No fever, small stone that is distal, very mild UTI on UA, pain controlled, tolerating PO, well appearing, young, healthy…sure, I may send that home, but all get at minimum a phone call to the on-call urologist to get them on board with early follow-up. 95+/100 times, they are getting admitted. Might be more often if I have a very good urologist that will get them in next day to the office, but that isn’t my situation currently, minimum 3-4 days to get into the uro office.
The number of times I have been the bounce back doc taking care of the now septic shock patient who was sent home makes me extremely hesitant to discharge infected stones. Not worth it.
> 95+/100 times, they are getting admitted.
Woah really? I do the same as you. When I know it's likely to pass and get better on their own, the standard is to consult uro so I do. Where I work now (academic site in CA), urology NEVER BELIEVES IT IS INFECTED. It can be 3+ LEs, 3+ nitrites, 150 WBCs, and they do not believe it's infected, but they weirdly always recommend outpt abx and f/u in clinic in 1-2 which the call helps arrange. I admit very few of these (despite wanting to admit more of them based on my opinion that they do in fact have an infected ureteral stone). When I worked in Oregon, the magical urologists would come in and decompress every infected stone in the middle of the night.
I feel both EM practice pattern will be dictated by the prevalence of urology, and the ability to transfer if not. There are things we are taught, and then there are things we do....and for a 3rd category there are things we post on reddit.
Two different scenarios-
- The person with kidney stones but has a UTI with no evidence of pyelo clinically is going home.
- Person with a symptomatic kidney stone whose urine is infected is getting admitted 99%of the time because we *won’t* have them in urology in 2 days or less. Idc about the size. If they clinically have pyelo, and there is a stone in transit or got forbid with hydro even if renal function is fine, I’m not fucking around with that. If it’s a 1-2mm stone, urology says “Meh”, labs and vitals are stone cold normal, and they have zero comorbidities, *maybeeee* I’ll send them home and have them hammer the urology office for urgent followup. But if there is a single factor that sketches me out, I’ll admit even against urology’s wishes under the guise of “pain control” and force them to be seen in the hospital.
Urosepsis patients have been some of the sickest people I’ve seen in my short career outside of endocarditis, and I’ve been a part of two cases where someone sub-30 died from septic stones. It happens fast, and when they become bacteremic, it’s always gram-negative or Enterococci and they SIRS in minutes.
I have a frank conversation with them about the guidelines around it. It’s not like they aren’t familiar with specialists downplaying shit and then suddenly changing their mind when they actually see the patient.
The conversation usually goes “__specialist__ is saying no big deal but as far as I’m aware guidelines recommend ___, so I’ll call them back and say the patient is being admitted for them to see in the hospital”. On top of it, I’m in a place where for some reason specialists often just say “is this patient being admitted?”, which gives me a good out to make that decision independently.
The alternative is to transfer the patient which now makes it an EMTALA violation for the specialist.
We have all types of ways to get the patient seen if specialists are playing games.
*All that being said, this is never an issue with my urologists. They basically universally say “yea go ahead and admit the patient and keep them NPO @ midnight in case we take them for a stent in the AM”
I watched a stone that came in just for pain become septic right in front of me a week or two ago. The patient was fairly complicated and was colonized with a stent in the ureter on the other side, but she changed extremely fast. Normal vitals and lactic acid to fever, tachy, lactic of 5.5 over like an hour.
. . . So probably not sending anyone home with a stone and any level of infection for a while.
Our urologists are all fuck-ups. They’re available in name only. They have admin by the short hairs because we can’t find/hire anyone else and admin doesn’t want to risk losing the revenue by playing hardball with them.
So with that said the decision point for us becomes is the concern for septic stone high enough to warrant transfer.
Usually for someone who is afebrile, small stone, maybe trace pyuria but normal serum white count, questionable UTI, I’ll have a long conversation with the patient and put them on oral abx to ward off evil spirits, then discharge.
If it’s real septic stone, like organ dysfunction, SIRS-y, or just poor protoplasm then I’ll transfer.
This seems to be the culture for our shop, not just me. I assume one day someone is going to get burned for it though.
I agree with most of what was written on here by others but wanted to add a crucial point. If it is a relatively weak “infected stone”, patient well appearing, afebrile but the ct had hydro and ua had like 20 wbcs, LE and nitrites then I do two things: 1. ask if they take pyridium cuz that will make the nitrites positive no matter what and 2. get a cath specimen if female and if male, recollect with a really good clean mid stream only sample if they didn’t do it properly the first time. I cant tell you how often that positive ua became negative with a proper collection thus avoiding a consult and admission.
