Title: Urosepsis • LITFL • CCC Infectious diseases
Headings: Urosepsis
Urosepsis
OVERVIEW
CAUSES
RISK FACTORS
CLINICAL FEATURES
INVESTIGATIONS
MANAGEMENT
References and links
Critical Care
Chris Nickson

Content: Urosepsis • LITFL • CCC Infectious diseases
Urosepsis
Chris Nickson
Nov 3, 2020
Home CCC
Reviewed and revised 3 January 2016
OVERVIEW
Urosepsis is sepsis with a source localised to the urinary tract (or male genital tract, e.g. prostate)
Urosepsis is a severe infection, distinguishing it from other urinary tract infections including mild pyelonephritis and accounts for ~5% of severe sepsis; whereas UTIs account for ~40% of nosocomial infections
CAUSES
Causative organisms are usually gram negative bacteria (~75%+)
Escherichia coli (~50%)
Proteus (~15%)
Klebsiella
Enterobacter
Pseudomonas aerogenosa (~5%)
Be wary of bacteria that may be ESCAPPM or an ESBL (require a carbapenem or fourth generation cephalosporin due to inducible resistance)
Gram positive bacteria are less common causes of urosespsis (<25%)
Enterococcus
Staphylococcus saprophyticus
Streptococcus agalactiae (GBS)
Fungal infections may occur in the immunosuppressed (e.g. Candida albicans and Candida glabrata)
Polymicrobial infections are more common in the elderly
RISK FACTORS
Urosepsis, as opposed to UTIs in general, are more likely to be complicated UTIs
obstruction
calculi
tumour
radiation
instrumentation
IDC
stent
nephrostomy tube
urological procedures
impaired voiding
neurogenic bladder
vesicoureteral reflux
cystocele
immunosuppression
post-transplant
neutropaenia
metabolic
diabetes mellitus
uraemia
nephrocalcinosis
All UTIs are more common in females
CLINICAL FEATURES
Clinical assessment
dysuria, frequency, haematuria, pyuria (UTI)
flank pain and fever (pyelonephritis)
pain on sitting and defection, tender boggy swelling on digital rectal exam (prostatitis)
perform per vaginal examination females (e.g. bimanually palpate abscess)
‘SIRS’ and septic shock
underlying risk factors
PMH of UTIs, antibiotics and resistance
complications
Complications
severe sepsis, septic shock and MODS
renal scarring and end stage renal failure
abscesses (e.g. renal, perinephric) and septic embolisation
emphysematous pyelonephritis gas formation in renal parenchyma, collecting ducts and perinephric space; usually in diabetics)
papillary necrosis, sloughing and obstruction
INVESTIGATIONS
Bedside
urine (dipstick, microscopy and culture)
blood gas
Laboratory
septic screen including blood cultures
evidence of SIRS and MODS
Imaging
renal tract ultrasound (e.g. exclude obstruction, kidney size, scars, emphysematous pyelonephritis, abscesses)
CTU (e.g. bacterial interstitial nephritis, renal micro-abscesses, renal papillary necrosis)
MANAGEMENT
Resuscitation
address life threats, such as septic shock
Antimicrobial therapy (antibiotic recommendations from Australian Therapeutic Guidelines)
early empiric antibiotics: amoxicillin 2 g IV q6h + gentamicin 5-7 mg/kg IBW IV loading dose then maintenance dosing
use gentamicin alone if penicillin hypersensitive
gentamicin maintenance dosing based on renal function and therapeutic drug monitoring
if gentamicin contra-indicated , use ceftriaxone 1 g IV q24h (Q12h if critically ill) OR 1 cefotaxime 1 g IV q8h (q6h if critically ill)
however these are not effective against Pseudomonas aeruginosa, enterococci or ESBLs
Urosepsis due to MDROs is an emerging problem (e.g. ESBLs), especially in patients who have travelled to South/ East Asia)
if suspected use meropenem 1g q8h IV
meropenem is also indicated if melioidosis is suspected (e.g. Indigenous Australians in tropical regions with prostatic abscess)
modify empirical antibiotic therapy based on the results of cultures and susceptibility testing and clinical response
early conversion to oral therapy if improving
if susceptibility results are not available by 72 hours and empirical IV therapy is still required, stop gentamicin and use ceftriaxone or cefotaxime
total duration of therapy (IV + oral) is usually 10 to 14 days, extended to 21 days in patients with a delayed response
repeat urine cultures 1 to 2 weeks after treatment is completed
perform investigations to exclude an anatomical or functional abnormality of the urinary tract, particularly if the patient does not respond to initial therapy – ensure that patient is not obstructed (renal tract U/S or CTU)
fungal infections (usually Candida spp)
non-severe UTIs usually resolve with IDC removal
however septic patients should be treated with antifungals (e.g. fluconazole, or caspofungin if azole-resistant Candida glabrata)
Source control
ideally perform within 6 hours of identification of the underlying problem
initial low-level invasive treatment
e.g. insertion of an indwelling catheter (IDC), JJ-stent or percutaneous nephrostomy
as sepsis improves, follow with definitive urological procedures (e.g. nephrectomy)
removal of pre-existing in situ devices (e.g. IDC, JJ stent)
should not delay antibiotic administration
antibiotics may only be transiently effective unless a pre-existing catheter or ureteric stent is removed or replaced, because most antibiotics penetrate poorly into biofilms that form on foreign material
treatment without device removal may also lead to superinfection with more resistant organisms
exact timing is controversial and varies on a case-by-case basis (e.g. duration in situ, response to antibiotics, severity of illness, ease of removal/ reinsertion of needed)
Seek and treat complications
Supportive care and monitoring
References and links
LITFL
CCC — Sepsis definitions
Journal articles
Kalra OP, Raizada A. Approach to a patient with urosepsis. Journal of global infectious diseases. 1 (1):57-63. 2009. [ pubmed ] [ free full text]
Wagenlehner FM, Lichtenstern C, Rolfes C. Diagnosis and management for urosepsis. International Journal of Urology. 20 (10):963-70.