Infection, documented or suspected, and somea of the following:
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
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
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
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
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 . 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 .
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.
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) .
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].