Urosepsis - an overview | ScienceDirect Topics (2023)

Urosepsis is defined as SIRS in setting of complicated urinary tract infection

From: Diagnostic Pathology: Hospital Autopsy, 2016

Related terms:

  • Pyelonephritis
  • Bladder
  • Biopsy
  • Urine
  • Escherichia coli
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Approach to the Patient with Urinary Tract Infection

Lee Goldman MD, in Goldman-Cecil Medicine, 2020


The principles of management of urosepsis are similar to those for patients with severe sepsis from any site. Parenteral empirical antimicrobial treatment and supportive care should be initiated promptly.14 The antimicrobials selected should provide broad-spectrum coverage for potential uropathogens, including resistant bacteria. Antimicrobial therapy should be reassessed when urine and blood culture results become available and the infecting organism and susceptibilities are identified.


In Diagnostic Pathology: Hospital Autopsy, 2016



Urosepsis is defined as SIRS in setting of complicated urinary tract infection

Accounts for 25% of all cases of sepsis

Certain groups are at increased risk of urosepsis

Patients with abnormal urinary tract anatomy

Patients with urinary tract catheters/hardware or history of urinary tract procedure

Patients with certain underlying conditions: Diabetes, sickle cell, neurogenic bladder

Usually result of ascending infection

Most often gram-negative enteric bacteria

Enterococci: In institutional settings in catheterized patients

Secondary involvement of urinary tract by bloodstream infection is less common

Typically Staphylococcus aureus

Urinary tract findings

Obstructive lesions: Extrinsic tumors, prostatic enlargement, bladder distension and trabeculation, hydroureter, hydronephrosis

Inflammatory urinary tract changes: Cystitis, pyelonephritis, renal abscess

Findings associated with sepsis

Changes of disseminated intravascular coagulation: Petechiae, ecchymoses, microthrombi

Anasarca, effusions

Diffuse alveolar damage

Changes of septic organ injury and failure

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Impact of Host Factors and Comorbid Conditions

Samir S. Taneja MD, in Complications of Urologic Surgery, 2018

Infection and Urosepsis

Although community-acquired urinary tract infections (UTIs) are very common and are considered relatively easy to treat, complicated UTIs such as those acquired in the hospital setting are a legitimate cause for concern in urology. The termcomplicated UTI connotes infections brought about by a functional or anatomic abnormality in the urinary tract, but it may also be used to indicate an infection that occurs in a patient with altered defense mechanisms.91 When an infection previously localized to the urinary tract enters the bloodstream and causes a systemic infection, urosepsis ensues.

Judicious use of prophylactic antibiotics in surgical procedures has served to minimize the incidence of these preventable yet potentially lethal complications in urologic practice.92 However, the rising incidence of antimicrobial resistance, especially of gram-positive pathogens such as methicillin-resistantStaphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), can lead to treatment failure and life-threatening sepsis.93 Moreover, the increasing numbers of patients who are immunocompromised either by an underlying disease (e.g., HIV/AIDS) or through concurrent medical therapy (e.g., steroids, chemotherapy)94 also lead to greater infection risk. These risk factors are particularly relevant when surgery entails instrumentation and manipulation of the urinary tract. Given that certain host factors predispose the urologic patient to complicated infection, it is necessary to determine the need for antimicrobial prophylaxis preoperatively and to prevent the occurrence of systemic septicemia.

Both demographic factors and medical conditions play a role in susceptibility to complicated UTI. Advanced age in a patient should alert the urologist to the possible presence of UTI. The prevalence of UTI increases with age and reaches approximately 3.6% in men ≥70 years old and 7% in women ≥50 years old.95 As previously discussed, nutritional imbalances leading to obesity and malnutrition could impair cellular immunity and thereby predispose patients to UTI. Preexisting local or systemic infections intuitively are associated with complicated UTI.

Recent antimicrobial use has been linked to complicated UTI, possibly through two mechanisms: (1) antibiotic therapy fails, and the initial infection, either systemic or local, progresses to complicated UTI or frank urosepsis; or (2) antibiotics used to eliminate competing pathogens promote the growth of resistant strains and lead to infection with a more virulent strain.96 Diabetes mellitus not only increases the incidence of UTI in adults but also contributes to a complicated course despite antibiotic prophylaxis and treatment. This situation is the result of defects in the secretion of urinary cytokines and increased adherence of microorganisms to the uroepithelial cells in diabetic patients.97

(Video) Sepsis and Septic Shock, Animation.

A 55-Year Old Woman from Turkey With Fever of Unknown Origin

Andreas J. Morguet, Thomas Schneider, in Clinical Cases in Tropical Medicine (Second Edition), 2022


A 55-year old Turkish woman presents with fever of unknown origin. She has travelled to Turkey shortly before and has a history of double heart valve replacement. Treatment with co-trimoxazole results in some improvement, but then the patient develops signs of congestive heart failure.

Answer to Question 1

What Are Differential Diagnoses in This Patient After Deterioration?

Urosepsis could have been the underlying cause of the deterioration in this patient. However, urinary tract infection is usually easily managed with a short course of early antibiotic treatment. The patient’s preceding stay in Turkey should raise the suspicion of another infection not detected so far, such as brucellosis, tuberculosis or Q-fever.

