What is the management of urosepsis?

Management of Urosepsis

Urosepsis requires immediate, aggressive management within the first hour: administer IV antimicrobials, initiate fluid resuscitation with 30 mL/kg crystalloid, obtain cultures, and establish urgent source control through drainage or relief of obstruction. 1, 2, 3

Immediate Actions (Within First Hour)

Early Recognition and Diagnosis

• Assess for organ dysfunction using qSOFA or full SOFA score to confirm sepsis diagnosis, as systemic inflammatory response syndrome criteria are no longer the standard 1, 4
• Obtain microbiological samples immediately before antibiotics (if no delay >45 minutes): at least two sets of blood cultures (aerobic and anaerobic), urine culture, and drainage fluid if applicable 1, 2
• Measure serum lactate levels at diagnosis and repeat within 6 hours if initially elevated (≥4 mmol/L) 1, 2, 5
• Perform urgent imaging (ultrasound or CT scan) to identify obstruction, stones, or abscesses requiring intervention 1, 6

Antimicrobial Therapy

• Administer broad-spectrum IV antibiotics within 1 hour of recognition - this is the single most critical time-dependent intervention 1, 2, 3, 7
• Use empiric therapy covering gram-negative pathogens (most common in urosepsis): piperacillin-tazobactam, carbapenems, or cephalosporin/beta-lactamase inhibitor combinations as monotherapy 7, 8
• Combine cephalosporins with aminoglycosides (preferred) or fluoroquinolones if not using monotherapy agents 7
• Consider local resistance patterns, particularly ESBL-producing organisms which are increasingly common in urosepsis 7, 8
• De-escalate to narrower spectrum within 48-72 hours once culture results and sensitivities are available 7, 8

Fluid Resuscitation

• Administer 30 mL/kg IV crystalloid within first 3 hours for sepsis-induced hypoperfusion (hypotension or lactate ≥4 mmol/L) 1, 2, 5
• Use crystalloids as first-line fluid - they are well-tolerated, effective, and cost-efficient 1
• Titrate fluid administration to clinical response: improvement in blood pressure, heart rate reduction, improved mental status, peripheral perfusion, and urine output 1
• Stop fluid resuscitation if no improvement occurs or if lung crepitations develop indicating fluid overload 1

Source Control (As Soon as Medically Feasible)

Urological Intervention

• Relieve any urinary tract obstruction immediately - this is essential and mortality-reducing 1, 8, 6
• Drain significant abscesses in the urinary tract through percutaneous or surgical approaches 1, 6
• Replace or remove indwelling catheters before starting antimicrobial therapy if catheter-associated infection is suspected 1
• Common obstructive causes requiring intervention: ureteral stones (most common), strictures, tumors, or prostatic obstruction 8, 6

Hemodynamic Support (Within First 6 Hours)

Vasopressor Therapy

• Target mean arterial pressure (MAP) ≥65 mmHg in all patients requiring vasopressors 1, 2, 5
• Use norepinephrine as first-line vasopressor for persistent hypotension despite adequate fluid resuscitation 1, 2, 3
• Add vasopressin (0.01-0.04 units/min) or epinephrine as rescue therapy in refractory shock 1
• Avoid routine dopamine due to toxicity profile and lack of benefit 1

Inotropic Support

• Add dobutamine if low cardiac output persists despite adequate fluid resuscitation and vasopressors, particularly when central venous oxygen saturation <70% 1
• Do not use inotropes routinely - reserve for documented low cardiac output with inadequate tissue perfusion 1

Corticosteroid Therapy

• Administer hydrocortisone 200-300 mg/day for at least 5 days in patients with refractory shock not responding to vasopressors, then taper 1, 5

Respiratory Support

• Apply supplemental oxygen to maintain SpO₂ ≥90-95% 1, 2, 5
• Position patient semi-recumbent (head of bed 30-45 degrees) to reduce aspiration risk 2, 3, 5
• Consider non-invasive ventilation in cooperative patients with moderate respiratory insufficiency before resorting to intubation 1, 2
• Use low tidal volume ventilation (6 mL/kg predicted body weight) if mechanical ventilation is required for ARDS 3, 5

Ongoing Monitoring and Management

Hemodynamic Monitoring

• Monitor continuously: blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and urine output (target ≥0.5 mL/kg/h) 1, 2
• Assess tissue perfusion markers: capillary refill, skin mottling, extremity temperature, peripheral pulses, mental status 2, 5
• Guide resuscitation to normalize lactate if initially elevated as a marker of adequate tissue perfusion 1, 2, 5

Multidisciplinary Approach

• Involve urologists, intensive care specialists, and infectious disease consultants early in management for optimal outcomes 1, 6, 9
• Never leave septic patients alone - ensure continuous observation and frequent clinical reassessment 1

Critical Pitfalls to Avoid

• Do not delay antibiotics for culture results - obtain cultures quickly but never delay treatment beyond 1 hour 1, 2, 3
• Do not overlook urological source control - imaging and intervention for obstruction is as important as antibiotics 1, 6, 9
• Do not continue aggressive fluid resuscitation without response - monitor for fluid overload and adjust strategy 1
• Do not use oral rehydration in septic patients - IV access is mandatory even if requiring surgical cut-down or intraosseous access 1
• Do not treat asymptomatic bacteriuria in catheterized patients unless undergoing traumatic urological procedures 1