Sepsis and septic shock in urology

Definition

Urosepsis is life-threatening organ dysfunction caused by a urinary tract infection. The most common causes are:

• infected upper urinary tract obstruction;
• pyelonephritis;
• pyonephrosis;
• infection associated with instrumentation.

Clinical assessment

• Fever or hypothermia.
• Tachycardia, hypotension.
• Confusion.
• Oliguria/anuria.
• Lower back or flank pain.
• Presence of a catheter, stent, or nephrostomy.

Diagnosis

• Urine and blood cultures before antibiotics, provided this does not delay the start of treatment.
• Lactate, creatinine, electrolytes.
• Ultrasonography to detect obstruction.
• Perform CT when the diagnosis is uncertain or a complication is suspected, provided imaging does not delay resuscitation and infection source control.

Emergency management: a parallel care bundle

1. Immediately assess ABCDE, start continuous monitoring, measure lactate, and assess for organ dysfunction.
2. Obtain blood and urine cultures before antibiotics only if this does not delay the start of treatment.
3. In septic shock or when sepsis is highly likely, start intravenous empirical antibiotics immediately, aiming for administration within 1 hour. In possible sepsis without shock, conduct a rapid assessment and, if suspicion persists, start therapy within 3 hours.

• Provide fluid therapy in parallel; start vasopressor support when indicated and involve an anesthesiologist/intensivist.
• In parallel, look for obstruction, an abscess, or a malfunctioning drain; do not delay treatment for nonessential imaging.
• In infected obstruction, urgently drain with a stent or percutaneous nephrostomy. Choose the method that is faster and safer in the particular clinical situation.

Algorithm