What is the recommended treatment for urosepsis?

Management of Urosepsis

The recommended treatment for urosepsis includes immediate broad-spectrum antimicrobial therapy, source control within 12 hours, and appropriate supportive care measures. 1

Initial Assessment and Diagnosis

• Evaluate severity using Sequential Organ Failure Assessment (SOFA) or quick SOFA (qSOFA) scores to determine risk of severe outcomes 2
• Obtain complete microbiological sampling before starting antimicrobials, including:
  • Urine culture
  • Two sets of blood cultures 1
• Perform early imaging studies (ultrasound, CT) to identify urinary tract obstruction, stones, or abscesses 2, 1

Immediate Management (First Hour)

• Begin intravenous fluid resuscitation with crystalloids for patients with hypoperfusion 1
• Initiate broad-spectrum antimicrobial therapy within one hour of recognition of septic shock 2, 1
• Empiric parenteral antimicrobial options include:
  • Piperacillin/tazobactam 2.5-4.5g TID 2
  • Ceftriaxone 1-2g daily 2
  • Ciprofloxacin 400mg BID (if local fluoroquinolone resistance <10%) 2
  • Cefepime 1-2g BID 2
  • Aminoglycoside (gentamicin 5mg/kg daily or amikacin 15mg/kg daily) 2

Source Control

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

Antimicrobial Selection Considerations

• For community-acquired urosepsis: third-generation cephalosporins, piperacillin/tazobactam, or ciprofloxacin 3
• For nosocomial urosepsis: combination therapy with an aminoglycoside or a carbapenem is recommended 3
• Consider local resistance patterns when selecting empiric therapy 1, 4
• Avoid fluoroquinolones if local resistance rates are ≥10% or if the patient has used them in the last 6 months 1

Ongoing Management

• Target mean arterial pressure of at least 65 mmHg in patients requiring vasopressors 1
• Reassess antimicrobial therapy daily for potential de-escalation based on culture results and clinical response 2, 1
• Adjust antimicrobial therapy according to pathogen susceptibility once culture results are available 2, 1
• Continue antimicrobial treatment for 7-10 days for most cases of urosepsis 2, 1
• Consider shorter course (5-7 days) for patients with rapid clinical resolution following effective source control 2, 1

Special Considerations

• For patients with renal impairment, adjust antimicrobial dosing based on creatinine clearance 5
• For catheter-associated urosepsis, follow recommendations for complicated UTI management 2
• Consider collaborative management involving urologists, intensive care specialists, and infectious disease experts 1

Common Pitfalls to Avoid

• Delaying antimicrobial therapy beyond one hour in patients with septic shock significantly increases mortality 2, 1
• Failing to obtain appropriate cultures before starting antimicrobials 1
• Neglecting source control, particularly in obstructive uropathy 1, 4
• Using fluoroquinolones empirically in areas with high resistance rates 1
• Overlooking the increasing prevalence of extended-spectrum β-lactamase (ESBL)-producing bacteria 6, 4

Antimicrobial De-escalation

• If combination therapy is used for septic shock, de-escalate by discontinuing combination therapy within the first few days in response to clinical improvement 2
• De-escalate from combination therapy to monotherapy after 48-72 hours if clinical improvement is observed 6
• Use culture results to narrow antimicrobial spectrum when possible 2, 1