What is the best course of action for a postoperative patient with urosepsis and an obstructing stone, who continues to show signs of sepsis, including hypotension, tachycardia, and impaired renal function, with a urine culture positive for Klebsiella, on postop day #1 after stent placement?

Immediate Management of Persistent Urosepsis Post-Stent Placement

This patient requires immediate escalation to broad-spectrum IV antibiotics (cefepime or carbapenem), aggressive fluid resuscitation with vasopressor support for septic shock, and urgent placement of a percutaneous nephrostomy because the retrograde stent has failed to adequately drain the infected, obstructed system. 1

Critical Assessment of Current Clinical Status

The patient demonstrates clear signs of ongoing septic shock on postoperative day #1:

• Hypotension (BP 90/53) with tachycardia (HR 100) and fever (100.5°F) indicates inadequate source control despite stent placement 1
• The urine culture showing >100,000 Klebsiella with pyuria (WBC TNTC, many WBC clumps, many bacteria) confirms active infection 2, 1
• The presence of WBC clumps in the urinalysis suggests pyelonephritis or pyonephrosis requiring urgent intervention 2

This clinical picture indicates that the retrograde ureteral stent is not providing adequate drainage, which is the fundamental problem that must be addressed immediately. 1

Immediate Antibiotic Management

Escalate to IV cefepime 2g every 8-12 hours or a carbapenem immediately 1, 3:

• Third-generation cephalosporins and cefepime demonstrate superiority over fluoroquinolones for obstructive pyelonephritis with documented clinical and microbiological cure rates 1
• Cefepime is specifically FDA-approved for complicated urinary tract infections including pyelonephritis caused by Klebsiella pneumoniae at 2g IV every 12 hours for severe infections 3
• Antibiotics alone are insufficient in obstructive pyelonephritis—the 92% survival rate with drainage plus antibiotics drops to 60% with medical therapy alone 1

Obtain blood cultures immediately before antibiotic escalation 1:

• Blood cultures are critical for guiding subsequent antibiotic therapy
• Plan to adjust antibiotics at 48-72 hours based on culture sensitivities and clinical response 1

Urgent Drainage Intervention Required

Proceed immediately with percutaneous nephrostomy (PCN) placement 1:

• PCN is preferred over stent revision in this clinical scenario because the patient demonstrates ongoing septic shock despite stent placement 1
• PCN provides superior drainage in pyonephrosis with larger tube caliber and direct renal pelvis decompression 1
• PCN yields critical bacteriological information from renal urine that bladder cultures miss in up to 50% of cases 1
• The European Association of Urology guidelines indicate that PCN has shorter hospitalization times and provides definitive drainage for pyonephrosis 1

Imaging to guide intervention 4, 5:

• Urgent ultrasound or non-contrast CT should be performed immediately to assess degree of hydronephrosis and confirm inadequate stent drainage 4, 5
• If clinical deterioration occurs or the patient remains febrile after 72 hours, contrast-enhanced CT should be considered to evaluate for complications such as perinephric abscess 4

Aggressive Sepsis Resuscitation

Initiate aggressive fluid resuscitation with crystalloids and vasopressor support 4, 1:

• Fluid resuscitation is the mainstay of support for patients with sepsis from urological sources 4
• Vasopressor support (norepinephrine first-line) should be initiated if hypotension persists despite adequate fluid resuscitation 4
• Consider ICU-level monitoring given the septic shock presentation 4

Definitive Stone Management Planning

Delay definitive stone treatment until sepsis resolves and the patient stabilizes 1:

• Plan for stone removal via ureteroscopy once infection clears, typically 4-6 weeks after resolution of sepsis 1, 6
• Studies show excellent outcomes (97% stone-free rate) with elective ureteroscopy following emergency drainage for urosepsis 6
• Targeted antimicrobial prophylaxis based on culture results can reduce sepsis complications from 50% to 9% for future procedures 1

If long-term stenting becomes necessary, routine stent exchanges every 3 months may be required to prevent recurrent infection 1

Common Pitfalls to Avoid

• Do not assume the retrograde stent is functioning adequately based solely on its placement—clinical deterioration indicates drainage failure 1
• Do not delay PCN placement while attempting stent revision or adjustment—this wastes critical time in a septic patient 1
• Do not rely on oral or less aggressive IV antibiotics (fluoroquinolones, first-generation cephalosporins) in this setting of septic shock 1, 3
• Do not attempt definitive stone treatment while the patient remains septic—this significantly increases mortality risk 1, 7