What is the best course of treatment for a patient on postoperative day #1 following stent placement for urosepsis with an obstructing stone, presenting with hypotension, tachycardia, mild hyperthermia, leukocytosis, impaired renal function, and a urine culture positive for Klebsiella?

Management of Postoperative Urosepsis with Persistent Klebsiella Infection

This patient requires immediate escalation to broad-spectrum intravenous antibiotics with combination therapy, aggressive fluid resuscitation, and urgent reassessment of stent patency given signs of ongoing sepsis despite source control.

Immediate Clinical Assessment

The patient demonstrates clear signs of persistent or worsening sepsis on postoperative day #1:

• Hemodynamic instability: Hypotension (90/53 mmHg) with compensatory tachycardia (100 BPM) and tachypnea (25 breaths/min) 1
• Persistent fever: Temperature 100.5°F despite stent placement 1
• Laboratory evidence of ongoing infection: Leukocytosis (11.64 K/μL) with neutrophilia (8.7 K/μL absolute), positive urine culture with >100,000 CFU Klebsiella, and florid pyuria (WBC TNTC, many WBC clumps, many bacteria) 1, 2
• Possible inadequate drainage: The patient "continues to not feel great" and is straining to urinate, suggesting potential stent malfunction or inadequate decompression 1

Critical Intervention: Verify Source Control

Before adjusting antibiotics, immediately verify stent patency and adequacy of drainage 1:

• Obtain urgent renal ultrasound or non-contrast CT to assess for persistent hydronephrosis
• If obstruction persists despite stent, consider nephrostomy tube placement as alternative drainage 1
• The American Urological Association emphasizes that definitive stone treatment must be delayed until sepsis resolves 1

Antibiotic Management

Immediate Antibiotic Escalation Required

Initiate broad-spectrum combination therapy immediately given signs of septic physiology with confirmed Klebsiella infection 2, 3:

Recommended regimen:

• Meropenem 1-2g IV every 8 hours (extended infusion preferred) PLUS
• Gentamicin or amikacin (weight-based dosing with therapeutic drug monitoring) 4, 3

Rationale for Combination Therapy

• Combination therapy shows significantly lower treatment failure rates compared to monotherapy for Klebsiella infections (25% vs 49%, p=0.01) 3
• Carbapenem-based combination therapy demonstrates superior outcomes compared to carbapenem monotherapy (26% vs 60% treatment failure, p=0.03) 3
• The WSES guidelines recommend fourth-generation cephalosporins or carbapenems for Enterobacteriaceae in critically ill patients with sepsis 4

Carbapenem Resistance Considerations

Assess local antibiogram and patient risk factors for carbapenem resistance 5, 6:

• Previous colistin use increases CRKP risk 19-fold (OR=19.108, p=0.010) 5
• Previous aminoglycoside use increases CRKP risk 12-fold (OR=12.189, p=0.031) 5
• If CRKP suspected or confirmed, consider: Ceftazidime-avibactam or meropenem-vavorbactam as preferred agents, or polymyxin-based triple combination therapy (polymyxin + carbapenem + tigecycline or aminoglycoside) 6, 3

Duration of Therapy

Continue IV antibiotics for 7-14 days depending on clinical response 2:

• 14 days recommended given severity of presentation and male gender (cannot exclude prostatitis) 2
• Transition to oral therapy only after: hemodynamic stability for 48-72 hours, defervescence, clinical improvement, and susceptibility data available 2

Supportive Care for Sepsis

Implement sepsis bundle immediately 4:

• Aggressive IV fluid resuscitation targeting MAP ≥65 mmHg
• Serial lactate measurements
• Consider vasopressor support if hypotension persists despite adequate fluid resuscitation
• Monitor urine output closely (should improve with adequate drainage and treatment)

Monitoring and Follow-up

Daily reassessment required 1, 2:

• Repeat blood cultures if fever persists beyond 72 hours
• Monitor renal function (creatinine, BUN) given baseline impairment suggested by low albumin (3.1) and protein (5.1)
• Adjust antibiotic dosing based on renal function and therapeutic drug monitoring for aminoglycosides
• Repeat imaging if clinical deterioration or failure to improve within 48-72 hours

Common Pitfalls to Avoid

• Do not rely on single-dose prophylactic antibiotics in this setting—this patient has established infection requiring therapeutic treatment 4
• Do not use fluoroquinolones as monotherapy despite FDA approval for Klebsiella UTI 7—this patient has urosepsis requiring more aggressive therapy 3
• Do not assume adequate drainage from stent placement alone—verify with imaging given persistent symptoms 1
• Do not delay nephrostomy tube if stent drainage inadequate—mortality increases significantly with delayed source control in urosepsis 1, 5

Prognostic Considerations

The presence of carbapenem-resistant Klebsiella, if confirmed, carries 28-day mortality of 71.9% compared to 37.5% for carbapenem-sensitive strains (OR=5.146, p=0.002) 5. Early aggressive combination therapy and verified source control are critical to improving outcomes.