What is the treatment for urosepsis?

Management of Urosepsis

For urosepsis, the recommended first-line treatment is a combination therapy with either amoxicillin plus an aminoglycoside, a second-generation cephalosporin plus an aminoglycoside, or an intravenous third-generation cephalosporin. 1, 2

Initial Assessment and Diagnosis

• Evaluate severity using Sequential Organ Failure Assessment (SOFA) or quick SOFA (qSOFA) scores to determine risk of severe illness or death 2
• Obtain complete microbiological sampling, including two sets of blood cultures and urine culture, before starting antimicrobials 1, 2
• Perform early imaging studies to identify urinary tract obstruction, stones, or abscesses that may be causing the infection 2, 3

Immediate Management (First Hour)

• Begin intravenous fluid resuscitation with crystalloids for patients with hypoperfusion 1, 2
• Initiate broad-spectrum antimicrobial therapy within one hour of recognition of septic shock 1, 2
• Use one of the following empiric treatment regimens:
  • Amoxicillin plus an aminoglycoside 1, 2
  • A second-generation cephalosporin plus an aminoglycoside 1, 2
  • An intravenous third-generation cephalosporin 1, 2
• For nosocomial urosepsis, consider piperacillin/tazobactam, carbapenems, or cephalosporin with aminoglycoside combination 4, 5

Source Control

• Identify and address any urinary tract obstruction or anatomical abnormality within 12 hours of diagnosis 1, 2
• Remove or replace any indwelling urinary catheter if present before starting antimicrobial therapy 1, 2
• Use the least invasive approach for source control (e.g., percutaneous drainage rather than surgical intervention) 1

Antimicrobial Considerations

• Avoid using fluoroquinolones if local resistance rates are ≥10% or if the patient has used them in the last 6 months 1, 2
• Gentamicin is indicated for serious infections of the urinary tract caused by susceptible strains of Pseudomonas, Proteus, E. coli, Klebsiella, and Staphylococcus species 6
• For patients with catheter-associated urosepsis, follow recommendations for complicated UTI management 1
• Consider the pharmacokinetic characteristics of antimicrobials, especially in patients with renal impairment 7

Ongoing Management

• Reassess antimicrobial therapy daily for potential de-escalation based on culture results and clinical response 1, 2
• De-escalate combination therapy to appropriate monotherapy within 48-72 hours based on culture results 5
• Continue antimicrobial treatment for 7-10 days for most cases of urosepsis 1
• Consider shorter course (5-7 days) for patients with rapid clinical resolution following effective source control 1

Special Considerations

• For patients with septic shock from Gram-negative infections, combination therapy with an extended-spectrum β-lactam and either an aminoglycoside or a fluoroquinolone may be beneficial initially 1
• In cases of ESBL-producing bacteria, carbapenems are the treatment of choice 5, 3
• For catheter-associated urosepsis, treat according to complicated UTI guidelines and ensure catheter removal or replacement 1

Common Pitfalls to Avoid

• Delaying antimicrobial therapy beyond one hour in patients with septic shock significantly increases mortality 1, 2
• Failing to obtain appropriate cultures before starting antimicrobials 1, 2
• Neglecting source control, particularly in obstructive uropathy 2, 3
• Using fluoroquinolones empirically in areas with high resistance rates 1, 2
• Continuing combination therapy beyond 3-5 days when monotherapy would be sufficient based on culture results 1, 5