What is the treatment for urosepsis (urinary tract infection causing sepsis)?

From the Guidelines

Urosepsis treatment primarily involves prompt administration of broad-spectrum antibiotics and supportive care, with the goal of reducing morbidity, mortality, and improving quality of life. Here's a concise approach:

• Start empiric antibiotic therapy immediately:
  • First-line: Piperacillin-tazobactam 4.5g IV every 6 hours, or
  • Ceftriaxone 2g IV daily plus Gentamicin 5-7mg/kg IV daily, as recommended by the Surviving Sepsis Campaign guidelines 1
• Adjust antibiotics based on culture results and local resistance patterns, taking into account the patient's underlying conditions, recent antimicrobial use, and potential risk factors for multidrug-resistant pathogens 1
• Provide fluid resuscitation:
  • Administer crystalloids (e.g., normal saline) 30 mL/kg within the first 3 hours, to maintain organ perfusion and prevent shock 1
• Manage septic shock if present:
  • Use vasopressors (e.g., norepinephrine) if hypotension persists after fluid resuscitation, to maintain blood pressure and perfusion of vital organs 1
• Control the source of infection:
  • Perform urinary catheterization or percutaneous nephrostomy if urinary obstruction is present, to prevent ongoing bacterial seeding and promote drainage 1
• Monitor and support organ function:
  • Assess urine output, renal function, and respiratory status, to identify potential complications and intervene early 1
  • Provide oxygen support as needed, to maintain adequate oxygenation and prevent respiratory failure 1
• Continue antibiotics for 7-14 days, depending on clinical response and pathogen, taking into account the severity of the infection, the patient's underlying conditions, and the risk of complications 1

This approach is supported by the most recent and highest-quality studies, including the Surviving Sepsis Campaign guidelines 1 and the European Association of Urology guidelines 1, which emphasize the importance of prompt and effective treatment of urosepsis to reduce morbidity, mortality, and improve quality of life.

From the FDA Drug Label

Gentamicin Injection, USP is indicated in the treatment of serious infections caused by susceptible strains of the following microorganisms: Pseudomonas aeruginosa, Proteus species (indole-positive and indole-negative), Escherichia coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species and Staphylococcus species (coagulase-positive and coagulase-negative) Clinical studies have shown gentamicin injection to be effective in bacterial neonatal sepsis; bacterial septicemia and serious bacterial infections of the central nervous system (meningitis), urinary tract, respiratory tract, gastrointestinal tract (including peritonitis), skin, bone and soft tissue (including burns) Gentamicin injection may be considered as initial therapy in suspected or confirmed gram-negative infections, and therapy may be instituted before obtaining results of susceptibility testing

The treatment for urosepsis (urinary tract infection causing sepsis) may include gentamicin as initial therapy in suspected or confirmed gram-negative infections, in conjunction with other antibiotics if necessary 2.

• Key points:
  • Gentamicin is effective against serious infections caused by susceptible strains of gram-negative microorganisms
  • It may be used as initial therapy in suspected or confirmed gram-negative infections
  • Therapy may be instituted before obtaining results of susceptibility testing
• Important considerations:
  • The decision to continue therapy with gentamicin should be based on the results of susceptibility tests, the severity of the infection, and other important concepts
  • If the causative organisms are resistant to gentamicin, other appropriate therapy should be instituted

From the Research

Treatment Strategies for Urosepsis

The treatment of urosepsis involves a combination of supportive therapy, antimicrobial therapy, control or elimination of the complicating factor, and specific sepsis therapy 3.

Antimicrobial Therapy

Empirical antibiotic therapy should be initiated within the first hour after diagnosis, with the selection of appropriate antimicrobials based on risk factors for resistant organisms and whether the sepsis is primary or secondary and community or nosocomially acquired 3, 4.

• Broad-spectrum beta-lactam antibiotics, such as piperacillin/tazobactam, carbapenems, and cephalosporin/beta-lactamase inhibitor combinations, are recommended for empirical treatment 4.
• Combination therapy with cephalosporins and aminoglycosides or fluoroquinolones may be used, but should be de-escalated to monotherapy after 48-72 hours 4.
• Local resistance surveillance should be performed to adjust for the best suitable empiric treatment 3.

Challenges in Treatment

The increasing antimicrobial resistance in Gram-negative bacteria, especially extended-spectrum β-lactamase (ESBL)-producing bacteria, poses a significant challenge in the treatment of urosepsis 3, 5.

• Patients with urosepsis due to multi-drug resistant (MDR) organisms are more likely to have co-morbidities such as diabetes and dementia, and are often admitted from long-term care facilities 5.
• The use of broad-spectrum antibiotics, such as carbapenems and piperacillin-tazobactam, may be necessary in patients with MDR infections 6.

Supportive Therapy and Control of Complicating Factors

Supportive therapy, such as stabilizing and maintaining blood pressure, is crucial in the management of urosepsis 3.

• Control or elimination of the complicating factor, such as urinary tract obstruction or abscess formation, is also essential in the treatment of urosepsis 3, 4.
• Early diagnostics and interventional focus control may be necessary to prevent further complications 4.