What is the treatment for a patient presenting with sepsis due to a urinary tract infection (UTI)?

Management of Sepsis Due to Urinary Tract Infection

The treatment of sepsis due to UTI requires immediate administration of broad-spectrum antibiotics within one hour of recognition, aggressive fluid resuscitation with 30 mL/kg crystalloid, source control through urinary catheter removal or drainage of obstruction, and vasopressor support with norepinephrine as needed to maintain MAP ≥65 mmHg. 1

Initial Empiric Antimicrobial Therapy

First-line Options:

• Broad-spectrum beta-lactam antibiotics:
  • Piperacillin-tazobactam: 4.5g IV q6h or 16g/2g by continuous infusion
  • Extended-spectrum cephalosporin (ceftriaxone 1-2g daily IV or cefotaxime 2g TID IV)
  • Carbapenem (meropenem or imipenem/cilastatin 1g TID IV) for suspected multidrug-resistant organisms 1

Combination Therapy Considerations:

• Add an aminoglycoside (gentamicin 5 mg/kg daily or amikacin 15 mg/kg daily) if local resistance patterns warrant or for high-risk patients 1, 2
• Gentamicin dosing must be adjusted for renal impairment:
  • For creatinine 1.1-1.3 mg/dL: use 80% of usual dose
  • For creatinine 1.4-1.6 mg/dL: use 65% of usual dose
  • For creatinine >2.0 mg/dL: significant dose reduction required 2

Source Control (Critical Step)

• Identify and address urinary obstruction within 12 hours - approximately 10.5% of patients with urosepsis have anatomic obstruction, which increases mortality by 16.1% 3
• Perform early imaging (ultrasound or CT) to identify obstruction requiring emergency intervention 3
• Remove infected urinary catheters if present 1
• Drain any abscesses or collections 1
• Place urinary catheter to monitor output during resuscitation

Fluid Resuscitation and Hemodynamic Support

• Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L 1

• Target initial resuscitation goals:

  • Mean arterial pressure ≥65 mmHg
  • Central venous pressure 8-12 mmHg
  • Urinary output ≥0.5 mL/kg/hr
  • Central venous oxygen saturation ≥70% 1

• Vasopressor therapy:

  • Norepinephrine as first-line agent
  • Consider adding vasopressin (up to 0.03 U/min) to decrease norepinephrine requirements
  • Add epinephrine if target MAP not achieved 1

Antibiotic Duration and De-escalation

• Obtain blood, urine, and any other relevant cultures before initiating antibiotics 4
• De-escalate to targeted therapy based on culture results within 48-72 hours 1
• Typical duration of antibiotic therapy is 7-10 days 1
• Consider procalcitonin levels to guide antibiotic discontinuation 4, 1
• Daily reassessment of antimicrobial regimen for potential de-escalation 1

Pathogen-Specific Considerations

• E. coli (most common cause): Third-generation cephalosporins or piperacillin/tazobactam 1
• Staphylococcus aureus: Vancomycin for 4-6 weeks due to high risk of metastatic complications 1
• Candida species: Fluconazole 200mg daily for 2 weeks for susceptible strains 1
• Carbapenem-resistant organisms: Consider newer agents such as ceftolozane/tazobactam, ceftazidime/avibactam, or meropenem-vaborbactam 1

Supportive Care

• Place arterial catheter for patients requiring vasopressors 1
• Consider IV hydrocortisone 200 mg/day as continuous infusion only for septic shock not responsive to adequate fluid resuscitation and vasopressor therapy 1
• Transfuse RBCs only when hemoglobin <7.0 g/dL (target 7.0-9.0 g/dL) once tissue hypoperfusion has resolved 1
• Implement lung-protective ventilation strategies if intubation required 1
• Elevate head of bed to 30-45 degrees 1

Special Considerations

• Multidrug resistance: The rate of multidrug-resistant UTIs may be very high in some ICUs, necessitating knowledge of local resistance patterns 5
• Biofilm infections: Common with urinary catheters and may increase MICs by several hundred-fold 6
• Renal impairment: Adjust antibiotic dosing based on creatinine clearance 2
• Urinary pH variations: May influence activity of certain antibiotics 6

Common Pitfalls to Avoid

1. Delaying antibiotics beyond one hour of recognition
2. Failing to identify and address urinary obstruction promptly
3. Inadequate fluid resuscitation
4. Not adjusting antibiotic doses for renal function
5. Failure to de-escalate antibiotics based on culture results
6. Overlooking the need for source control

By following this comprehensive approach to managing sepsis due to UTI, focusing on early antibiotics, aggressive resuscitation, and prompt source control, you can significantly improve patient outcomes and reduce mortality.