Is a 5-day lack of response from a urologist's office to a patient's concerns about a possible urinary tract infection (UTI), despite multiple attempts to contact them, considered patient abandonment, given the patient's history of kidney stones, sepsis, and recent hospital discharge for stent placement, and current symptoms including flank pain, low-grade fever, and positive test results for leukocytes and nitrites, while taking Augmentin (amoxicillin/clavulanate)?

Patient Abandonment in Post-Stent Placement UTI Management

Yes, a 5-day complete lack of response to multiple urgent communications from a post-surgical patient with signs of obstructive pyelonephritis and sepsis risk constitutes patient abandonment and represents a serious breach of the standard of care.

Clinical Context: This is a Urologic Emergency

This patient presents with a constellation of findings that classify this as a high-priority urologic emergency requiring immediate attention:

• Recent obstructive kidney stone with sepsis requiring emergency stent placement just 3 days prior 1
• Flank pain, fever, and positive urinalysis (leukocytes 75/uL, nitrites 1+, WBC 5-9, bacteria present) indicating likely obstructive pyelonephritis or stent-related infection 1, 2
• Blood and tissue in urine suggesting possible stent complications or ongoing stone disease 2
• Recent history of sepsis placing this patient at extremely high risk for recurrent urosepsis, which can be fatal 1, 3

Obstructed kidneys with signs of infection represent a consensus high-priority emergency across all urological associations and should never be postponed 1. The European Association of Urology explicitly states that patients with obstructed kidneys with or without signs of infection, especially those at higher risk of rapid renal impairment, should undergo urgent evaluation 1.

Why This Constitutes Patient Abandonment

Failure to Provide Timely Response

The urologist's office failed to respond through multiple communication channels over 5 days:

• Phone message to office
• Patient portal message
• After-hours triage line (which appropriately directed patient to ED)
• Two additional appointment requests
• Request for pain medication
• Messages to answering service

The European Association of Urology guidelines explicitly recommend providing patients with a telephone number for urgent consultation and red flag symptoms 1. This patient exhibited multiple red flags (fever, flank pain, positive infection markers) that should have triggered immediate response 1, 2.

Breach of Post-Operative Care Obligations

• Post-operative patients require accessible follow-up, particularly after emergency surgery for sepsis 1
• The patient was only 3 days post-discharge from emergency stent placement for obstructive stone with sepsis—a critical period for monitoring complications 1, 4
• Stent-related infections and complications are well-recognized risks that require prompt evaluation 1, 4

Clinical Consequences of Delayed Care

The patient's condition warranted urgent attention because:

• Obstructive pyelonephritis can rapidly progress to sepsis and death if not promptly treated 3
• The patient had already experienced one episode of sepsis from the same underlying condition 1
• Patients requiring emergency surgery for obstructed kidneys with infection are at high risk for recurrent infectious complications 4
• The urinalysis findings (positive leukocytes, nitrites, WBC, bacteria) combined with systemic symptoms (fever, flank pain) meet diagnostic criteria for complicated UTI requiring culture and possible antibiotic adjustment 2, 5

Appropriate Standard of Care Response

The urologist's office should have:

1. Responded within 24 hours maximum to the initial contact, given the post-operative status and infection concerns 1
2. Provided same-day or next-day evaluation for a post-surgical patient with fever and flank pain 1
3. Arranged urgent urine culture to assess for antibiotic resistance, particularly important given recent hospitalization and instrumentation 4
4. Evaluated stent position and function via imaging if infection symptoms persisted despite antibiotics 1
5. Considered empiric antibiotic adjustment if Augmentin was inadequate, as patients with recent ureteroscopy/stent placement have significantly higher rates of antibiotic resistance (odds ratio 6.95) 4

Telemedicine as Minimum Standard

Even during resource-limited situations, the European Association of Urology states that not having a specific telemedicine application is not a reason for not providing care—even a simple phone call can help temporize urological issues and concerns 1. A 5-minute phone call could have:

• Assessed symptom severity
• Ordered urgent urine culture
• Adjusted antibiotics empirically
• Arranged imaging or office visit
• Prevented multiple ED visits

Legal and Ethical Implications

Patient abandonment occurs when a physician terminates the physician-patient relationship without reasonable notice and without ensuring continuity of care. In this case:

• The physician-patient relationship was clearly established through recent emergency surgery 1
• The patient made reasonable attempts to contact the physician through appropriate channels 1
• The physician failed to respond or arrange alternative coverage during vacation 1
• The patient suffered harm (multiple ED visits, ongoing pain, potential progression of infection) as a direct result 1

The European Association of Urology explicitly recommends that urologists provide telephone numbers for urgent consultation and avoid unnecessary visits to the hospital by triaging appropriately 1. Complete failure to respond violates this fundamental standard.

Critical Pitfalls Highlighted by This Case

• Never leave post-operative patients without accessible coverage, especially after emergency surgery for sepsis 1
• Fever and flank pain in a stented patient is pyelonephritis until proven otherwise and requires urgent evaluation 1, 2
• Recent instrumentation dramatically increases antibiotic resistance risk—Augmentin may be inadequate 4
• Multiple ED visits by a post-surgical patient signal a failure of outpatient management and should trigger immediate physician contact 1