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Early Discharge Following Decompression for Sepsis and an Obstructing Stone? A Multi-Institutional Study to Identify Predictors of Antibiotics Sensitivity
Timothy Tran, MD1, Madeline Cancian, MD1, Egor Parkhomenko, MD2, Mantu Gupta, MD2, Gyan Pareek, MD1.
1Alpert Medical School at Brown University, Providence, RI, USA, 2Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Background: Patients presenting with sepsis and an obstructing stone undergo urgent urinary tract decompression. Following this, patients are hospitalized for hemodynamic support and broad spectrum antibiotics. Urine culture results are used to tailor outpatient antibiotic therapy. At times patients achieve early clinical stability but remain hospitalized while awaiting antibiotic sensitivities. We sought to identify predictors of antibiotic resistance that may allow clinicians to select candidates for discharge on empiric oral antibiotics prior to culture results being available.
Methods: All patients that underwent emergent urinary tract decompression for sepsis and an obstructing ureteral stone over the last 2 years at the two above institutions were included. Clinical factors, including urine culture sensitivities and patient demographics were recorded. Student’s t-test and the chi-squared test were used to identify statistical difference.
Results: 134 patients were identified that met inclusion criteria. Eighty-four patients (62.7%) had urine cultures with antibiotic resistance. Comparison was made between patients with pan-sensitive and resistant urine cultures (Table 1). Patients with resistant cultures were more likely to have had previous urologic surgery (44.7% vs. 22.0%, p = 0.008) - the most notable difference was in patients that had had previous ureteroscopy (38.9% vs. 8.0%, p = 0.0002). Those with resistant cultures were more likely to require postoperative ICU-level care (27.1% vs. 12.0%, p = 0.039), have bacteremia (48.2% vs. 24.0%, p = 0.005) and a longer length of stay (5.4 vs. 3.4 days, p = 0.026). Resistance patterns were noted to be similar between the two institutions (Table 2).
Conclusions: Patients that have had previous urologic surgery, especially ureteroscopy, appear to be poor candidates for early discharge on empiric antibiotics prior to the completion of urine culture results due to a higher likelihood of having antibiotic resistance. These results were noted to be consistent at both institutions participating in this study.
Table 1. Differences in demographic and clinical factors between patients with resistant and sensitive urine cultures. | | | | | Sensitive (n = 50) | Resistant (n = 84) | p value | | Age | 59.9 years | 58.9 years | 0.763 | | Gender | 22.0% male | 27.1% male | 0.516 | | BMI | 31.2 kg/m2 | 31.8 kg/m2 | 0.874 | | Diabetes | 22.0% | 22.4% | 0.962 | | Paraplegia | 2.0% | 4.7% | 0.425 | | Stone Size | 6.7 mm | 7.6 mm | 0.249 | | WBC, serum | 15.0 | 15.9 | 0.403 | | Temperature | 99.3°F | 100.4°F | 0.489 | | Systolic Blood Pressure | 113 mmHg | 113 mmHg | 0.782 | | Heart Rate | 107 bpm | 109 bpm | 0.498 | | Previous Urologic Surgery | 22.0% | 44.7% | 0.008 | | Previous Ureteroscopy | 8.0% | 38.9% | 0.0002 | | Previous PCNL | 4.0% | 7.1% | 0.471 | | ICU admission (postop) | 12.0% | 27.1% | 0.039 | | Length of stay, mean | 3.4 days | 5.4 days | 0.026 | | Positive Blood Culture | 24.0% | 48.2% | 0.005 |
Table 2. Antibiotic resistance patterns noted by institution | | | | | Antibiotic | Providence, Rhode Island | New York, New York | p value | | Ampicillin / sulbactam | 12.3% | 60.0% | 0.0002 | | Aztreonam | 7.7% | 10.0% | 0.746 | | Cephalexin | 13.8% | 30.0% | 0.212 | | Ciprofloxacin | 35.4% | 45.0% | 0.619 | | Gentamicin | 16.9% | 30.0% | 0.330 | | Levofloxacin | 29.2% | 45.0% | 0.302 | | Meropenem | 1.5% | 5.0% | 0.378 | | Piperacillin / tazobactam | 3.1% | 20.0% | 0.009 | | Trimethoprim / sulfamethoxazole | 29.5% | 45.0% | 0.302 |
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