Diagnosis: Stent Colonization with Persistent Leukocytosis (Not Active Infection)
This patient most likely has asymptomatic bacterial colonization of her DJ stent rather than an active urinary tract infection, and ceftriaxone should be discontinued since she has been afebrile for 48 hours and hemodynamically stable. 1, 2
Understanding Stent Colonization vs. Active Infection
The key distinction here is critical for appropriate management:
- Colonization occurs rapidly after DJ stent placement, with bacterial biofilm formation beginning within 2 weeks and present in 28-44% of stents 3, 4
- Asymptomatic bacteriuria in patients with ureteral stents reflects device colonization, not true infection, and should not be treated as it promotes multidrug-resistant bacteria 1, 2
- Active infection requires clinical symptoms: fever ≥38.3°C, flank pain, signs of sepsis (hypotension, tachycardia), or progressive clinical deterioration 1, 2, 5
Your patient is afebrile for 48 hours and hemodynamically stable, which strongly indicates colonization rather than active infection despite the elevated WBC count. 1
Why the Leukocytosis Persists
Several factors explain persistent leukocytosis in this context:
- Recent chemotherapy with cisplatin and paclitaxel can cause bone marrow dysregulation and reactive leukocytosis independent of infection 1
- The DJ stent itself acts as a foreign body, triggering inflammatory responses that elevate WBC counts without true infection 4, 6
- Stent colonization with biofilm formation (present in 30-44% of cases by day 4) causes local inflammation but not systemic infection 3, 4
- Cervical cancer itself can produce paraneoplastic leukocytosis 1
Recommended Management Algorithm
Immediate Actions (Next 24-48 Hours):
1. Discontinue ceftriaxone since clinical criteria for active infection are not met (afebrile >48 hours, stable hemodynamics) 1, 2
2. Obtain urine culture if not already done, but do not treat asymptomatic bacteriuria even if positive 1, 2
3. Monitor clinical parameters, not laboratory values:
- Temperature every 6 hours 1
- Blood pressure and heart rate 1
- Flank pain or new symptoms 1, 2
- Renal function (creatinine, urea) 1
Short-Term Management (Next 2-4 Weeks):
4. Schedule routine stent exchange at 3 months or sooner if high-risk features develop 1, 5
5. Consider targeted prophylaxis at the time of stent exchange based on urine culture obtained 2-3 days before the procedure (typically ceftriaxone or ampicillin/sulbactam) 1, 5
Long-Term Strategy:
6. Plan for definitive stent removal when oncologically appropriate, as infection risk correlates directly with duration of placement 1, 5
7. If stent must remain long-term, implement routine 3-month exchanges to prevent obstruction and reduce infectious episodes (cost $3,000 per exchange vs. $40,000 per infection episode) 1
Critical Pitfalls to Avoid
Do not treat based on WBC count alone in the absence of fever or clinical deterioration—this is the most common error in stent management 1, 2
Do not continue antibiotics for "persistent leukocytosis" when the patient is clinically well, as this drives multidrug-resistant organisms 1, 2
Do not obtain repeat urine cultures to "prove clearance" in asymptomatic patients with stents—colonization is expected and normal 1, 2
Do not remove the stent prematurely based on colonization alone unless there are symptoms of obstruction or true infection 1
When to Restart Antibiotics
Restart empiric antibiotics (ceftriaxone 1-2g daily or piperacillin/tazobactam 3.375-4.5g TID) immediately if any of these develop: 7, 5
- Fever ≥38.3°C 1, 2
- New or worsening flank pain 1
- Hemodynamic instability (hypotension, tachycardia) 1, 2
- Rising creatinine suggesting obstruction 1
- Clinical deterioration of any kind 1
Special Considerations in This Patient
Immunosuppression from recent chemotherapy (last dose on [DATE]) increases her risk for progression from colonization to true infection, warranting closer clinical surveillance 7, 8
Female sex and underlying malignancy are risk factors for stent colonization (64% in women vs. 35% in men), but this still does not warrant treatment in the absence of symptoms 3, 8
The stent is necessary for obstructive uropathy from cervical cancer, so removal is not an option until the cancer is controlled—focus on symptom-based management and scheduled exchanges 7, 1