A 52-year-old man with a 10-year history of recurrent calcium oxalate stones presents with acute left flank pain and fever (38.5°C). Urinalysis shows pyuria and hematuria. NCCT abdomen reveals a 15 mm stone in the left proximal ureter with moderate hydronephrosis and perinephric fat stranding. Serum creatinine is 2.2 mg/dL (baseline 1.0 mg/dL). Blood cultures are pending. What is the most appropriate immediate management?

Explanation

## Management of Obstructive Pyelonephritis with Ureteric Stone **Key Point:** Obstructive pyelonephritis (infected obstructed kidney) is a urological emergency. The infected urine proximal to the obstruction cannot drain, leading to sepsis and rapid renal deterioration. Decompression takes precedence over definitive stone removal. ### Pathophysiology 1. **Infected urine trapped above obstruction** → increased intraluminal pressure → pyelovenous/pyelolymphatic backflow → bacteremia and sepsis. 2. **Rapid renal damage** if not decompressed within 24–48 hours. 3. **Mortality risk** if septic shock develops without urgent drainage. ### Management Algorithm ```mermaid flowchart TD A[Obstructive pyelonephritis suspected]:::outcome --> B[Blood cultures + UA + imaging]:::action B --> C{Fever + obstruction confirmed?}:::decision C -->|Yes| D[Start broad-spectrum IV antibiotics]:::action D --> E[Urgent decompression needed]:::urgent E --> F{Anesthetic risk?}:::decision F -->|High risk/unstable| G[Percutaneous nephrostomy]:::action F -->|Stable/low risk| H[Ureteric stent or ureteroscopy]:::action G --> I[Infection control, renal function recovery]:::outcome I --> J[Definitive stone management after 4–6 weeks]:::action H --> K[Simultaneous stone removal + drainage]:::outcome ``` ### Why Percutaneous Nephrostomy First? | Reason | Explanation | |---|---| | **Rapid decompression** | Immediate drainage of infected urine; can be done under local anesthesia if patient unstable | | **Sepsis control** | Allows antibiotics to reach therapeutic levels; reduces bacteremia | | **Renal function recovery** | Creatinine often improves after drainage | | **Safer than ureteroscopy** | Avoids manipulation of infected urinary tract during acute sepsis | | **Allows definitive treatment later** | Stone can be managed electively (ureteroscopy, ESWL, PCNL) after infection resolves | **High-Yield:** The acronym **"INFECTED STONE"** — **I**mmediately decompress, **N**ephrostomy preferred, **F**ever + obstruction = emergency, **E**arly antibiotics, **C**reatinine rises, **T**reat stone later, **E**nd sepsis first, **D**rainage before definitive therapy. **Clinical Pearl:** If the patient is hemodynamically stable and anesthesia risk is low, ureteric stent placement or ureteroscopy with simultaneous stone removal may be attempted, but this requires experienced urologists and carries higher risk of urosepsis if manipulation is prolonged. ### Antibiotic Regimen - **First-line:** Ceftriaxone (1–2 g IV 12-hourly) + gentamicin (5–7 mg/kg IV daily) or fluoroquinolone (levofloxacin 750 mg IV daily) - **Adjust based on culture and sensitivity** once results available - **Duration:** Minimum 7–14 days IV, then oral step-down based on clinical response **Warning:** Do NOT attempt ureteroscopy or ESWL in acute sepsis without prior decompression — this risks worsening bacteremia and septic shock.