Protocol improves pyelonephritis/sepsis management

San Francisco-Implementation of a hospital-wide clinical care protocol for managing obstructive pyelonephritis (OPN) and sepsis from stones shows potential for improving patient outcomes, according to the experience of researchers at New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York.

The protocol was developed as a collaborative project between the departments of urology and interventional radiology.

Although both retrograde ureteral stenting and percutaneous nephrostomy (PCN) tube insertion are considered acceptable first-line options for intervention and there are no data to suggest either method has superior outcomes, the protocol takes into account some limited evidence that PCN tube placement could be a better initial approach in septic patients because it potentially requires less manipulation, fails less often, and can be performed with less need for general anesthesia, said Elisabeth M. Sebesta, MD, urology resident at Columbia, working with Ojas Shah, MD, and colleagues.

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To evaluate effects of the protocol on patient outcomes, the investigators conducted a retrospective analysis of data collected from patients presenting in the 12 months before and after its implementation, which occurred in May 2016. The number of patients seen in the pre- and post-protocol periods was similar (43 and 40, respectively), and the two groups had similar demographics and clinical presentations.

In a study presented at the 2018 AUA annual meeting in San Francisco, the investigators reported that utilization of PCN tubes increased after implementation of the protocol compared with the preceding 12 months (38% vs. 21%, p=.09). The comparison between the two periods also showed a significant reduction in mean time to intervention following protocol implementation (312 vs. 450 min, p=.05). There was a nonsignificant decrease in mean hospital length of stay by about 1 day (4.3 vs. 5.2 days, p=.42), and a similar number of patients required intensive care unit admission after intervention (22.5% vs. 16.3%, p=.47). There were no patient deaths in the post-protocol cohort, while during the preceding year, one patient died after retrograde stenting.

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“Obstructive pyelonephritis with sepsis requires urgent intervention with ureteral stenting or PCN. Only a few studies have compared PCN and ureteral stenting for management of patients with OPN and sepsis. We feel that minimizing the time to intervention may be the most critical factor for getting the best outcome, and so we collaborated with the department of interventional radiology to develop a pathway to expedite and streamline patient evaluation and management,” Dr. Sebesta said.

“Our initial experience shows that we were successful, which we believe is due to engaging both departments in the care of these complex and acutely ill patients. By having both teams available and ready to intervene in this critical clinical scenario, we are hoping that our overall outcomes continue to improve for these patients.”

Speaking to Urology Times, Dr. Sebesta suggested that the protocol works well because decision points are based on clear and simple metrics. Patients presenting with OPN from stones preferentially undergo PCN unless they are without hydronephrosis or have a coagulopathy prohibiting safe PCN placement.

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“According to the protocol, however, urologists remain the gatekeeper and can opt to place a retrograde stent if they feel it will be safer or faster,” Dr. Sebesta said.

The investigators noted that to their knowledge, few if any institutions have established a care pathway such as theirs for patients with OPN and sepsis due to stones. Based on their positive experience and outcomes, they believe others should consider implementing something similar to improve and expedite patient care.

“Additionally, an approved protocol prevents the debate that can occur between the two specialties (urology and interventional radiology) involved in the care of these patients,” Dr. Sebesta said.

Going forward, Dr. Sebesta and colleagues are analyzing their data to see if they can identify an interventional time frame for optimizing patient outcomes.

“There is no data to suggest a time threshold for intervention with PCN or stenting. We hope we might gain some insight on this issue by looking at our data,” Dr. Sebesta told Urology Times.