What are the next steps for a female patient with a history of urinary stone obstruction and sepsis, who is experiencing flank pain, low-grade fever, and hematuria with leukocytes 3 days after discharge from the hospital and stent placement, despite being on antibiotics?

Management of Recurrent Infection After Ureteral Stent Placement

This patient requires urgent urologic evaluation with strong consideration for stent exchange or removal, as she has developed recurrent obstructive pyelonephritis with persistent symptoms despite antibiotics, and the current stent may be colonized or malpositioned. 1

Critical Clinical Context

This patient's presentation is concerning for stent-associated obstructive pyelonephritis, not simple stent irritation:

• Fever, flank pain, leukocytosis, and positive urinalysis (leukocytes + nitrites) indicate active infection 2
• Persistent moderate hydronephrosis with delayed nephrogram and periureteral stranding on CT suggests ongoing obstruction despite stent placement 1
• The combination of leukocyte esterase OR nitrite has 88% sensitivity and 79% specificity for UTI, with nitrite alone having 98% specificity 1
• Blood and tissue in urine with elevated inflammatory markers are NOT normal stent symptoms 2

Why the Urologist's Office Response Was Inadequate

The dismissal of symptoms as "normal with a stent" represents a dangerous misinterpretation:

• Mechanical stent irritation causes urgency, frequency, and dysuria—not fever, flank pain, and leukocytosis 3
• The negative urine culture does NOT exclude infection in this context, as she was already on antibiotics which can suppress culture growth while infection persists 2
• Imaging findings of hydronephrosis with enhancement of the renal pelvis suggest pyelonephritis, not simple stent discomfort 2

Immediate Next Steps

1. Urgent Urologic Re-evaluation (Within 24-48 Hours)

The patient needs direct urologic assessment, not phone triage, given:

• Recurrent symptoms within days of initial sepsis episode 1
• CT findings showing persistent obstruction and inflammatory changes 2
• Risk of progression to urosepsis, which carries 27.3% mortality in obstructed patients versus 11.2% without obstruction 4

2. Stent Exchange or Removal Should Be Strongly Considered

The main risk factor for device-related urinary infections is the length of time the device remains in place, and colonized stents can serve as a nidus for recurrent infection: 1

• Stents commonly become colonized with Klebsiella and other uropathogens 1
• Routine stent exchanges every 3 months prevent recurrent infection 1
• In this case, the stent was placed during active sepsis and may have been colonized from the outset 1

3. Imaging Confirmation of Stent Position

Follow-up CT imaging should be performed for patients with clinical signs of complications such as fever, worsening flank pain, or ongoing symptoms: 2

• The CT already shows the stent is in position BUT there is persistent moderate hydronephrosis 2
• This suggests the stent may be inadequate for drainage or partially obstructed 2

4. Antibiotic Management Adjustment

If the patient remains symptomatic despite current antibiotics:

• Fluoroquinolones and cephalosporins are the only agents recommended for empiric treatment of pyelonephritis 2
• Nitrofurantoin and fosfomycin should be avoided as there are insufficient data regarding their efficacy for pyelonephritis 2
• Ceftriaxone 1-2g IV daily demonstrates superiority over fluoroquinolones in obstructive pyelonephritis 1
• Targeted prophylaxis based on prior culture results (from the initial sepsis episode) reduces sepsis complications from 50% to 9% 1

Common Pitfalls to Avoid

Pitfall #1: Assuming Negative Culture Means No Infection

• Patients on antibiotics frequently have suppressed culture growth while maintaining active infection 2
• Clinical and imaging findings trump culture results in this scenario 2

Pitfall #2: Attributing All Symptoms to "Normal Stent Discomfort"

• Fever, leukocytosis, and inflammatory changes on imaging are NEVER normal stent symptoms 3
• Stent-related symptoms are mechanical (urgency, frequency, dysuria) and resolve after removal 3

Pitfall #3: Delaying Intervention in Obstructive Pyelonephritis

• Antibiotics alone are insufficient in treating acute obstructive pyelonephritis—decompression is essential 1
• Medical therapy without decompression has only 60% survival compared to 92% with percutaneous nephrostomy 1
• Urinary obstruction is an important complicating factor with significantly higher mortality (27.3% vs 11.2%) 4

Pitfall #4: Accepting Phone Triage for Post-Sepsis Complications

• Patients with recent urosepsis who develop recurrent symptoms require direct evaluation, not phone management 1
• Close monitoring for worsening sepsis is required, as postprocedural bacteremia and sepsis are common when infected urinary tracts are drained 1

Risk Stratification for This Patient

This patient has multiple high-risk features for complications:

• Recent hospitalization for sepsis (within 2 weeks) 5
• Female gender (higher risk for infectious complications) 5
• Indwelling ureteral stent (long duration increases infection risk) 5
• Persistent hydronephrosis despite stent placement 2
• Recurrent symptoms within days of discharge 1

Specific Action Plan

1. Contact urology office and explicitly request urgent appointment (within 24-48 hours) for stent evaluation 1
2. If fever exceeds 101°F or symptoms worsen, return to ER immediately 2
3. Request consideration for stent exchange or cystoscopy to assess stent position and function 1
4. Ensure antibiotic coverage is appropriate for pyelonephritis (fluoroquinolone or cephalosporin, NOT nitrofurantoin) 2
5. If urologist remains unavailable or dismissive, seek second opinion from another urologist or return to ER for admission 1

When to Return to Emergency Department

Immediate ER evaluation is warranted for: 2

• Temperature >101°F (38.3°C) 2
• Worsening flank pain despite pain medication 2
• Nausea/vomiting preventing oral intake 2
• Confusion, altered mental status, or signs of sepsis (rapid heart rate, low blood pressure) 1
• Inability to urinate or decreased urine output 2