Can a ureteric stent be placed in a patient with an active urinary tract infection?

Can Ureteric Stents Be Placed in Active UTI?

Yes, ureteric stents can and should be placed in the setting of active urinary tract infection when there is concurrent urinary obstruction, as this represents obstructive pyelonephritis requiring emergent decompression—antibiotics alone are insufficient and decompression is lifesaving. 1, 2

Clinical Context: When Stenting is Indicated Despite Active Infection

Obstructive Pyelonephritis/Pyonephrosis

• Retrograde ureteral stenting is a first-line treatment option for obstructive pyelonephritis alongside antibiotic therapy, with equivalent efficacy to percutaneous nephrostomy (PCN). 1, 2
• Urinary tract decompression can be lifesaving in patients with pyonephrosis (hydronephrosis with infection), with patient survival of 92% when decompression is performed versus only 60% with medical therapy alone. 1, 2
• Antibiotics alone are insufficient in treating acute obstructive pyelonephritis—decompression is mandatory for survival. 1, 2

Choice Between Stent vs. PCN

• Either retrograde ureteral stenting or PCN are acceptable for emergent drainage depending on local practice preferences, patient stability, and comorbidities. 1
• PCN may be preferred in unstable or septic patients with hypotension, as it provides larger tube decompression and has higher technical success rates in certain scenarios. 1, 2
• Retrograde stenting shows decreased duration of hospital stay and ICU admission rates compared to PCN, though prolonged guidewire manipulation can increase urosepsis risk. 2

Critical Management Algorithm

Step 1: Immediate Antibiotic Coverage

• Start empiric broad-spectrum IV antibiotics immediately before any instrumentation, with ceftriaxone 1-2g IV daily as first-line therapy. 3, 2
• Ceftriaxone demonstrates superiority over fluoroquinolones (ciprofloxacin) in both clinical and microbiological cure rates for obstructive pyelonephritis. 1, 2
• Preprocedural antibiotics reduce serious sepsis-related complications from 50% to 9% in high-risk patients. 3

Step 2: Obtain Cultures

• Collect blood and urine cultures before initiating antibiotics, then adjust therapy based on sensitivities. 3, 4
• PCN can yield superior bacteriological information compared to bladder urine cultures alone, improving pathogen identification. 1

Step 3: Emergent Decompression

• Proceed with either retrograde ureteral stenting or PCN placement emergently—do not delay for infection clearance. 1, 2, 4
• The decision for emergent versus urgent placement depends primarily on clinical symptoms of sepsis (fever, hypotension, tachycardia). 1

Important Caveats and Pitfalls

Risk of Postprocedural Sepsis

• Postprocedural bacteremia and sepsis are common when infected urinary tracts are drained—close monitoring is required immediately intraprocedure and postprocedure. 1, 2, 4
• This risk does not contraindicate the procedure; rather, it mandates appropriate antibiotic coverage and monitoring.

Stent Colonization Despite Sterile Urine

• A sterile urine culture does not rule out stent colonization—31% of patients with sterile urine cultures have colonized stents. 5
• Stent colonization occurs in 54% of cases even with sterile urine, most commonly with Enterococcus, E. coli, and Staphylococcus. 5
• Prophylactic antibiotics must cover both gram-negative uropathogens and gram-positive bacteria including enterococci when manipulating existing stents. 5

Non-Obstructive UTI Without Obstruction

• In simple UTI without obstruction, routine stent placement is not indicated and would only add morbidity from stent-related symptoms and infection risk. 1, 6
• Internal double-J ureteral stents have an 11% infection rate and are particularly prone to bacterial colonization and biofilm formation. 3, 6

Post-Procedure Management

Stent Maintenance

• Schedule routine stent exchanges every 3 months to prevent recurrent infection, as infection risk correlates directly with duration of placement. 3, 2
• Periodic reassessment of device necessity with removal when no longer required is essential. 3

Definitive Treatment Timing

• Delay definitive stone treatment until sepsis is resolved, then plan for stent removal once underlying pathology is definitively treated and infection cleared. 2