Management and outcome of obstructive ureteral stones in the emergency department: Emphasis on urine tests and antibiotics usage

High risk and low prevalence diseases: Infected urolithiasis

INTRODUCTION

Infected urolithiasis is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of infected urolithiasis, including presentation, diagnosis, and management in the emergency department based on current evidence.

DISCUSSION

Although urolithiasis is common and the vast majority can be treated conservatively, the presence of a concomitant urinary tract infection significantly increases the risk of morbidity, to include sepsis and mortality. Identification of infected urolithiasis can be challenging as patients may have symptoms similar to uncomplicated urolithiasis and/or pyelonephritis. However, clinicians should consider infected urolithiasis in toxic-appearing patients with fever, chills, dysuria, and costovertebral angle tenderness, especially in those with a history of recurrent urinary tract infections. Positive urine leukocyte esterase, nitrites, and pyuria in conjunction with an elevated white blood cell count may be helpful to identify infected urolithiasis. Patients should be resuscitated with fluids and broad-spectrum antibiotics. Additionally, computed tomography and early urology consultation are recommended to facilitate definitive care.

CONCLUSIONS

An understanding of infected urolithiasis can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Predicting Sepsis in Patients with Ureteral Stones in the Emergency Department

BACKGROUND

In the absence of overt infectious signs, clinical criteria for early intervention in patients with ureteral stones are poorly defined. We aimed to develop a model that can identify patients who are at risk for developing sepsis if discharged home from the emergency department (ED).

MATERIALS AND METHODS

We retrospectively reviewed patients between January 2010 and December 2019 who were discharged from the ED after diagnosis of ureteral stones. The primary outcome was sepsis requiring urgent surgical decompression. We used multivariable logistic regression to identify predictors of sepsis. We refined the model using backwards stepwise regression with a threshold p-value 0.05.

RESULTS

We identified 1,331 patients who were discharged from the ED with ureteral stones. Of these patients, 22 (2%) subsequently developed sepsis requiring urgent decompression. In the initial multivariable model, female gender (OR 2.82, p=0.039) and urine white blood cells (WBC) (OR 1.02 per cell count, p<0.001) were predictive of sepsis. After performing backwards stepwise regression, female gender, urine WBC, and leukocytosis (WBC > 15,000/mm3) met criteria for inclusion in the model. A logistic model including these variables predicted sepsis with an internally cross-validated area under the curve of 0.79. Among patients with urine cultures completed in the ED, rates of sepsis were 9% in patients with positive cultures and 1% in patients with negative cultures (p<0.001). Antibiotic usage was not protective against developing sepsis.

CONCLUSIONS

Sepsis is a rare complication among patients with ureteral stones selected for conservative management. The presence of elevated urine WBC and female gender can help identify patients who are at risk of developing sepsis. Patients with risk factors should be managed with an increased index of suspicion for infection and may benefit from early intervention to reduce the risk of sepsis. Sepsis is more common in patients with positive urine cultures.