What is the best course of action for a patient with a history of urinary tract issues, currently with a stent in place and scheduled for removal in 6 days, presenting with fever, flank pain, nausea, leukocytosis (elevated white blood cell count), hematuria (blood in urine), and bilateral ankle edema, with urinalysis results showing pyuria (presence of pus in urine), bacteriuria (presence of bacteria in urine), and positive nitrites, after passing large pieces of tissue with noticeable blood?

Immediate Hospitalization and Broad-Spectrum IV Antibiotics Required

This patient has obstructive pyelonephritis with a ureteral stent in place—a urologic emergency requiring immediate hospitalization, blood and urine cultures, IV antibiotics, and urgent urology consultation for possible stent removal or exchange. 1

Critical Clinical Assessment

This presentation represents complicated pyelonephritis with multiple high-risk features:

• Fever + flank pain + positive urinalysis confirms upper urinary tract infection 1, 2
• Indwelling ureteral stent automatically classifies this as a complicated UTI requiring aggressive management 2, 3
• Tissue passage with blood suggests obstruction, stone fragments, or infected debris—all requiring urgent imaging 1
• Bilateral ankle edema may indicate systemic inflammatory response, volume overload, or early renal dysfunction 2
• Positive nitrites + pyuria + bacteriuria confirms active bacterial infection 2, 4

Immediate Management Algorithm

1. Hospitalize Immediately

• Any patient with pyelonephritis who appears systemically ill requires IV antibiotics 1
• The presence of a foreign body (stent) with infection creates high risk for urosepsis 3, 5
• Tissue passage suggests possible obstruction requiring urgent intervention 1

2. Obtain Cultures Before Antibiotics

• Blood cultures (two sets) to assess for bacteremia 1
• Urine culture via catheterization with antimicrobial susceptibility testing is mandatory for complicated UTI 1, 2
• Do not delay antibiotic administration beyond obtaining cultures 1

3. Start IV Empiric Antibiotics

• Third-generation cephalosporin IV (ceftriaxone 1-2g daily or cefotaxime) is first-line for complicated pyelonephritis 1
• Alternative: IV fluoroquinolone (ciprofloxacin 400mg IV q12h or levofloxacin 750mg IV daily) if local resistance <10% 1, 6
• Do NOT use oral antibiotics initially given systemic illness and stent presence 1

4. Urgent Imaging Within 24 Hours

• CT scan with contrast or renal ultrasound to evaluate for:
  • Obstruction (stone, clot, stent malposition) 1
  • Perinephric abscess 1
  • Hydronephrosis 1
• Imaging is mandatory given tissue passage and stent presence 1, 2

5. Urgent Urology Consultation

• Stent may need immediate removal or exchange if obstructed or infected 7, 5
• Scheduled removal in 6 days is too late if stent is contributing to infection 5
• Infected foreign body requires removal for source control 3, 5

Critical Pitfalls to Avoid

Do not treat this as simple cystitis or uncomplicated UTI:

• The stent presence alone makes this complicated, requiring broader spectrum coverage and longer duration therapy 2, 3
• Outpatient oral antibiotics are inadequate for this presentation 1

Do not delay imaging:

• If fever persists >72 hours on appropriate antibiotics, obtain CT immediately 1
• Tissue passage strongly suggests obstruction requiring urgent evaluation 1

Do not assume the stent can wait 6 days:

• Infected stents are a source of persistent bacteremia and treatment failure 5
• Early removal/exchange may be necessary for clinical improvement 7, 5

Antibiotic Duration and Follow-up

• Total treatment duration: 10-14 days for complicated pyelonephritis 1
• Switch to oral antibiotics only after:
  • Afebrile for 48 hours 1
  • Hemodynamically stable 1
  • Culture results available to guide targeted therapy 1, 2
• Tailor antibiotics to culture sensitivities, using narrowest spectrum effective agent 1, 2

Additional Monitoring

• Serial renal function tests given bilateral edema and possible acute kidney injury 2
• Daily clinical assessment for sepsis progression (hypotension, altered mental status, oliguria) 1
• Repeat imaging if no improvement within 72 hours of appropriate therapy 1