antibiotic of choice for outpt pyelo management

[jdh71]

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With respect, just a note: if you think everyone else has the problem, you have the problem.

If you are being misunderstood so frequently and so strongly, I would think that the onus is on you to clear things up; I would not conclude that EM docs are just thin-skinned.

With respect.

Heh. With respect, I've REPEATED myself - gone out of my way to clear things up.

Now once I've done that. I'm pretty sure it's no longer *me* that has "the problem". 😉

 

[cpants]

Surely not every patient with pyelo needs imaging. Imaging should be obtained (or repeated) if not getting better after 24-48 hours of appropriate antibiotics to look for renal/perirenal abscess or obstructing stone. If the story is good for a stone, it should be done up front.

Not every patient with pyelo and a stone needs to be admitted. The key here is not the presence of the stone but the presence of obstruction. An obstructed kidney will not clear the infection, and in fact the patient will get sicker and can die without decompression. A non-obstructing stone does not warrant admission. These patients get treated like any other pyelo.

I would be very surprised if your urologists are encouraging you to send out pyelo patients with obstructing stones. In fact, it's wouldn't even be appropriate to wait for inpatient consultation in the morning. This is a true surgical emergency which requires urgent, middle-of-the-night decompression of the kidney with a stent or nephrostomy tube.

 

[RPedigo]

Honestly, I didn't know that people sent chest pain home that often. It seems anyone with chest pain and/or syncope gets an auto admit here

Emergency physicians will typically send home any low risk chest pain that can get an outpatient stress test within 72 hours (per guidelines), anything higher than low risk gets admitted (again, per guidelines). If it's low risk chest pain and you work in a resource-poor setting where you cannot get a 72-hour stress test, then per guidelines you must be admitted. Currently, if our outpatient stress test list is full, low risk chest pain may get admitted, or if it's a Friday on a holiday weekend where Monday is off and they can't do stress tests, etc. These are obviously systems issues and are suboptimal to patient care, and our hospital is working on expanding to prevent needless admissions. As an aside, my thoughts on low-risk chest pain and how I think the evidence shows it should be managed are much different than the current guidelines, but if something goes south you don't have a legal leg to stand on, so we have to over-treat/over-test low risk chest pain.

Emergency physicians will also typically send home any low-risk syncope, as defined by various clinical decision rules (ROSE, San Francisco, etc.) and gestalt. But if you have hypotension, anemia, CHF, a concerning EKG, are old, have lots of comorbidities, have a concerning story, etc. then you get admitted. I do not admit 30-something year olds with a good story for vasovagal syncope without comorbidities, but if an 80-year-old had a good story for vasovagal syncope, it might get admitted anyway.

Lastly, internal medicine residents have a huge bias when it comes to perception of what does and does not get admitted. Medicine residents often think we admit all "blank" where blank is any pathology that sometimes gets admitted. For instance, in this thread people thought all pyelo gets admitted -- which is not true. You just have the selection bias for the people we chose to admit for whatever reason (not tolerating PO, obstructing/infected stone, perinephric abscess, severe sepsis / septic shock). All the 20-year-old women we see with pyelo who are hemodynamically stable, tolerate PO, and have no comorbidities go a la casa and you never see that subset of patients.

 

[Bostonredsox]

I am surprised you are sending home infected stones. If there is any hydro at all, there is a physiologic obstruction to the flow of urine increasing the likelihood of outpatient failure.

If the patient looks well, is not vomitting, has no CVA tenderness and no fever how did you come to the conclusion they had pyelo?

Lastly, for all the admissions of low risk chest pain, syncope, chronic back pain in which the utiltiy of a tele admission or floor admission in general is 0, I'm surprised on the resistance to admit a patient with real pathology and a chance of turning south, quickly.

Do you guys routinely US your pts with pyelo? I would wager an acute pyelo with a clean US is unlikely to have any stone of significant size and thus unlikely to come in to me and JDH 24 hours later in florid uroseptic shock. No data to support this, but it would presume no hydro on US essentially rules out a stone >5mm.

