Dr Ahmed I think at least one week parenteral antibiotic is needed for pseudomonas infection prior to PCNL. If there is a clinically significant infection (Fever & leucocytosis) or cases with obstruction stenting is recommended preoperatively either DJ or more preferable PCN.

Thank you Dr Mohamed for the answer.

But if urine culture after the antibiotics for one week is still positive, Can you go for PCNL or give another course of treatment?

It is a difficult clinical scenario I met before. Some recommended prolonged courses of antibiotics before PCNL. But if you rendered urine culture negative is it safe to do PCNL for infected stones? I think the risk is still there as bacteria is burried inside the layers of the stones.

I had a mortality case post PCNL last year. Egyptian pt 54 years old HCV+ve admitted to our hospital in Kuwait with calcular pyelonephritis imaging revealed branched stone 3 cm branching stone without hydronephrosis. Urine culture was +ve (Proteus mirabilis).

Parenteral antibiotic was given for 1 week according to urine c& s and patient was appointed for ellective PCNL after 2 months. On admission urine C &S was -ve. PCNL was performed and was straightforward and patient was stone free. Ureteric catheter was removed 2nd day and nephrostomy was slipped 3rd postoperative day and patient was discharged. He was admitted one day later with faver. U.S no backpressure or stones. Blood culture +ve Proteus mirabilis and the patient had a downhill course of severe septicemia liver failure and renal failure , Myocardial infarction died 2 days later in ICU. I want your opinion in this case what was the shortcoming in management.

This is a very stormy course of post operative septicemia leading to septic shock.

In this case, I think the infecting organism was hidden inside the stone and once you disintegrate it the organism was released in the field and access the blood.

To avoid this in the future, I think in such patient antibiotic coverage according to culture and sensitivety from the first positive culture have to be given for at least one day before PCNL even if the second culture was negative.

This is very tricky scenario. It will be very difficult to make it culture negative before surgery. Give imipenem for 5 days . If WBC count is with in normal limits , Surgery can be done. If it takes too long . Procedure can be staged

this is a case with multi limitations, age, allergies, and infected stone with a highly pathogenic bacteria.