Liu B. et al., 2024: Predictive markers for infections after extracorporeal shockwave lithotripsy in patients with kidney stone based on a large prospective cohort.

Wednesday, 12 June 2024

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Liu B, Pan S, Wang L, Bai S, Liu D.
Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning, 110004, People's Republic of China.
Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China.
Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning, 110004, People's Republic of China.
Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning, 110004, People's Republic of China.
#Contributed equally.

Abstract

Objective: Infections in patients with kidney stones after extracorporeal shockwave lithotripsy (SWL) is a common clinical issue. However, the associated factors are unclear. Therefore, we aim to develop and validate a predictive model for infections after SWL in patients with kidney stone.

Methods: Between June 2020 and May 2022, consecutive kidney stone patients were enrolled. Of them, 553 patients comprised the development cohort. One hundred sixty-five patients comprised the validation cohort. The data were prospectively collected. The stepwise selection was applied using the likelihood ratio test with Akaike's information criterion as the stopping rule; A predictive model was constructed through multivariate logistic regression. The performance was evaluated regarding discrimination, calibration, and clinical usefulness.

Results: Predictors of infections after SWL in treating kidney stones included older age (OR = 1.026, p = 0.041), female (OR = 2.066, p = 0.039), higher BMI (OR = 1.072, p = 0.039), lower stone density (OR = 0.995, p < 0.001), and higher grade of hydronephrosis (OR = 5.148, p < 0.001). For the validation cohort, the model showed good discrimination with an area under the receiver operating characteristic curve of 0.839 (95% CI 0.736, 0.941) and good calibration. Decision curve analysis demonstrated that the model was also clinically useful.

Conclusion: This study indicated that age, gender, BMI, stone density, and hydronephrosis grade were significant predictors of infections after SWL in treating kidney stones. It provided evidence in optimizing prevention and perioperative treatment strategies to reduce the risk of infection after SWL.

World J Urol. 2024 Jan 30;42(1):63. doi: 10.1007/s00345-024-04769-w. PMID: 38289424

Comments 1

Hans-Göran Tiselius on Wednesday, 12 June 2024 11:00

It is important to avoid infection complications after SWL and decades of experience has shown that preventive measures are necessary. One of the most important steps is to diagnose preoperatively whether the patient has bacteriuria or not. It is not mentioned in this report, however, if antibiotics were administered based on immediate pre-treatment of bacteriuria or not.
The risk-factors listed in the report were old age, female gender, high BMI, low HU of the stone(s) and high grade of hydronephrosis. Neither can I find any information on pre-operative history of infections, that would have resulted in adequate antibiotic regimen. Avoiding this step is indeed clinically risky.
Unfortunately, there is no information on the outcome of SWL after one single session or to which extent obstructive stones were the cause of hydronephrosis and infection. It is not clear what the authors mean by “control of pain” or “increased bacterial burden”.
It is true that SIRS and urosepsis caused by infection are severe complications that always must be avoided. My own routine over the years has been to administer an intravenous dose of appropriate antibiotics in case there is an infection history with known bacterial sensitivity pattern. But no SWL should be carried out with on-going infection!! For asymptomatic patients with positive test for bacteria, an intravenous single dose of a broad-spectrum antibiotic one hour before SWL has proven to be of great value.
It had been interestingly to learn how the authors prevented infection complications after SWL in the five risk situations mentioned in the article.

Hans-Göran Tiselius

It is important to avoid infection complications after SWL and decades of experience has shown that preventive measures are necessary. One of the most important steps is to diagnose preoperatively whether the patient has bacteriuria or not. It is not mentioned in this report, however, if antibiotics were administered based on immediate pre-treatment of bacteriuria or not. 
The risk-factors listed in the report were old age, female gender, high BMI, low HU of the stone(s) and high grade of hydronephrosis. Neither can I find any information on pre-operative history of infections, that would have resulted in adequate antibiotic regimen. Avoiding this step is indeed clinically risky.
Unfortunately, there is no information on the outcome of SWL after one single session or to which extent obstructive stones were the cause of hydronephrosis and infection. It is not clear what the authors mean by “control of pain” or “increased bacterial burden”.
It is true that SIRS and urosepsis caused by infection are severe complications that always must be avoided. My own routine over the years has been to administer an intravenous dose of appropriate antibiotics in case there is an infection history with known bacterial sensitivity pattern. But no SWL should be carried out with on-going infection!! For asymptomatic patients with positive test for bacteria, an intravenous single dose of a broad-spectrum antibiotic one hour before SWL has proven to be of great value.
It had been interestingly to learn how the authors prevented infection complications after SWL in the five risk situations mentioned in the article.

Hans-Göran Tiselius

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