Management of Urosepsis with Vesical Calculus
For patients with urosepsis associated with a vesical (bladder) calculus, urgent decompression of the collecting system with either percutaneous drainage or ureteral stenting is indicated, followed by definitive treatment of the stone after sepsis resolution.
Initial Management of Urosepsis
- Obtain urine and blood cultures before initiating antibiotics, but do not delay antibiotic administration while awaiting results 1
- Immediate broad-spectrum antibiotic therapy should be initiated, with third-generation cephalosporins showing superior outcomes compared to fluoroquinolones 1
- Urgent decompression of the collecting system is mandatory as the compromised delivery of antibiotics into the obstructed kidney requires drainage to promote resolution of infection 2, 1
- The choice between percutaneous drainage or ureteral stenting is at the discretion of the urologist, as both have been shown to be equally effective in the setting of obstructive pyelonephritis/pyonephrosis 2, 3
- DJ stenting has been shown to be safe and effective in patients with sepsis and obstructing calculi, with decreased duration of hospital stay and ICU admission rates compared to percutaneous nephrostomy in some cases 3
Definitive Management After Sepsis Resolution
- Definitive treatment of the stone should be delayed until sepsis is resolved and the infection is cleared following a complete course of appropriate antimicrobial therapy 2, 1
- For vesical calculi, percutaneous cystolithotomy (PCCL) is a minimally invasive approach that spares the urethra and is associated with shorter hospitalization and lower risk of urethral strictures 4
- Open cystolithotomy may be necessary for very large vesical calculi, particularly when adherent to bladder mucosa 5
- Transurethral cystolithalopaxy is another option but carries a risk of urethral trauma which could lead to strictures 4
Specific Considerations for Vesical Calculi
- Vesical calculi are often secondary to bladder outlet obstruction and may present with recurrent urinary tract infections, hematuria, or urinary retention 5
- Complete removal of the stone is essential to eradicate causative organisms, relieve obstruction, prevent further stone growth, and eliminate the source of infection 1
- Follow-up imaging to confirm complete stone removal is essential after definitive treatment 1
Monitoring During Treatment
- Patients should be followed with periodic imaging studies to monitor stone position and to assess for hydronephrosis 2
- For septic patients, monitoring of organ function using either the full SOFA or qSOFA score is recommended 2, 6
- Early imaging investigations, including sonography and computed tomography scans, should be conducted to identify any complications 2
Antibiotic Management
- Empirical treatment consists of a broad-spectrum beta-lactam antibiotic 7
- While piperacillin/tazobactam, carbapenems, and newer cephalosporin/beta-lactamase inhibitor combinations can be given as monotherapy, cephalosporins should be combined with aminoglycosides (preferred) or fluoroquinolones 7
- If combination therapy is given, it should be de-escalated to monotherapy after 48-72 hours based on culture results 7
Prevention of Complications
- Blind basketing (stone extraction without endoscopic visualization) should never be performed due to risk of ureteral injury 2
- Collaborative treatment involving urologists, intensive care, and infectious disease specialists is recommended for optimal patient care 2
- Early adequate tissue oxygenation, appropriate initial antibiotic therapy, and rapid identification and control of the septic focus are critical steps in successful management 8