Answer to Question 2

What Are the Most Promising Next Diagnostic Steps?

With two prosthetic heart valves, our patient has an increased risk of infective endocarditis. Transoesophageal echocardiography is indicated to rule out cardiac involvement. Cultivation of blood cultures should be extended to up to 6 weeks in culture-negative endocarditis to reveal Brucella or Coxiella species.

The Case Continued…

After 4 weeks, the blood cultures taken initially grew Brucella melitensis biovar 2. Transoesophageal echocardiography revealed a large vegetation attached to the prosthetic mitral valve (Fig. 76.1). These findings led to the diagnosis of active Brucella endocarditis. Treatment with rifampicin, doxycycline and gentamicin was initiated. The patient improved rapidly. C-reactive protein returned to normal after 6 weeks of triple therapy. Two months later, however, an annular abscess cavity around the aortic prosthesis was demonstrated on echocardiography; the patient at that time was on oral rifampicin and doxycycline. Finally, she gave her consent to a third thoracotomy, for prostheses exchange. After surgery she made a complete and sustained recovery.

Summary box


Brucellosis is one of the most common zoonotic infections worldwide. Its true incidence is unknown, because it typically affects rural communities and it is difficult to diagnose. Hot spots of the disease are Eastern Europe, the Middle East, Central and South Asia, Central and South America and Africa.

The disease is caused by intracellular bacteria of the genus Brucella. The Brucella species most importantly involved in human disease are B. melitensis (goats, sheep, camels), B. abortus (cattle), B. suis (pigs) and B. canis (dogs).

Brucellosis is most commonly acquired by eating raw or undercooked meat and offal or untreated dairy products. Also, close contact with infected livestock poses a risk. It is an important occupational hazard among herdsmen, dairy farmers, abattoir workers and laboratory technicians.

Symptoms are non-specific, with fever, sweating, fatigue, weight loss, headache and joint pain persisting for weeks or even months. Its presentation as a non-specific febrile illness poses a differential diagnostic challenge in geographical regions where malaria and tuberculosis are highly prevalent and diagnostic resources are scarce, such as in sub-Saharan Africa. In the latter context, brucellosis is frequently missed as a major aetiology of fever, as has been shown from Tanzania.

Brucellosis may involve nearly every organ of the body. Although endocarditis is a less common manifestation of the disease, cardiac valve involvement was the most frequent cause of death from brucellosis in the past.

Definitive diagnosis requires the isolation of the bacteria from the blood, body fluids or tissues. This can be challenging as culture may take several weeks. In endemic settings, serological tests are often the only available diagnostic test and their interpretation may be challenging.

Treatment of brucellosis requires combination antibiotic therapy of several weeks’ to several months’ duration to prevent relapses.

The choice of the regimen and treatment duration depend upon clinical course and organ manifestation. Drugs most commonly used are doxycycline, gentamicin, rifampicin and co-trimoxazole.

In the case of cardiac valve involvement, spondylitis or neurobrucellosis, extended parenteral antimicrobial therapy is recommended. Patients with Brucella endocarditis will frequently require valve replacement in addition to antibiotic therapy.

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Infections of the Urogenital Tract

Jean-Louis Vincent MD, PhD, in Textbook of Critical Care, 2017


In 20% to 30% of all septic patients, the initial infectious focus is in the urogenital tract. The most frequent causes for urosepsis are obstructive diseases of the urinary tract such as ureteral stones, anomalies, stenosis, or tumor. Early relief from the obstruction controls the infectious focus and improves organ perfusion. This is one reason why mortality in urosepsis is usually lower than that in other septic forms (Fig. 123-2).33

Immediately after microbiological sampling of urine and blood, empiric broad-spectrum antibiotic therapy should be started parenterally. Adequate initial (e.g., in the first hour) antibiotic therapy ensures improved outcome in septic shock.34,35 Inappropriate antimicrobial therapy in severe UTIs is linked to a higher mortality rate.36 Empiric antibiotic therapy is based upon the expected bacterial spectrum, institution-specific resistance rates, specific pharmacokinetic and pharmacodynamic factors in UTIs, and individual patient characteristics.

The bacterial spectrum in urosepsis predominantly consists of Enterobacteriaceae such asE. coli,Proteus spp.,Enterobacter andKlebsiella spp., nonfermenting organisms such asP. aeruginosa, and gram-positive organisms.37-38Candida spp. andPseudomonas spp. occur as causative agents in urosepsis mainly if the host defense is impaired. Patients with candiduria show frequently invasive candidiasis and candidemia.39,40 Candiduria at any time in an ICU is associated with higher mortality rates (OR, 2.86).40 Viruses are not common causes of urosepsis.

