catheters, infected ureteral stents with persistent fever require removal because:

• Biofilm formation prevents antibiotic penetration 1, 6
• The stone itself serves as an additional nidus for infection 3
• Elderly patients are at higher risk for complications and mortality 4

Do not attempt definitive stone treatment until sepsis completely resolves. 5 The stone can be addressed with ureteroscopy, shock wave lithotripsy, or percutaneous nephrolithotomy weeks later after infection clears.

Do not forget to replace the stent after removal. 2, 3 The patient still has an obstructing infected stone - removing the stent without replacement risks worsening obstruction and progression to urosepsis.

When to Escalate Care

Immediate urological consultation is mandatory if:

• Patient develops septic shock (hypotension, organ dysfunction) 3
• Imaging shows persistent obstruction despite stent 5
• Fever persists >72 hours after stent exchange and appropriate antibiotics 2
• Blood cultures remain positive >72 hours after intervention 2

In these cases, consider percutaneous nephrostomy as an alternative drainage method, and obtain transesophageal echocardiography to rule out endocarditis if bacteremia persists. 2