Complicated urinary tract infection with multidrug-resistant pseudomonas aeruginosa in an elderly male with multiple comorbidities managed with combination antibiotic therapy and DJ stenting

Berlin*, Mohamed Asir

Clinical Pharmacist, Kauvery Hospital, Tirunelveli, Tamil Nadu

*Correspondence

Abstract

Urinary tract infections are a most common among bacterial infections and a major cause of hospitalization and sepsis. Complicated urinary tract infections are a significant cause of morbidity in elderly patients, particularly those with multiple comorbidities, and may progress to severe infections such as pyelonephritis and sepsis. We report the case of a 73-year-old male with Type 2 Diabetes Mellitus, Hypertension, Parkinson’s Disease, and Benign Prostatic Hyperplasia who presented with fever, dysuria, and altered sensorium. Initial evaluation suggested prostatitis; however, further investigations confirmed complicated urinary tract infection with Acute Pyelonephritis. Urine culture revealed multidrug-resistant Pseudomonas aeruginosa. The patient was managed with combination antibiotic therapy and DJ stenting, resulting in significant clinical improvement within 6 days. This case highlights the importance of early diagnosis, culture-guided therapy, and timely urological intervention in high-risk patients.

Keywords: Complicated UTI; Pyelonephritis; Pseudomonas aeruginosa; Multidrug resistance; DJ stenting.

Introduction

Urinary tract infections are among the most common bacterial infections encountered in clinical practice and are a major cause of hospitalization and sepsis worldwide.1 Complicated urinary tract infection is defined as an infection occurring in the presence of structural or functional abnormalities, immunocompromised states, or in male patients, all of which increase the risk of treatment failure and adverse outcomes.2 Elderly patients are particularly vulnerable due to age-related physiological changes and associated comorbidities. Conditions such as Type 2 Diabetes Mellitus predispose patients to infections through impaired immune responses, while Benign Prostatic Hyperplasia leads to urinary stasis, facilitating bacterial proliferation.3 Acute Pyelonephritis represents a severe form of urinary tract infection involving the renal parenchyma and may present with systemic features such as fever and altered sensorium.4 Among causative organisms, Pseudomonas aeruginosa is particularly important due to its intrinsic resistance to multiple antibiotics and its association with healthcare-related infections.5 This case highlights the importance of early diagnosis, appropriate antimicrobial therapy, and timely urological intervention in managing complicated urinary tract infections in high-risk elderly patients.

Case Presentation

A 73-year-old male presented with complaints of fever with chills and painful micturition for two days, along with decreased alertness at the onset of fever. He was a known case of Type 2 Diabetes Mellitus, Hypertension, Parkinson’s Disease, and Benign Prostatic Hyperplasia and was on regular medications. On admission, the patient was hemodynamically stable. Initial clinical evaluation suggested chronic prostatitis, and empirical therapy with Inj. Teicoplanin 400mg and Tab. Methenamine hippurate 1gm was initiated. However, due to worsening clinical and laboratory parameters, further evaluation was carried out, and the diagnosis was revised to complicated urinary tract infection with acute pyelonephritis. Antibiotic therapy was escalated with Inj. Amikacin 500mg and Inj. Fosfomycin 6gm. Urine culture revealed growth of multidrug-resistant Pseudomonas aeruginosa. In view of suspected obstructive uropathy, a left-sided DJ stenting procedure was planned and successfully performed. During hospitalization, a drug interaction between Tab. Methaclear 1gm and Tab. Syndopa 110mg was identified, presenting as dizziness, and appropriate dose modification was done. Following intervention and targeted therapy, the patient showed significant clinical improvement and clinically stable after six days.

Fig (1): KUB X-ray image of DJ stenting

Investigations

Haematological parameters

Laboratory evaluation revealed significant haematological and biochemical abnormalities consistent with an acute infective process. Haemoglobin was 11.8 g/dL, indicating mild anemia. The total white blood cell count was elevated at 15,470 cells/cumm at presentation, suggestive of infection, which later decreased to 6,130 cells/cumm following treatment, indicating clinical improvement. Platelet count was approximately 1.6 lakh/cumm and remained within normal limits. Also, the patient’s Widal test was non-reactive, no malarial parasites were detected on peripheral blood film, and the aPTT was within the standard therapeutic range.

