What is the appropriate diagnostic work‑up and management for a 34‑year‑old woman with cervical cancer treated with cisplatin and paclitaxel who presents with acute pyelonephritis, had a double‑J ureteral stent placed four days ago, and now has persistent leukocytosis with neutrophilia despite four days of ceftriaxone therapy?

Management of Persistent Leukocytosis in Cervical Cancer Patient with Acute Pyelonephritis Despite DJ Stent and Ceftriaxone

This patient requires urgent stent exchange or percutaneous nephrostomy (PCN) immediately, as antibiotics alone are insufficient in treating obstructive pyelonephritis and the persistent leukocytosis after four days of appropriate therapy indicates ongoing infection related to the colonized stent. 1, 2

Immediate Diagnostic Work-Up

Obtain cultures before any intervention:

• Blood cultures (at least two sets) to assess for bacteremia/sepsis 2
• Urine culture with antibiogram from a fresh specimen 2
• Stent culture when the device is removed, as colonized stents harbor polymicrobial biofilms that perpetuate infection 1

Imaging assessment:

• CT scan with contrast to evaluate for:
  • Perinephric stranding or abscess formation 3
  • Hydronephrosis severity 3
  • Ureteral obstruction from tumor progression versus stent malposition 3
  • Pyonephrosis (infected hydronephrosis), which requires urgent decompression 2

Key clinical indicators that mandate urgent intervention (already present in this patient):

• Leukocytosis >14,000/mm³ (likelihood ratio 3.7 for bacterial infection) 1
• Persistent fever and neutrophilia despite 4 days of appropriate antibiotics 1
• Presence of indwelling stent (infection rate 11-19% with colonized stents) 1

Urgent Management: Stent Exchange vs. PCN

Replace the colonized DJ stent immediately as the primary intervention, with PCN as an equivalent alternative. 1, 2

Rationale for stent exchange:

• The current stent is almost certainly colonized with biofilm-producing bacteria that are protected from antibiotic penetration 1
• Combining urgent decompression with IV ceftriaxone improves survival from ≈60% (antibiotics alone) to ≈92% 1
• Retrograde stent exchange is first-line for cervical cancer patients with obstructive uropathy 3

When to choose PCN instead:

• If retrograde stent placement fails technically 3
• If the patient develops septic shock with hypotension (PCN may be safer in unstable patients) 3, 2
• If there is tumor involvement of the ureterovesical junction making retrograde access difficult 3
• PCN provides larger-diameter drainage for pyonephrosis 2

Antibiotic Management

Continue ceftriaxone 1-2g IV daily as it remains the optimal empiric choice, demonstrating superiority over fluoroquinolones for obstructive pyelonephritis. 2, 4

Adjust antibiotics based on culture results:

• Targeted therapy reduces septic complications from ≈50% to ≈9% 1
• Common organisms colonizing stents include Klebsiella, which ceftriaxone covers effectively 2
• If cultures reveal resistant organisms, escalate to carbapenems (meropenem 1g IV three times daily or imipenem 0.5g IV three times daily) 4

Duration of therapy:

• Continue antibiotics until complete clinical and laboratory resolution: normalization of WBC, absence of fever, and sterile urine culture 1
• Typical duration is 10-14 days for β-lactams 4

Addressing the Underlying Cause

Assess for tumor progression causing obstruction:

• Cervical cancer can cause extrinsic ureteral compression leading to stent failure 3
• In advanced cervical carcinoma with obstruction, PCN may have higher technical success than retrograde stenting, especially with ureterovesical junction involvement or strictures >3cm 3

Risk factors for stent-related infection in this patient:

• Duration of stent placement is the principal modifiable risk factor 1
• Prior chemotherapy (cisplatin/paclitaxel) may cause neutropenia, increasing pyelonephritis risk 3
• Cervical cancer itself increases infection risk with indwelling devices 1

Follow-Up Management

Schedule routine stent exchanges every 3 months to prevent recurrent infections once acute infection resolves. 1, 2

Monitor for resolution:

• Daily WBC counts until normalization 1
• Temperature monitoring for defervescence 1
• Repeat urine culture 48-72 hours after stent exchange to confirm sterility on therapy 1

Reassess stent necessity:

• If obstruction is due to tumor progression, consider whether the patient is a candidate for further cancer-directed therapy versus palliative care 3
• In patients with advanced disease and poor prognosis, PCN may offer little benefit and can increase morbidity 3
• Remove the stent as soon as clinically feasible if obstruction resolves 1

Common Pitfalls to Avoid

• Do not continue antibiotics alone without addressing the colonized stent – this approach has only 60% survival versus 92% with decompression 1, 2
• Do not delay intervention awaiting culture results – persistent leukocytosis after 4 days of appropriate antibiotics mandates immediate action 1, 2
• Monitor closely for post-procedural sepsis – bacteremia commonly occurs when draining infected urinary tracts 2
• Do not assume the stent is functioning properly – malposition or encrustation can cause persistent obstruction despite stent presence 3