What is the best course of treatment for a female patient with a history of kidney stones, currently presenting with fever, chills, leukocytes and nitrites on a urine strip test, diffuse body aches, nausea, and a temperature of 101.6, who has been taking Flexeril (cyclobenzaprine) and has been experiencing severe pain and restlessness?

Immediate Management of Suspected Obstructive Pyelonephritis with Sepsis

This patient requires immediate hospitalization, urgent urinary tract decompression via percutaneous nephrostomy or retrograde ureteral stenting, blood and urine cultures, and empiric intravenous antibiotics—this is a urological emergency that can be life-threatening without prompt intervention. 1

Clinical Recognition: This is Obstructive Pyelonephritis Until Proven Otherwise

This presentation screams obstructive pyelonephritis in a patient with known kidney stone history:

• Fever (101.6°F), chills, and systemic symptoms (diffuse body aches, nausea) indicate systemic infection 1
• Positive leukocytes AND nitrites on urine dipstick strongly suggests bacterial UTI with gram-negative organisms (typically E. coli) 1, 2
• History of kidney stones makes obstruction highly likely 1
• Severe, unrelenting pain despite muscle relaxants (moaning all night, unable to hold still) suggests more than simple renal colic 1
• Return visit within 30 hours with worsening symptoms indicates progression to complicated infection 2

Immediate Actions in the Emergency Department

1. Urgent Imaging to Assess for Obstruction

• Order CT scan without contrast immediately to identify hydronephrosis, stone location, and degree of obstruction 1
• Ultrasound is insufficient in this acute setting when sepsis is suspected—CT provides definitive anatomical information 1
• Do not delay imaging when obstructive pyelonephritis is suspected, as this can rapidly progress to urosepsis and septic shock 1, 2

2. Obtain Cultures Before Antibiotics (But Don't Delay Treatment)

• Blood cultures × 2 sets given systemic illness and fever 2
• Urine culture via catheterization if patient cannot provide clean-catch specimen 1
• Collect urine for antibiogram testing before AND after decompression 1

3. Start Empiric IV Antibiotics Immediately

First-line regimen: Ceftriaxone 1-2g IV once daily 1, 2

Alternative options if ceftriaxone unavailable:

• Ciprofloxacin 400mg IV twice daily 2
• Levofloxacin 750mg IV once daily 2
• Cefotaxime 2g IV three times daily 2

Critical point: In obstructive pyelonephritis, antibiotics alone are insufficient and potentially dangerous—decompression is mandatory 1

4. Urgent Urological Consultation for Decompression

If imaging confirms obstruction, immediate decompression is required via:

• Percutaneous nephrostomy (PCN) OR
• Retrograde ureteral stenting 1

Choice between PCN vs stenting depends on:

• PCN may be preferred if patient is unstable, has pyonephrosis, or needs larger drainage 1
• PCN has 91-92% technical success and can be lifesaving in pyonephrosis 1
• Retrograde stenting may be attempted first if patient is stable and urologist is immediately available 1
• Both methods are equally effective for emergency decompression 1

Timing is critical: Patient survival is 92% with PCN versus 60% with medical therapy alone in obstructive pyelonephritis 1

Why This Cannot Wait

• Obstructive pyelonephritis can progress to septic shock within hours 1
• Postprocedural bacteremia and sepsis are common when infected obstructed systems are drained, but the alternative (no drainage) has 60% mortality 1
• Preprocedural antibiotics are mandatory before any drainage procedure 1

Definitive Stone Treatment is Delayed

• Do not attempt stone removal during acute infection 1
• Definitive stone treatment (ureteroscopy, lithotripsy) should be delayed until sepsis completely resolves 1
• Focus is on drainage and infection control first 1

Common Pitfalls to Avoid

• Treating with antibiotics alone without imaging in a patient with fever and stone history—this can be fatal 1
• Delaying decompression while waiting for antibiotic response—obstruction prevents antibiotic penetration 1
• Assuming this is simple pyelonephritis because patient denies urinary symptoms—obstructive pyelonephritis often lacks typical dysuria/frequency 1
• Continuing Flexeril (cyclobenzaprine) as primary pain management—this is inadequate for infected obstructed kidney and may mask worsening symptoms 1

Monitoring and Disposition

• Admit to hospital for IV antibiotics and monitoring 1, 2
• Monitor vital signs closely for sepsis progression (hypotension, tachycardia, altered mental status) 1
• Re-evaluate antibiotic regimen once culture and sensitivity results return 1
• Total antibiotic duration: 7-14 days depending on clinical response 2
• Consider ICU admission if patient develops hemodynamic instability 1