Inflammatory markers

Inflammatory markers were markedly elevated. C-reactive protein was initially greater than 150 mg/L, indicating severe inflammation, and later decreased to 75.63 mg/L, showing a favourable response to treatment. Procalcitonin was elevated at 0.21 ng/mL, supporting the diagnosis of bacterial infection. Urine routine examination revealed slightly turbid urine with 20–25 pus cells per high-power field and the presence of bacteria, confirming urinary tract infection. Red blood cells were absent.

Urine culture, sensitivity and renal function test

Urine culture demonstrated significant bacteriuria with a colony count of 100,000 CFU/mL and growth of Pseudomonas aeruginosa. It was resistant to multiple antibiotics including ciprofloxacin, meropenem, amikacin, ceftazidime, cefepime, and aztreonam, indicating a multidrug-resistant strain. Renal function tests were within normal limits, with blood urea measuring 18.4 mg/dL and serum creatinine at 0.85 mg/dL. Electrolyte analysis showed mild hyponatremia with sodium levels of 132.9 mEq/L, while potassium levels were within normal range at 3.74 mEq/L.

HbA1c

Glycemic assessment revealed an HbA1c of 5.9%, corresponding to an estimated average glucose of 122 mg/dL, indicating reasonably controlled diabetes.

Additional investigations

Coagulation parameters, including prothrombin time of 15 seconds, INR of 1.14, and activated partial thromboplastin time of 32 seconds, were within normal limits. Additional investigations, including malarial parasite testing, were negative, thereby helping to rule out other causes of fever.

Discussion

Complicated urinary tract infections are commonly encountered in elderly patients with comorbid conditions such as diabetes mellitus and urinary tract obstruction and are associated with increased morbidity.1,6 Diabetes mellitus predisposes patients to infections through impaired immune responses, glycosuria, and increased bacterial adherence, leading to more severe and recurrent infections.3,7 Similarly, benign prostatic hyperplasia contributes to urinary stasis, which facilitates bacterial colonization and ascending infection. Acute pyelonephritis occurs when pathogens ascend from the lower urinary tract to the kidneys, resulting in inflammation of the renal parenchyma and systemic manifestations.7 In this case, the isolation of Pseudomonas aeruginosa is clinically significant due to its multidrug resistance and association with healthcare-related infections, which complicates treatment strategies. The markedly elevated CRP levels and leukocytosis observed in this patient indicate a severe inflammatory response. Early initiation of broad-spectrum antibiotics followed by culture-guided therapy is essential in managing such infections.8 In this case, the use of Amikacin and Fosfomycin provided effective coverage against Gram-negative organisms. Although Teicoplanin is known to have synergistic effects with aminoglycosides against Gram-positive organisms, its role in this case was primarily empirical. An important aspect of management was the timely placement of a DJ stent, which relieved obstruction and facilitated drainage of infected urine, significantly improving clinical outcomes.

Conclusion

This case highlights how complicated urinary tract infections in elderly patients with comorbidities can quickly progress to severe conditions like pyelonephritis. The combination of Amikacin and Fosfomycin provided effective Gram‑negative coverage, while empiric Teicoplanin offered additional support through its potential synergistic activity with aminoglycosides. Timely DJ stent placement was crucial, relieving obstruction and enabling adequate drainage, which significantly improved clinical outcomes. Overall, early diagnosis, appropriate antimicrobial therapy, and prompt urological intervention are essential, especially when managing multidrug‑resistant organisms such as Pseudomonas aeruginosa.

Reference

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  6. Garcia-Bustos V, Escrig AIR, López CC, Estellés RA, Jerusalem K, Cabañero-Navalón MD, et al. Prospective cohort study on hospitalised patients with suspected urinary tract infection and risk factors por multidrug resistance. Sci Rep 2021;11:11927. https://doi.org/10.1038/s41598-021-90949-2.
  7. Herder C, Roden M, Venteclef N. Diabetes and pulmonary infection: how hyperglycaemia shapes the immune system. Signal Transduct Target Ther 2024;9:67. https://doi.org/10.1038/s41392-024-01784-6.
  8. IDSA 2025 guideline update on complicated urinary tract infections. Idsociety.org n.d. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections/ (accessed April 1, 2026).

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