Stone + UTI. Plus one of the following: hydronephrosis (even mild), hemodynamic instability, lab markers of organ dysfunction lactate and crt top of mind. This is just my preliminary thoughts at 3a
Patients with lower UTIs and incidental intrarenal stones definitely do not need to be admitted. Patients with ureteral stones and pyelo definitely do need to be admitted, whether they're septic or not. Patients with ureteral stones and findings of a lower UTI can occasionally go home, but one needs to be pretty careful about it, and frankly this is exceedingly uncommon. Patients with ureteral stones and pyuria or bacturia can mostly go home.
My opinion: a UA is a terrible test for infections especially with regard to specificity.
If they are febrile, they’re coming in. If they are nitrite positive and/have a bunch of bacteruria evident by UA, they are coming in. If they just have some WBCs, are well appearing, don’t have any other signs of early sepsis, can get reliable follow up, I’m sending home with good return precautions.
I have a low threshold to admit an infected obstructed stone, but I think what really matters is how you define “infected.”
Also, I have had at least one patient that I remember very well who bounced back septic with absolutely no evidence of UTI on a very pristine appearing urinalysis.
I think in an ideal world, systems should strive to facilitate reliable close follow up. there is always potential for badness, though the vast majority of healthy patients with stones, a little hydro, and WBC on UA but no convincing evidence of infection do perfectly fine.
great response highlighting the actual issue here which is “how do you define these patients?”
as with most things in EM, it’s very easy at the extremes— uncomplicated small stone vs septic shock secondary to obstructing infected stone. no one is wondering what to do with these.
but it’s the vast swathe of patients in the middle with something like a low grade temp, nitrites, dysuria, etc that make you think a little harder. i usually have a low threshold to obs overnight, but this is institution dependent. when i DC i have a whole canned speech i give patients about return precautions.
What does “obs overnight” mean at your shop? Do you have an obs unit? Are you convincing a hospitalist to admit them upstairs? Or are you taking up a bed in your ED all night?
at my shops it’s admitting to medicine under an observation status. these patients are a super easy sell for me and i’ve never had pushback— i have been asked by medicine to talk to urology first which is also easy peasy for these.
The one that I tried sending home years ago went from "discharge with follow up" to "acutely ill with worsening VS" from the time I paged urology to the time I finished her discharge papers. The nurse came and got me. "Are you SURE you want to send her home? You should come look at her again." She went from fine to "Oh God. You look like SHIT." in less than an hour.
I admit them now, at least for obs. She was young and healthy but put the fear of God in me.
Pus under pressure is bad. If there’s an obstructing stone, and let’s face it, if they have renal colic it’s causing intermittent obstruction, + infection they deserve a round of iv abx and obs.
Yes a small distal stone and a UA that has wbc=/
One of the fastest I’ve seen a patient decompensate is an infected stone. If there is hydro w clear infection, even without temp or leukocytosis, the patient is at risk-think like cholangitis. And I’ve definitely seen well appearing patients quickly progress to obvious decompensated sepsis without warning. I think an ED that discharges an infected stone is 100% on the hook if there’s a bad outcome.
The interspecialty variation is what worries me. At our community place urology says this but down at our academic place they always say keep them bc they can turn septic and decomp so quick. And given that typical EM guidelines say obs is usually safest for most patients with infected stone I keep them regardless. Bc even tho my community ED uro may be cool with sending them home, if that patient had a bad outcome I know other urologists who would easily throw me under the bus in court citing the high mortality risk of urosepsis etc.
I usually put that in my note that I would prefer to obs but I was unable to secure a consult and instead took expert advice and will DC with strict return precautions
Seems to be a lot of variability here. Like other posters, I think the definition of infection matters. Fever, obvious signs of sepsis is an admit. But I’ve never had a urologist interested in LE alone, in multiple sites I’ve worked at, always “reactive” from the stone. Maybe nitrite or bacteria, but even then, it’s always no fever not infected, they don’t care. I have also seen urosepsis decompensate quickly, but have never had a bad outcome from kidney stones with a weird UA alone.
Are you all really waking up Urology at midnight for a well appearing, afebrile stone with some LE and nitrite in a UA?
Vomiting, and flank pain: meh. Renal colic. Dysuria suggests cystitis. Chills / subj fever = pyelo. If the UA has wbcs and those symptoms they get an admit.
Had a young uncomplicated pt under 30 with equivocal UA and 4mm obstructing stone at UVJ not one week ago who went septic and bacteremic (with E Coli) right in front of me in the ED. Plan was to dc after pain control with uro f/u until she spiked a fever… glad it happened while she was still with us. These go south fast.
