What is the treatment approach for a patient with an Extended-Spectrum Beta-Lactamase (ESBL) urinary tract infection, a ureteral stent, and a nephrostomy tube, and how does the management plan change if the stent is removed?

Management of ESBL UTI with Ureteral Stent and Nephrostomy Tube

For a patient with ESBL urinary tract infection who has both a nephrostomy tube and ureteral stent in place, continue appropriate antimicrobial therapy for 7-14 days regardless of whether the stent remains or is removed, as both devices provide adequate urinary drainage and the treatment duration is determined by infection severity rather than drainage method. 1, 2, 3

Primary Management Strategy

Immediate antimicrobial therapy:

• Start empiric broad-spectrum antibiotics immediately with ceftriaxone or ampicillin-sulbactam while awaiting culture sensitivities, as this reduces serious sepsis-related complications from 50% to 9% in high-risk patients 2
• Obtain blood and urine cultures before initiating antibiotics, then adjust therapy based on sensitivities 2
• For confirmed ESBL organisms, carbapenems (ertapenem, imipenem, meropenem) are the most effective agents 4, 5
• Alternative oral options for ESBL E. coli include fosfomycin (94.9% susceptibility), pivmecillinam (96% susceptibility), and nitrofurantoin (93% susceptibility) 6, 5

Treatment duration:

• Short courses (≤7 days) are as effective as longer courses (>7 days) for complicated ESBL UTIs, with equivalent 30-day mortality rates (5.7% vs 5%) and reinfection rates (8.6% vs 10%) 3
• Extend to 14 days for severe presentations with sepsis, bacteremia, or significant comorbidities 4, 3

Device Management Considerations

The nephrostomy tube has already been exchanged, which is appropriate:

• Both nephrostomy tubes and ureteral stents provide adequate urinary drainage to allow antibiotic penetration and infection resolution 7
• The main goals are preserving renal function and ensuring adequate drainage, which both devices accomplish 7

If the stent is removed, treatment approach does NOT fundamentally change:

• The nephrostomy tube alone provides sufficient drainage for infection management 7
• Continue the same antimicrobial regimen for the planned duration 1, 2
• The presence or absence of the stent does not alter antibiotic choice or duration—the infection itself dictates treatment 3

Critical Device-Specific Considerations

Colonization vs. infection distinction:

• Asymptomatic bacteriuria in patients with indwelling devices reflects colonization, not infection, and should NOT be treated 1
• Only treat symptomatic infections with fever, flank pain, leukocytosis, or signs of sepsis (hypotension, tachycardia) 1, 2
• Focus on clinical symptoms rather than culture results for treatment decisions 1

Infection risk factors with devices:

• Internal double-J stents have an 11% infection rate and colonize rapidly after placement 2, 8
• Risk factors for stent-related infection include: duration >30 days (bacteriuria rate increases from 4.2% to 34% after 90 days), female sex (24.3% vs 13.9% in males), diabetes mellitus (33.3%), chronic renal failure (39.6%), and diabetic nephropathy (44.4%) 8
• Routine stent replacement every 3 months (or more frequently in high-risk patients) is cost-effective compared to treating infectious complications ($3,000 per exchange vs $40,000 per infection episode) 1

Ongoing Management Algorithm

While devices remain in place:

• Monitor for clinical symptoms of infection rather than obtaining surveillance cultures 1
• Check renal function (creatinine, urea) to detect obstruction 1
• Perform periodic imaging (ultrasound) to evaluate for hydronephrosis 1
• Consider targeted prophylactic antibiotics based on colonizing organisms from urine culture obtained a few days before scheduled exchanges, which is more protective than standard prophylaxis 1

Device removal timing:

• Remove devices definitively when clinically possible to eliminate ongoing infection risk 1
• Infection risk correlates directly with duration of device placement 2
• If stent is removed but nephrostomy tube remains, continue monitoring for obstruction and infection as above 7

Common Pitfalls to Avoid

Do not treat asymptomatic bacteriuria:

• Treating colonization promotes multidrug-resistant bacteria without clinical benefit 1
• Distinguish between device colonization (biofilm formation) and true infection requiring treatment 1, 2

Do not use inadequate antibiotics:

• Avoid fluoroquinolones (20.7% susceptibility), trimethoprim-sulfamethoxazole (34.3%), and ampicillin-clavulanate (42.9%) for ESBL organisms 5
• Third-generation cephalosporins are ineffective against ESBL producers 9

Do not remove drainage prematurely:

• Maintain adequate urinary drainage throughout the infection treatment course 7
• Whether via nephrostomy tube alone or combined with stent, drainage must be preserved until infection resolves 7

Monitor for sepsis progression:

• Infected obstructed systems can rapidly progress to urosepsis requiring urgent intervention 7, 2
• Women with systemic disease (diabetes, renal failure) are at highest risk for premature device removal due to septicemia (77.8% of cases) 8