How Do I Manage the Septic Urologic Patient?

Infection, documented or suspected, and some^a of the following:

General variables

Fever (core temperature >38.3 °C)

Hypothermia (core temperature <36 °C)

Heart rate >90 min⁻¹ or >2 SD above the normal value for age

Tachypnea

Altered mental status

Significant oedema or positive fluid balance (>20 mL/kg over 24 h)

Hyperglycemia (plasma glucose >120 mg/dL or 7.7 mmol/L) in the absence of diabetes

Inflammatory variables

Leukocytosis (WBC count >12,000 μL⁻¹)

Leukopenia (WBC count <4000 μL⁻¹)

Normal WBC count with >10 % immature forms

Plasma C-reactive protein >2 SD above the normal value

Plasma procalcitonin >2 SD above the normal value

Hemodynamic variables

Arterial hypotension (SBP <90 mmHg, MAP <70, or an SBP decrease >40 mmHg in adults or <2 SD below normal for age)

Sv O₂ >70 %

Cardiac index >3.5 L^.min^−1ˑM-23

Organ dysfunction variables

Arterial hypoxemia (PaO₂/FIO₂ <300)

Acute oliguria (urine output <0.5 mL·kg⁻¹·h⁻¹ or 45 mmol/L for at least 2 h)

Creatinine increase >0.5 mg/dL

Coagulation abnormalities (INR >1.5 or aPTT >60 s)

Ileus (absent bowel sounds)

Thrombocytopenia (platelet count <100,000 μL⁻¹)

Hyperbilirubinemia (plasma total bilirubin >4 mg/dL or 70 mmol/L)

Tissue perfusion variables

Hyperlactatemia (>1 mmol/L)

Decreased capillary refill or mottling

Adapted from Levy et al. [1]

WBC white blood cell, SBP systolic blood pressure, MAP mean arterial blood pressure, SvO ₂mixed venous oxygen saturation, INR international normalized ratio, aPTT activated partial thromboplastin time

^aThe authors specify in the text that the term “some” reflects the need to diagnose patients’ septic condition at the bedside and the list of the above criteria are a guidance of the factors to consider rather than a proper entry list criteria

Incidence of severe sepsis has been observed to be higher in male, black ethnicity and young patients [1, 10]. Other risk factors are listed in Box 8.1.

Urosepsis or urogenital sepsis is among the most common type of sepsis ranging from 8.6 to 30.6 % of the septic patients [9]. It is the most frightening complication of urogenital tract infections which prevalently are carried out by Gram negative bacteria; E. Coli is the most common infective agent being detected in even more than 50 % of cases on either urine or blood cultures, followed by other bacteria of the Enterobacteriaceae family in different proportion according to different cohorts [4, 15].

Gram positive bacteria account to a 5 % of the cases; fungal urosepsis are less common.

Diagnosis and Early Management of Urosepsis

Time is the most important factor in treating effectively any sepsis.

Urologists have the crucial role to recognize quickly the clinical signs and symptoms that may indicate a diagnosis of urosepsis: they may variably involve flank pain, low urinary tract symptoms, acute urinary retention, perineal pain, hematuria, etc., according to the source of the infection (s. Box 8.2).

Urine and blood tests are mandatory to confirm urine infection and uroseptic condition; blood test should include Full Blood Count, C-Reactive Protein, serum Procalcitonin, Coagulation profile comprising INR and aPTT, Creatinine and Electrolytes, and Lactate (s. Table 8.1).

Imaging is necessary to detect abdominal-pelvic collections or dilatation of the urinary tracts; CT scan is the preferred option, and if not available Ultrasound Scan (US) and X-ray should be performed instead.

Patients with a presumed or established diagnosis of urosepsis need to be admitted to a Intensive Care Unit in the last three decades it has been observed that mortality for sepsis has dropped from 80 to 20–30 % thanks to the advances achieved in the management of septic patients with the introduction of standardized protocols in intensive care [5].

A state-of-the art intensive care should provide real-time monitoring of patients’ condition, optimal hemodynamic control, ideal respiratory and metabolic support, appropriate antimicrobial coverage and medical management of any organ-specific impairment.

Urological Intervention

All septic patients need to be catheterized, also in absence of urinary retention, in order to monitor fluid balance.

Urgent derivation of urinary tract is likely to be necessary in case of obstructive uropathy: in a recent series it was shown that urgent urinary tract decompression with either nephrostomy tube or retrograde stent could halve mortality in uroseptic patient with obstructive stones respect to patients non receiving decompressive intervention (8.82 % vs 19.2 %, respectively; p < 0.001) [2].

However, evidence in literature is lacking with respect to which approach should be preferred between retrograde stenting or percutaneous nephrostomy; a recent systematic review was inconclusive on this regard as only two small randomized controlled trials could be retrieved from literature search with contrasting results [11–13].

Only gold members can continue reading. Log In or Register to continue