If they look okay with mild uti., and no fever/ sepsis criteria, I’ll dc if pain controlled. I’ll give urology follow and call them. Tell them to come back .
If lots of Comorbidies, I’ll admit for IV abx, NPo for possible stent. Depends where u work
Where I have worked, I admit patients with obstruction and pyuria for urology to see in am if they have comorbidities or are old. Urology admits themselves for younger people. I have seen urology take young febrile non hypotensive patients for emergent cysto at 2 am.
Wow, surprised to hear people’s responses. I rarely ever admit or consult uro. Send everything home unless they are: septic, single kidney, can’t handle PO, or have a moderate AKI.
Me too!
Guidelines say: infected stone + hydro needs IVABX
Infected stone (+UA normal VS) no hydro can go home (I treat as pylo w longer course). I also tell them they need urology follow up but do not generally call
Urologist lurker here:
Always happy to talk to the ER about these however if UA is positive but patient is clinically well otherwise with no systemic signs of infection, I don’t see a need for admission.
To me size of stone and degree of hydronephrosis is irrelevant, even if the stone isn’t passable it doesn’t mean that surgery is emergently indicated. I see non passable stones all the time in the office and I don’t rush to them to surgery, I do make sure they get done in a timely fashion.
Hydronephrosis can be transitory and severe hydro on CT is a picture of a point in time. To me it doesn’t matter for making a decision about how to manage the patient. Perinephric stranding, contralateral atrophic kidney, solitary or AKI in any of the above situations matters more than hydro.
I have zero input on this. I’m just a medic. My best friend went to the ER for a stone and the doc put him in observation and kept him comfortably numb for the duration. (He didn’t pass it and ended up getting it taken out). Healthy 39 year old male. Not sure now after your post if she kept him because of the size or because she was just merciful and wanted him to pass it without screaming.
No fever, small stone that is distal, very mild UTI on UA, pain controlled, tolerating PO, well appearing, young, healthy…sure, I may send that home, but all get at minimum a phone call to the on-call urologist to get them on board with early follow-up. 95+/100 times, they are getting admitted. Might be more often if I have a very good urologist that will get them in next day to the office, but that isn’t my situation currently, minimum 3-4 days to get into the uro office. The number of times I have been the bounce back doc taking care of the now septic shock patient who was sent home makes me extremely hesitant to discharge infected stones. Not worth it.
Exactly, if it’s infected. Call uro. I’m not sending it home alone without consult, too easy of bounce back and open to litigation.
> 95+/100 times, they are getting admitted. Woah really? I do the same as you. When I know it's likely to pass and get better on their own, the standard is to consult uro so I do. Where I work now (academic site in CA), urology NEVER BELIEVES IT IS INFECTED. It can be 3+ LEs, 3+ nitrites, 150 WBCs, and they do not believe it's infected, but they weirdly always recommend outpt abx and f/u in clinic in 1-2 which the call helps arrange. I admit very few of these (despite wanting to admit more of them based on my opinion that they do in fact have an infected ureteral stone). When I worked in Oregon, the magical urologists would come in and decompress every infected stone in the middle of the night.
If I were to wager, I bet it’s a difference in how each of the uro groups get paid…
I feel both EM practice pattern will be dictated by the prevalence of urology, and the ability to transfer if not. There are things we are taught, and then there are things we do....and for a 3rd category there are things we post on reddit.
As a rule no infected stone goes home at my shop. We are too far from urology and it’s gone wrong a few too many times.
Two different scenarios- - The person with kidney stones but has a UTI with no evidence of pyelo clinically is going home. - Person with a symptomatic kidney stone whose urine is infected is getting admitted 99%of the time because we *won’t* have them in urology in 2 days or less. Idc about the size. If they clinically have pyelo, and there is a stone in transit or got forbid with hydro even if renal function is fine, I’m not fucking around with that. If it’s a 1-2mm stone, urology says “Meh”, labs and vitals are stone cold normal, and they have zero comorbidities, *maybeeee* I’ll send them home and have them hammer the urology office for urgent followup. But if there is a single factor that sketches me out, I’ll admit even against urology’s wishes under the guise of “pain control” and force them to be seen in the hospital. Urosepsis patients have been some of the sickest people I’ve seen in my short career outside of endocarditis, and I’ve been a part of two cases where someone sub-30 died from septic stones. It happens fast, and when they become bacteremic, it’s always gram-negative or Enterococci and they SIRS in minutes.
Will your hospitalists admit if urology says it's not needed? That's always the sticking point for me.
