What is the best course of action for a patient with a history of obstructing ureteral stone and infection, currently on Augmentin (amoxicillin/clavulanate), presenting with severe flank pain, signs of infection, impaired liver function, and anemia, 3 days after discharge following stent placement?

This Patient Requires Immediate Hospital Admission for IV Antibiotics and Urgent Urological Re-evaluation

Despite having a ureteral stent in place, this patient has persistent obstructive pyelonephritis with ongoing infection, and Augmentin monotherapy is inadequate for this complicated urinary tract infection with systemic involvement.

Critical Clinical Assessment

This patient presents with multiple red flags indicating treatment failure and ongoing complicated UTI:

• Persistent hydronephrosis despite stent placement suggests inadequate drainage, which is the cornerstone of managing obstructive pyelonephritis 1
• Severe flank pain (8/10) with chills indicates ongoing systemic infection despite 3 days of oral antibiotics 2, 1
• Elevated liver enzymes (AST 54, ALT 71, Alk Phos 199) and hepatomegaly (20cm) suggest either septic involvement or drug-induced hepatotoxicity from Augmentin 2
• Persistent pyuria (WBC 15-19) and hematuria with periureteral stranding on CT confirm active infection 1
• Leukocytosis (WBC 12.43) with monocytosis indicates ongoing inflammatory response 2

Why Discharge is Inappropriate

The urologist's statement that "there was nothing else to be done" from a procedural standpoint does not address the fundamental problem: this patient has failed outpatient management of complicated UTI with obstruction 1. The European Association of Urology guidelines explicitly recommend immediate hospitalization, urgent urinary tract decompression, and empiric intravenous antibiotics for patients with obstructive pyelonephritis 1.

Immediate Management Required

1. Hospital Admission is Mandatory

• Admit for IV antibiotics and close monitoring for sepsis progression, as recommended for obstructive pyelonephritis 1
• The patient meets criteria for complicated UTI requiring 7-14 days of treatment, which cannot be adequately delivered as an outpatient given treatment failure 2
• Blood cultures should be obtained immediately before starting IV antibiotics (two sets recommended) 1

2. Switch to IV Antibiotic Therapy

Augmentin is inadequate for this scenario for multiple reasons:

• Klebsiella resistance patterns may not be adequately covered by amoxicillin/clavulanate in complicated UTI 2
• The European Association of Urology recommends IV third-generation cephalosporin (ceftriaxone 1-2g IV once daily) or combination therapy (amoxicillin plus aminoglycoside, or second-generation cephalosporin plus aminoglycoside) as first-line for complicated UTI with systemic symptoms 2, 1
• Tailor antibiotics once culture and sensitivity results return to the narrowest spectrum agent 1

3. Urgent Urological Re-evaluation

The stent may be malpositioned, obstructed, or inadequate:

• Request urgent urological consultation to assess stent function and consider percutaneous nephrostomy (PCN) if stent is not providing adequate drainage 2, 1
• PCN may be preferred if the patient has persistent obstruction despite stenting, with technical success rates of 91-92% 1
• The delayed nephrogram on CT suggests inadequate renal drainage despite the stent 2

4. Address Hepatic Dysfunction

• Discontinue Augmentin immediately given elevated transaminases and alkaline phosphatase, which may represent drug-induced liver injury 2
• Monitor liver function tests closely during hospitalization 2
• The enlarged liver (20cm) requires further evaluation once the acute infection is controlled 2

Treatment Duration and Monitoring

• Total antibiotic duration should be 7-14 days depending on clinical response, with IV therapy until afebrile for at least 48 hours, then possible transition to oral therapy 2, 1
• Close monitoring of vital signs for sepsis progression using qSOFA criteria (respiratory rate ≥22, altered mental status, systolic BP ≤100 mmHg) 2
• Reassess symptoms within 48-72 hours to ensure clinical improvement 1

Common Pitfalls to Avoid

• Do not rely on pain control alone as the management strategy for obstructive pyelonephritis—this addresses symptoms but not the underlying infection 1
• Do not continue oral antibiotics when there is clear evidence of treatment failure with systemic involvement 2, 1
• Do not assume the stent is functioning adequately just because it was placed—persistent hydronephrosis and delayed nephrogram indicate inadequate drainage 2
• Do not ignore hepatic dysfunction—Augmentin can cause cholestatic hepatitis, and continuing it may worsen liver injury 2

The patient's refusal of admission should be met with clear documentation of risks including sepsis, renal failure, and death, with strong recommendation to reconsider given the severity of presentation 2, 1.