Is stent placement always necessary for urosepsis?

From the Guidelines

Stent placement is not always necessary for urosepsis, and the decision to place a stent should be based on the underlying cause and severity of the obstruction. The management of urosepsis typically involves broad-spectrum antibiotics, fluid resuscitation, and hemodynamic support [ 1 ]. If imaging reveals significant obstruction, urgent decompression via ureteral stent or percutaneous nephrostomy is indicated within 24 hours [ 1 ]. The urgency increases with septic shock, where decompression should occur within 6-12 hours.

Key Considerations

• Initial management of urosepsis includes broad-spectrum antibiotics (such as piperacillin-tazobactam 4.5g IV every 6 hours, or meropenem 1g IV every 8 hours), fluid resuscitation, and hemodynamic support.
• Stents are typically placed when there is urinary tract obstruction (such as from kidney stones, strictures, or tumors) causing the infection, as the obstruction must be relieved to effectively treat the sepsis.
• In cases without obstruction or with mild, partial obstruction that can be managed medically, stents may be avoided.
• Ureteral stent placement has been shown to be safe and effective in the presence of obstructing ureteral stones and sepsis with an overall decreased duration of hospital stay and intensive care unit admission rate compared with PCN placement [ 1 ].

Clinical Decision Making

The decision to place a stent should be individualized based on the patient's specific clinical scenario, taking into account the severity of the obstruction, the presence of sepsis, and the patient's overall medical condition. In general, stent placement should be considered in patients with significant obstruction, sepsis, or severe symptoms, while conservative management without stent placement may be appropriate in patients with mild symptoms and no significant obstruction [ 1 ].

From the Research

Stent Placement for Urosepsis

• Stent placement is not always necessary for urosepsis, as treatment comprises four major aspects: early diagnosis, early goal-directed therapy, identification and control of the complicating factor, and specific sepsis therapy 2.
• The decision to place a stent depends on the presence of urinary tract obstruction, which is a common cause of urosepsis 2, 3.
• In cases of acute upper urinary tract obstruction with urosepsis, percutaneous nephrostomy (PCN) and retrograde ureteral stent (RUS) are two possible treatment options 4.
• A study comparing PCN and RUS found that PCN had a better outcome than RUS in emergency drainage with urosepsis, especially for patients with severe inflammation and fever 4.
• However, the use of ureteral stents can be complicated by associated urinary tract infections and urosepsis due to bacterial adhesion onto the indwelling implant surfaces 5.

Treatment Approaches

• Early adequate tissue oxygenation, adequate initial antibiotic therapy, and rapid identification and control of the septic focus in the urinary tract are critical steps in the successful management of a patient with urosepsis 2.
• Empirical antibiotic therapy should be instigated within the first hour after diagnosis, and urine cultures and blood cultures should be performed before antibiotic treatment 6.
• The selection of appropriate antimicrobials depends on risk factors for resistant organisms and whether the sepsis is primary or secondary and community or nosocomially acquired 3.