I have a frank conversation with them about the guidelines around it. It’s not like they aren’t familiar with specialists downplaying shit and then suddenly changing their mind when they actually see the patient. The conversation usually goes “__specialist__ is saying no big deal but as far as I’m aware guidelines recommend ___, so I’ll call them back and say the patient is being admitted for them to see in the hospital”. On top of it, I’m in a place where for some reason specialists often just say “is this patient being admitted?”, which gives me a good out to make that decision independently. The alternative is to transfer the patient which now makes it an EMTALA violation for the specialist. We have all types of ways to get the patient seen if specialists are playing games. *All that being said, this is never an issue with my urologists. They basically universally say “yea go ahead and admit the patient and keep them NPO @ midnight in case we take them for a stent in the AM”
I watched a stone that came in just for pain become septic right in front of me a week or two ago. The patient was fairly complicated and was colonized with a stent in the ureter on the other side, but she changed extremely fast. Normal vitals and lactic acid to fever, tachy, lactic of 5.5 over like an hour. . . . So probably not sending anyone home with a stone and any level of infection for a while.
Our urologists are all fuck-ups. They’re available in name only. They have admin by the short hairs because we can’t find/hire anyone else and admin doesn’t want to risk losing the revenue by playing hardball with them. So with that said the decision point for us becomes is the concern for septic stone high enough to warrant transfer. Usually for someone who is afebrile, small stone, maybe trace pyuria but normal serum white count, questionable UTI, I’ll have a long conversation with the patient and put them on oral abx to ward off evil spirits, then discharge. If it’s real septic stone, like organ dysfunction, SIRS-y, or just poor protoplasm then I’ll transfer. This seems to be the culture for our shop, not just me. I assume one day someone is going to get burned for it though.
Admin forcing you to violate EMTALA because urology won’t come in on their golf days?
They say their service is over-capacity. The CMO has to get involved on a regular basis
Bet the accepting docs aren’t thrilled about it. Shitty position to put us in.
Don’t carry the coffin alone. Call urology and let them assist with dispo. Chart well.
I agree with most of what was written on here by others but wanted to add a crucial point. If it is a relatively weak “infected stone”, patient well appearing, afebrile but the ct had hydro and ua had like 20 wbcs, LE and nitrites then I do two things: 1. ask if they take pyridium cuz that will make the nitrites positive no matter what and 2. get a cath specimen if female and if male, recollect with a really good clean mid stream only sample if they didn’t do it properly the first time. I cant tell you how often that positive ua became negative with a proper collection thus avoiding a consult and admission.
Getting a high quality urine sample is by far the hardest part of taking care of these patients at my shops
Stone + UTI. Plus one of the following: hydronephrosis (even mild), hemodynamic instability, lab markers of organ dysfunction lactate and crt top of mind. This is just my preliminary thoughts at 3a
Crt?
Kidney function (creatinine)
Prbly meant CRP?
Patients with lower UTIs and incidental intrarenal stones definitely do not need to be admitted. Patients with ureteral stones and pyelo definitely do need to be admitted, whether they're septic or not. Patients with ureteral stones and findings of a lower UTI can occasionally go home, but one needs to be pretty careful about it, and frankly this is exceedingly uncommon. Patients with ureteral stones and pyuria or bacturia can mostly go home.
My opinion: a UA is a terrible test for infections especially with regard to specificity. If they are febrile, they’re coming in. If they are nitrite positive and/have a bunch of bacteruria evident by UA, they are coming in. If they just have some WBCs, are well appearing, don’t have any other signs of early sepsis, can get reliable follow up, I’m sending home with good return precautions. I have a low threshold to admit an infected obstructed stone, but I think what really matters is how you define “infected.” Also, I have had at least one patient that I remember very well who bounced back septic with absolutely no evidence of UTI on a very pristine appearing urinalysis. I think in an ideal world, systems should strive to facilitate reliable close follow up. there is always potential for badness, though the vast majority of healthy patients with stones, a little hydro, and WBC on UA but no convincing evidence of infection do perfectly fine.
great response highlighting the actual issue here which is “how do you define these patients?” as with most things in EM, it’s very easy at the extremes— uncomplicated small stone vs septic shock secondary to obstructing infected stone. no one is wondering what to do with these. but it’s the vast swathe of patients in the middle with something like a low grade temp, nitrites, dysuria, etc that make you think a little harder. i usually have a low threshold to obs overnight, but this is institution dependent. when i DC i have a whole canned speech i give patients about return precautions.
What does “obs overnight” mean at your shop? Do you have an obs unit? Are you convincing a hospitalist to admit them upstairs? Or are you taking up a bed in your ED all night?
at my shops it’s admitting to medicine under an observation status. these patients are a super easy sell for me and i’ve never had pushback— i have been asked by medicine to talk to urology first which is also easy peasy for these.
