What is the best course of treatment for a patient with a history of sepsis and recent stent placement for a urinary stone obstruction, who is now experiencing flank pain, low-grade fever, hematuria, and leukocytes in their urine, with abnormal urinalysis and elevated white blood cell count, and is currently taking antibiotics?

Management of Recurrent Infection After Ureteral Stent Placement

This patient requires immediate hospital admission for IV antibiotics and urgent urological intervention to address persistent obstructive pyelonephritis with signs of ongoing infection despite oral antibiotic therapy. 1

Immediate Actions Required

Emergency Department Assessment

• Obtain blood cultures immediately (two sets) before administering antibiotics, as this patient has systemic signs of infection with fever and elevated WBC 1
• Start empiric IV antibiotics without delay - ceftriaxone 1-2g IV once daily is the first-line regimen for hospitalized patients with complicated UTI and obstructive pyelonephritis 2, 1
• Order contrast-enhanced CT scan to evaluate stent position, degree of hydronephrosis, and assess for complications such as abscess formation or persistent obstruction 2, 1
• Send urine culture via catheterization if clean-catch specimen cannot be obtained, with antimicrobial susceptibility testing 2, 1

Critical Recognition Points

This patient has obstructive pyelonephritis with sepsis, evidenced by:

• Recent hospitalization for sepsis and stone obstruction requiring emergency stent placement 1
• Persistent right-sided hydronephrosis/hydroureter despite stent placement 2
• Positive leukocytes and nitrites indicating gram-negative bacterial infection 1
• Elevated WBC count, fever, and systemic symptoms 1, 3
• Periureteral stranding on CT suggesting ongoing infection 1

The presence of diabetes mellitus and ureteral stones significantly increases the risk of urosepsis - this patient requires aggressive management 3

Urgent Urological Consultation

Stent Evaluation and Potential Intervention

• Request immediate urology consultation to evaluate stent function and need for intervention 1
• The CT findings of "mild right-sided hydronephrosis/hydroureter noted in the setting of a right-sided nephroureteral stent with right-sided delayed nephrogram" suggest inadequate drainage despite stent placement 2
• Stent malfunction or obstruction must be ruled out - options include stent exchange, percutaneous nephrostomy (PCN) placement, or additional drainage procedures 2, 1

Drainage Options

• PCN may be preferred if the patient remains unstable, has pyonephrosis, or needs larger drainage capacity (technical success rate 91-92%) 2, 1
• Retrograde stent exchange can be attempted if the patient stabilizes and a urologist is immediately available 1
• Ureteral stent placement has been shown safe and effective in obstructing stones with sepsis, though patients may experience higher documented fever rates 2

Antibiotic Management

Initial IV Therapy

• Ceftriaxone 1-2g IV once daily is the recommended first-line agent 2, 1
• Alternative regimens if ceftriaxone is contraindicated include:
  • Ciprofloxacin 400mg IV twice daily 2
  • Cefotaxime 2g IV three times daily 2
  • Cefepime 1-2g IV twice daily 2
• Consider adding an aminoglycoside (gentamicin 5-7mg/kg/day IV) for severe sepsis or if Pseudomonas is suspected 2, 4

Duration and De-escalation

• Total antibiotic duration should be 7-14 days depending on clinical response and source control 2, 1
• Tailor antibiotics once culture results return - adjust based on susceptibility patterns 2, 1
• Transition to oral therapy once afebrile for 24-48 hours and able to tolerate oral intake, using ciprofloxacin, levofloxacin, or trimethoprim-sulfamethoxazole based on sensitivities 5

Monitoring and Expected Recovery

Clinical Monitoring

• Monitor vital signs closely for sepsis progression - this patient has already had one episode of sepsis requiring 3-day hospitalization 1
• Expected defervescence within 48-72 hours of appropriate therapy - 95% of patients with uncomplicated pyelonephritis become afebrile within 48 hours, nearly 100% within 72 hours 5, 6
• Persistent fever beyond 72 hours indicates treatment failure and requires repeat imaging to evaluate for complications 5, 6

Imaging Follow-up

• Repeat CT imaging is indicated for patients with deep lacerations, clinical signs of complications (fever, worsening flank pain, ongoing blood loss), or persistent symptoms despite appropriate therapy 2, 5
• Common complications requiring extended recovery include renal or perinephric abscess formation, emphysematous pyelonephritis, and persistent obstruction 6

Critical Pitfalls to Avoid

Common Management Errors

• Delaying appropriate therapy worsens outcomes - failure to identify and relieve obstruction within 12 hours significantly worsens prognosis 6
• Inadequate initial antibiotic selection - oral β-lactams without initial parenteral dosing are insufficient for complicated UTI with sepsis 6
• Missing complications in high-risk patients - not obtaining imaging when fever persists beyond 72 hours can lead to poor outcomes 6
• Ignoring local resistance patterns - do not use ciprofloxacin empirically if local resistance rates exceed 10% or if the patient has used fluoroquinolones in the last 6 months 2

Source Control is Essential

• No attempt should be made to eradicate infection unless correctable urological abnormalities are addressed - treatment without source control results only in emergence of resistant organisms 7
• The stent must be functioning properly - inadequate drainage despite stent placement requires intervention 2, 1

Pain Management Considerations

This patient has been without adequate pain control after running out of pain medication and being denied refills by the urology office. While hospitalized:

• Provide appropriate analgesia for flank pain - this is a legitimate medical need 2
• Pain control should not be the primary reason for admission but is an important component of comprehensive care 2
• Coordinate outpatient pain management with urology before discharge to prevent recurrence of this situation 2