struvite and Sepsis

This study aims to identify clinical factors that may predispose struvite stone patients to urosepsis following percutaneous nephrolithotomy (PCNL).. A retrospective review was conducted on patients who received PCNL for struvite stones. The Systemic Inflammatory Response Syndrome (SIRS) criteria and quick-Sepsis Related Organ Failure Assessment (q-SOFA) criteria were used to identify patients who were at an increased risk for urosepsis. Statistical analysis was performed using Fisher's exactness test, Wilcoxon rank test, and logistic regression.. Chart review identified 99 struvite stone patients treated with PCNL. Post-operatively, 40 patients were SIRS positive (≥2 criteria) and/or q-SOFA positive (score ≥2). Using SIRS as an approximation for urosepsis, longer operative times (p<0.001), higher pre-operative white blood cell counts (p=0.01), greater total stone surface area (p<0.0001), and pre-operative stenting (OR, 5.75; p=0.01) were identified as independent risk factors for urosepsis. Multivariate analysis demonstrated pre-operative stenting (OR, 1.46; p=0.01) to be a risk factor. With q-SOFA, univariable analysis found that antibiotic use within 3 months prior to a PCNL (OR, 4.44; p=0.04), medical comorbidities (OR, 4.80; p=0.02), longer operative times (p<0.001), lengthier post-operative hospitalization (p<0.01), and greater total stone surface area (p<0.0001) were risk factors for urosepsis. Multivariate analysis revealed that bladder outlet obstruction (OR, 2.74; p<0.003) and pre-operative stenting (OR, 1.27; p=0.01) significantly increased odds of being q-SOFA positive.. Several risk factors for urosepsis following PCNL for struvite stones have been identified. These risk factors should be taken into consideration in peri-operative care to mitigate the risks of urosepsis.

Topics: Adult; Aged; Female; Humans; Kidney Calculi; Male; Middle Aged; Nephrolithotomy, Percutaneous; Postoperative Complications; Retrospective Studies; Risk Factors; Sepsis; Struvite; Urinary Tract Infections

To examine urine and stone bacteriology of struvite stone formers in a large cohort of patients undergoing percutaneous nephrolithotomy (PCNL).. A total of 1191 patients, with stone and urine cultures, treated with PCNL for renal calculi were included in the study. Statistical differences were assessed using Mann-Whitney U and T-tests.. Stone cultures were positive in 72% of patients with struvite stones. Urea-splitting organisms accounted for only half of the positive stone cultures. Enterococcus (9/50, 18%), Proteus (9/50, 18%), and Escherichia coli (6/50, 12%) were the most commonly identified organisms. Notably, two-thirds of struvite formers with negative stone culture had at least one positive culture for a urea-splitting organism on urine culture going back 1 year from the time of surgery. A majority (67%) of struvite stone cultures were found to be resistant to first- and second-generation cephalosporins.. The bacteriology of struvite stones has shifted away from traditional urea-splitting organisms and antibiotic coverage must be expanded to include organisms such as Enterococcus that do not respond to cephalosporins. Causative organisms may be found by going back in time to identify the initial organism that could have induced struvite stone formation to inform preventative therapy.

Topics: Adult; Enterococcus; Escherichia coli; Escherichia coli Infections; Female; Humans; Kidney Calculi; Male; Middle Aged; Nephrolithotomy, Percutaneous; Proteus; Proteus Infections; Sepsis; Streptococcal Infections; Struvite; Tertiary Care Centers; Urea; Urinalysis

Some patients undergoing percutaneous nephrolithotomy (PCNL) have purulent fluid in the pelvicaliceal system at the time of puncture, although preoperative features are not suggestive of infection. We report the management and outcome of 19 such patients.. Among the 639 patients who underwent PCNL at our center from July 2000 to October 2003, 19 had purulent fluid in the kidney at initial puncture. The preoperative findings, operative details, hospital course, and final outcome in these patients were analyzed. Twelve patients had stone removal at the first sitting (option 1), while seven had a nephrostomy tube placed initially with stone removal deferred for 3 to 7 days (option 2).. With option 1, stones were cleared with one to three tracts in 45 to 120 minutes. Seven patients recovered smoothly, three had transient fever, while one had grade I and another had grade II sepsis. The purulent fluid grew E. coli in two cases and Proteus or Serratia in one case each and was sterile in eight. With option 2, stones were cleared using one to three tracts in 60 to 100 minutes. The fluid grew E. coli or Klebsiella in one case each and was sterile in five. Three patients had a smooth recovery, two had transient fever, one had grade I sepsis, and another had grade II sepsis. Risk factors for sepsis, irrespective of the option, were a recent history of febrile urinary-tract infection, borderline elevation of total leukocyte count, thick or foul pus as opposed to mere turbidity, the use of a single tube or tract or delayed creation of second tracts, and operating time >90 minutes.. Despite normal preoperative urine and blood values, one may find purulence on puncture during PCNL, which is not always infected. If any one or more of the above risk factors is present, it is safer to drain the kidney initially, making sure that all blocked calices are drained, inserting multiple tubes if necessary.

Topics: Adult; Calcium Oxalate; Female; Fever; Gram-Negative Bacteria; Gram-Negative Bacterial Infections; Humans; Kidney Calculi; Kidney Calices; Kidney Pelvis; Magnesium Compounds; Male; Middle Aged; Nephrostomy, Percutaneous; Phosphates; Risk Factors; Sepsis; Struvite; Suppuration; Treatment Outcome