 

[cpants]

Do you guys routinely US your pts with pyelo? I would wager an acute pyelo with a clean US is unlikely to have any stone of significant size and thus unlikely to come in to me and JDH 24 hours later in florid uroseptic shock. No data to support this, but it would presume no hydro on US essentially rules out a stone >5mm.

No and no. Again, the only thing that matters is obstruction. Your assumptions are all wrong here. No hydro on ultrasound means no obstruction, so yes that is reassuring and an appropriate interpretation of the test. However, an ultrasound with or without hydronephrosis does not rule out a kidney stone of any size. Ultrasounds are not very sensitive for detecting kidney stones. Furthermore, stones less than 5mm can and do cause obstruction.

 

[Bostonredsox]

No and no. Again, the only thing that matters is obstruction. Your assumptions are all wrong here. No hydro on ultrasound means no obstruction, so yes that is reassuring and an appropriate interpretation of the test. However, an ultrasound with or without hydronephrosis does not rule out a kidney stone of any size. Ultrasounds are not very sensitive for detecting kidney stones. Furthermore, stones less than 5mm can and do cause obstruction.

5mm and under can cause obstruction, but 5mm and under also has a greater than 50% chance of passing on its own.

Anyway just wondering if the modality was used much for pyelo in the Ed

 

[cpants]

5mm and under can cause obstruction, but 5mm and under also has a greater than 50% chance of passing on its own.

Anyway just wondering if the modality was used much for pyelo in the Ed

Imaging not really needed for any kind of routine pyelo. If the patient is very sick I would go right to CT. Ultrasound is a good study in equivocal cases because it is sensitive for hydronephrosis. If you rule out hydro you rule out obstruction for the most part. If there is hydro on ultrasound the patient needs a CT.

Chance of passage has no relevance in this setting. The 50% chance you quote is 50% chance of passage in the next 30 days. The patient is going to be dead in the next 2-3 days if they truly have pyelo in an obstructed system.

 

[Bostonredsox]

Imaging not really needed for any kind of routine pyelo. If the patient is very sick I would go right to CT. Ultrasound is a good study in equivocal cases because it is sensitive for hydronephrosis. If you rule out hydro you rule out obstruction for the most part. If there is hydro on ultrasound the patient needs a CT.

Chance of passage has no relevance in this setting. The 50% chance you quote is 50% chance of passage in the next 30 days. The patient is going to be dead in the next 2-3 days if they truly have pyelo in an obstructed system.

Fair enough

 

[BJJVP]

I agree with Boston's initial statement: no hydro on US equals no obstruction and therefore less risk for severe decompensation.

My understanding is that while US's ability to actually visualize the stone is dismal, it is good for identifying hydro. Therefore, the lack of hydronephrosis on US is fairly good at ruling out an obstructing stone. This makes sense as anecdotally, I've never seen a significant obstruction without associated hydronephrosis.

Having said that I dont routinely US pyelo because I have found that the H&P and UA alone is sufficient for differentiating an obstructing infected stone from simple pyelo or a simple nonifected ureteric stone. If there is a possibility for pyelo with concurrent stone/obstruction, I go straight to CT because the US is unlikely to identify the source of the obstruction or characterize it with sufficient detail (stone size and location) for the consultants down the line.

 

[cpants]

]I agree with Boston's initial statement: no hydro on US equals no obstruction and therefore less risk for severe decompensation.[/B]

My understanding is that while US's ability to actually visualize the stone is dismal, it is good for identifying hydro. Therefore, the lack of hydronephrosis on US is fairly good at ruling out an obstructing stone. This makes sense as anecdotally, I've never seen a significant obstruction without associated hydronephrosis.

Having said that I dont routinely US pyelo because I have found that the H&P and UA alone is sufficient for differentiating an obstructing infected stone from simple pyelo or a simple nonifected ureteric stone. If there is a possibility for pyelo with concurrent stone/obstruction, I go straight to CT because the US is unlikely to identify the source of the obstruction or characterize it with sufficient detail (stone size and location) for the consultants down the line.