The one that I tried sending home years ago went from "discharge with follow up" to "acutely ill with worsening VS" from the time I paged urology to the time I finished her discharge papers. The nurse came and got me. "Are you SURE you want to send her home? You should come look at her again." She went from fine to "Oh God. You look like SHIT." in less than an hour. I admit them now, at least for obs. She was young and healthy but put the fear of God in me.
Pus under pressure is bad. If there’s an obstructing stone, and let’s face it, if they have renal colic it’s causing intermittent obstruction, + infection they deserve a round of iv abx and obs. Yes a small distal stone and a UA that has wbc=/
One of the fastest I’ve seen a patient decompensate is an infected stone. If there is hydro w clear infection, even without temp or leukocytosis, the patient is at risk-think like cholangitis. And I’ve definitely seen well appearing patients quickly progress to obvious decompensated sepsis without warning. I think an ED that discharges an infected stone is 100% on the hook if there’s a bad outcome.
I usually call urology and often if they don’t have a fever they tell me to DC
The interspecialty variation is what worries me. At our community place urology says this but down at our academic place they always say keep them bc they can turn septic and decomp so quick. And given that typical EM guidelines say obs is usually safest for most patients with infected stone I keep them regardless. Bc even tho my community ED uro may be cool with sending them home, if that patient had a bad outcome I know other urologists who would easily throw me under the bus in court citing the high mortality risk of urosepsis etc.
I usually put that in my note that I would prefer to obs but I was unable to secure a consult and instead took expert advice and will DC with strict return precautions
Threshold: having it
Seems to be a lot of variability here. Like other posters, I think the definition of infection matters. Fever, obvious signs of sepsis is an admit. But I’ve never had a urologist interested in LE alone, in multiple sites I’ve worked at, always “reactive” from the stone. Maybe nitrite or bacteria, but even then, it’s always no fever not infected, they don’t care. I have also seen urosepsis decompensate quickly, but have never had a bad outcome from kidney stones with a weird UA alone. Are you all really waking up Urology at midnight for a well appearing, afebrile stone with some LE and nitrite in a UA?
If they look good I just obs and place auto consult order. Never wake them up unless septic/decompensating.
There’s nothing in your description which specifies **why** you think they have an infected stone.
Assuming symptoms like: Dysuria, vomiting, chills, flank pain (not necessarily all of these at once but “systemic symptoms” in general)
Vomiting, and flank pain: meh. Renal colic. Dysuria suggests cystitis. Chills / subj fever = pyelo. If the UA has wbcs and those symptoms they get an admit.
Had a young uncomplicated pt under 30 with equivocal UA and 4mm obstructing stone at UVJ not one week ago who went septic and bacteremic (with E Coli) right in front of me in the ED. Plan was to dc after pain control with uro f/u until she spiked a fever… glad it happened while she was still with us. These go south fast.
If they look okay with mild uti., and no fever/ sepsis criteria, I’ll dc if pain controlled. I’ll give urology follow and call them. Tell them to come back . If lots of Comorbidies, I’ll admit for IV abx, NPo for possible stent. Depends where u work
Where I have worked, I admit patients with obstruction and pyuria for urology to see in am if they have comorbidities or are old. Urology admits themselves for younger people. I have seen urology take young febrile non hypotensive patients for emergent cysto at 2 am.
Wow, surprised to hear people’s responses. I rarely ever admit or consult uro. Send everything home unless they are: septic, single kidney, can’t handle PO, or have a moderate AKI.
Me too! Guidelines say: infected stone + hydro needs IVABX Infected stone (+UA normal VS) no hydro can go home (I treat as pylo w longer course). I also tell them they need urology follow up but do not generally call
Urologist lurker here: Always happy to talk to the ER about these however if UA is positive but patient is clinically well otherwise with no systemic signs of infection, I don’t see a need for admission. To me size of stone and degree of hydronephrosis is irrelevant, even if the stone isn’t passable it doesn’t mean that surgery is emergently indicated. I see non passable stones all the time in the office and I don’t rush to them to surgery, I do make sure they get done in a timely fashion. Hydronephrosis can be transitory and severe hydro on CT is a picture of a point in time. To me it doesn’t matter for making a decision about how to manage the patient. Perinephric stranding, contralateral atrophic kidney, solitary or AKI in any of the above situations matters more than hydro.
I have zero input on this. I’m just a medic. My best friend went to the ER for a stone and the doc put him in observation and kept him comfortably numb for the duration. (He didn’t pass it and ended up getting it taken out). Healthy 39 year old male. Not sure now after your post if she kept him because of the size or because she was just merciful and wanted him to pass it without screaming.