That's not what he said exactly. He said he was looking for a stone size on ultrasound to make decisions, which is not the appropriate use of ultrasound. It may seem like splitting hairs, but it's an important distinction. Stone size means nothing. They could have a 2cm stone in the renal pelvis. No obstruction, no problem. But a 2mm stone in the distal ureter with mild hydro needs to go to the OR.

Your statements are correct though.

 

[Bostonredsox]

That's not what he said exactly. He said he was looking for a stone size on ultrasound to make decisions, which is not the appropriate use of ultrasound. It may seem like splitting hairs, but it's an important distinction. Stone size means nothing. They could have a 2cm stone in the renal pelvis. No obstruction, no problem. But a 2mm stone in the distal ureter with mild hydro needs to go to the OR.

Your statements are correct though.

noo thats exactly what i said. i said do you look for hydro. lack of hydro means lack of obstruction and thus less likely to come bak in septic shock. i said that lack of hydro also usually correlates with a small stone <5mm if one is in fact present. i never mentioned using the stone size as a dispo tool. the lack of hydro and thus lack of hydro is the dispo tool, which can be ruled out on us, whichis why i askef if you routinely use it in the first place.

 

[cpants]

Do you guys routinely US your pts with pyelo? I would wager an acute pyelo with a clean US is unlikely to have any stone of significant size and thus unlikely to come in to me and JDH 24 hours later in florid uroseptic shock. No data to support this, but it would presume no hydro on US essentially rules out a stone >5mm.

5mm and under can cause obstruction, but 5mm and under also has a greater than 50% chance of passing on its own.

Anyway just wondering if the modality was used much for pyelo in the Ed

noo thats exactly what i said. i said do you look for hydro. lack of hydro means lack of obstruction and thus less likely to come bak in septic shock. i said that lack of hydro also usually correlates with a small stone <5mm if one is in fact present. i never mentioned using the stone size as a dispo tool. the lack of hydro and thus lack of hydro is the dispo tool, which can be ruled out on us, whichis why i askef if you routinely use it in the first place.

Maybe I misinterpreted you, but my reading of your post was that you thought a negative ultrasound would rule out a stone >5mm (which it doesn't) and therefore that patient would be less likely to return in septic shock. Anyway, not trying to bust your chops, and if you are using an ultrasound to look for hydro (aka obstruction), then you are doing it right.

 

[Bostonredsox]

Maybe I misinterpreted you, but my reading of your post was that you thought a negative ultrasound would rule out a stone >5mm (which it doesn't) and therefore that patient would be less likely to return in septic shock. Anyway, not trying to bust your chops, and if you are using an ultrasound to look for hydro (aka obstruction), then you are doing it right.

perhaps it was my wording. A negative US with no hydro rules out an obstructive stone. Yes a stone can still be present and US is a bad modality to see stones. Also, the greater majority, no not all, but the majority of stones that cause obstructive uropathy are 5mm and up. So my de facto logic, I was saying, if most stones that can cause obstruction are >/= to 5mm, and you do an US which shows no hydro and thus no obstruction, it is unlikely that you have a stone >/= to 5mm, atleast not in a position where it would cause obstruction, as you have just proven there isnt one.

i suppose its irrelevant as the lack of obstruction is the only important part of that statement and the only part of it that would get used in an ED docs disposition.

So I guess you are technically correct, my wording was wrong and thus my original statement was incorrect. What I was trying to get it was do you all routinely US pyelos to eval for obstruction which in my mind, and I am not an ED doc, would definitely change my management and disposition. Particularly seeing it is fast, non invasive and non carcinogenic (just for you JDH)

 

[Apollyon]

But a 2mm stone in the distal ureter with mild hydro needs to go to the OR.

Maybe times have changed; when I was first out of residency, a uro attending in the community told me that he visualized mild hydro increasing the pressure, to help expel the stone. In the community, if I said that mild hydro needs to go to the OR, I think I would be laughed out the door, especially with no creatinine bump.

Quite honestly, if you could educate me, I would listen.

 

[med2UCC]

My urologists as well regard mild hydronephrosis as benign unless the stone is a whopper. Only the moderate to marked hydronephrosis goes to the OR,or the ones with infection, or creatinine rise or the really large stones,or those that don't pass in 2 days andl are still symptomatic. They do come every time we call though and review the patient. I only call if I am fairly certain the stone meets one or more of the above criteria. Most of our stones get xxx settled in emergency,then sent home with very specific instructions to return if they feel febrile,the pain worsens or sx do not settle in 2 days. They are also told to screen their urine. Cheers,
M
Oh,and we don't routinelyadmit pyelo,only if really sick and/or unable to tolerate PO intake or at the extremes of age or frail for some other reason.

 

[KYTNOH]

But a 2mm stone in the distal ureter with mild hydro needs to go to the OR.

Hydro is not a reason to go to the OR. I assume you didn't really mean that? Assuming no infection, renal colic is really just about pain and symptom control until the stone passes. Even a 1cm stone can go home with outpatient follow up for scheduled removal if symptoms (pain and vomiting) are controlled. Sending every 2mm stone with hydro to the OR, in my mind, is going to needlessly increase operative risk and cost when 90-something % will pass on their own within a couple days. As long as they have follow up with a urologist that can deal with a stone that won't pass there really is not a reason to admit assuming symptoms are controlled.

As for pyelo (true pyelo....not "my low back hurts"), I only admit if pregnant, have persistent vomiting or uncontrolled pain (rare), are elderly, or have failed outpatient therapy. I typically use bactrim or keflex. Our hospital has a fairly poor sensitivity to cipro.

 

[xaelia]

Actually the stuff you said you would send home are all stuff I admitted in the past 3 months >_> Honestly, I didn't know that people sent chest pain home that often.

Come work in Texas with me. If you can walk and you can eat, you can go home.

 

[cpants]

Maybe times have changed; when I was first out of residency, a uro attending in the community told me that he visualized mild hydro increasing the pressure, to help expel the stone. In the community, if I said that mild hydro needs to go to the OR, I think I would be laughed out the door, especially with no creatinine bump.

Quite honestly, if you could educate me, I would listen.

Hydro is not a reason to go to the OR. I assume you didn't really mean that? Assuming no infection, renal colic is really just about pain and symptom control until the stone passes. Even a 1cm stone can go home with outpatient follow up for scheduled removal if symptoms (pain and vomiting) are controlled. Sending every 2mm stone with hydro to the OR, in my mind, is going to needlessly increase operative risk and cost when 90-something % will pass on their own within a couple days. As long as they have follow up with a urologist that can deal with a stone that won't pass there really is not a reason to admit assuming symptoms are controlled.

As for pyelo (true pyelo....not "my low back hurts"), I only admit if pregnant, have persistent vomiting or uncontrolled pain (rare), are elderly, or have failed outpatient therapy. I typically use bactrim or keflex. Our hospital has a fairly poor sensitivity to cipro.

All of this is in the context of a patient you have diagnosed with pyelonephritis. Noninfected patient gets trial of passage and outpatient follow up (if there are no other indications to intervene). Obstructing stone with a fever, they need to go to the OR.

 

[KYTNOH]

All of this is in the context of a patient you have diagnosed with pyelonephritis. Noninfected patient gets trial of passage and outpatient follow up (if there are no other indications to intervene). Obstructing stone with a fever, they need to go to the OR.

Gotcha. I misunderstood. I thought you were saying you send all of your (noninfected) renal colic patients with hydro to the OR. 👍

 

[ORL10]

Yes the entire thread was regarding infected stones +/- obstruction.

Overall about 1/12 patients will have pyelo when having a stone based on urine culture. I can't see how sending home someone with a probable infected obstructing stone sounds reasonable. The kidney is vascular, there is a proximal infection, and a distal obstruction making bacteremia possible. Therefore in my mind if you have an obstruction and a story consistent with pyelo supported by vital signs/HPI and labs they should be admitted with emergent urology consultation.

If you have a stone and no obstruction and you suspect pyelo I guess it is more in the grey zone. I would probably ask myself what are the chances this patient came to my ed with a stone and pyelonephritis independent of one another. So likely either you don't have pyelo or one helped set up the other and resolution of both is dependent on stone clearance, which you can "somewhat" reliably predict based on stone size.