Although urosepsis is a systemic disease, the activity of an antibiotic at the site of the infection is critical. A variety of studies have shown that inflammatory mediators such as IL-6, CXC chemokines, endotoxin, or HMGB1 are produced and released in the urinary tract.41-43 Therefore, predominantly antimicrobial substances with high activities in the urogenital tract are recommended.44,45

The increasing antibiotic resistance rates of pathogens causing urosepsis significantly diminish the choice of antibiotics available for adequate empiric initial therapy in urosepsis. In particular, the increasing rates of Enterobacteriaceae producing ESBL pose clinically relevant problems.5,46-48 Other recent developments of concern include increased rates of fluoroquinolone-resistant enterobacteria and vancomycin-resistant enterococci.49,50 Currently, there are no specific pharmacokinetic/pharmacodynamic parameters available for the treatment of patients with urospesis.

Urinary Tract Infections in the Intensive Care Unit

François Marquis, ... Martine Leblanc, in Critical Care Nephrology (Second Edition), 2009


As a primary disease, urosepsis is rarely asymptomatic, except in very debilitated or immunosuppressed patients. However, as a nosocomial infection in an already critically ill patient, urosepsis may be asymptomatic and the clinician must rely on the vitals (fever, tachycardia, low blood pressure), blood work, urine analysis, and cultures to reach an accurate diagnosis.6

General sepsis treatment guidelines apply for urosepsis as for any sepsis. Rapid liquid repletion with concomitant parenteral wide-spectrum antibiotics should be started immediately. The source (pyelonephritis, renal or perirenal abscess, but rarely simple UTIs) should be identified.6 Indwelling urinary catheters should be removed and replaced only if necessary. When the source and the nature of the microorganism are known, targeted actions should be taken and antibiotic spectrum should be narrowed. The clinician should remember that even if the urinary tract is one of the most frequent sites of origin for gram-negative bacteremia, gram-positive bacteremia and fungus cannot be ignored, especially in a critically ill patient.

(Video) Urinary Tract Infections & Urosepsis!

Complications such as adult respiratory distress syndrome and disseminated intravascular coagulation can be seen as a result of cytokine release and activation of several mediators involved in the pathophysiology of gram-negative sepsis.

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Duplicated Collecting System

In Diagnostic Imaging: Obstetrics (Third Edition), 2016

Natural History & Prognosis

Prognosis depends on degree of renal damage from reflux and obstruction

Prenatal diagnosis decreases risk of urosepsis and renal damage

Obstructed upper pole moiety prone to infection due to urinary stasis

When diagnosis is known, prophylactic antibiotics administered from birth

Decreases rate of neonatal urinary tract infection

Improved outcome with prenatal vs. postnatal diagnosis

Much lower incidence of preoperative infection

Much lower recurrent infection after correction

Higher rate of resolution of reflux

Younger age at correction

Early surgical intervention preserves renal function

Excellent prognosis with early correction

If not diagnosed in utero, duplication with obstruction/reflux usually presents in infancy

Recurrent urinary tract infections


Urinary retention

Unsuccessful toilet training in girls, epididymitis in boys

From ectopic insertion

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Professor's Pearls

In Obstetrics and Gynecology: A Competency-Based Companion, 2010

Answer 4: Clinical Considerations: Treatment of Endometrial Cancer in a Very Elderly Patient

Such patients are occasionally managed by our gynecologic oncology service. The family should be informed that her urosepsis must be stabilized. A nutrition consult should be obtained and parameters, such as serum prealbumin, assessed for possible intervention with enteral alimentation. A CT (or MRI) of the abdomen and pelvis should be obtained to rule out ureteral obstruction or extrauterine malignancy. We would review our own operative findings from the D&C. How large was the uterus on examination under anesthesia and by sounding? Was the cervix involved? These data would help in clinical staging and further treatment plans. She should be placed on low–molecular-weight heparin, until fully ambulatory, to avoid deep vein thrombosis and pulmonary embolism. Physical therapy should be consulted. If the clinical stage is I, we would place her on high-dose oral megestrol acetate (unless contraindicated). If she cannot undergo a major operation after these interventions, we would perform another endometrial biopsy or repeat D&C (depending on the size of the uterus) about 2 to 3 months later. If persistent invasive cancer is found, radiation should be considered. Either brachytherapy alone or with the addition of external-beam irradiation is possible. The family can be told that in this scenario, the 5-year survival rate drops about 10% for stage I disease to around 80%, compared with operative management. If there is no cancer found on repeat D&C, consideration for continued oral megestrol acetate should be given.

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Genitourinary Interventions

In Diagnostic Imaging: Interventional Procedures (Second Edition), 2018

Getting Started

Things to check

Patient history and physical

Procedure indications

Medications: Anticoagulant or antiplatelet agents


Signs or symptoms of urosepsis

Preprocedure antibiotics if untreated

Hemodynamic support

Pregnancy: Consider trial of conservative management prior to intervention

Laboratory parameters

Complete blood count: Platelet > 50,000/μL

Coagulation profile

International normalized ratio ≤ 1.5

Normal prothrombin time, partial thromboplastin time

Serum electrolytes

Correct any renal failure-associated hyperkalemia



1% lidocaine local anesthetic

Procedural sedation (if hemodynamically stable)

Low threshold for anesthesiology assistance due to risk of sepsis/septic shock

Prophylactic antibiotics

Specific agent based on available cultures

Empiric gram-negative coverage if no cultures

Equipment list


US equipment

3.5-MHz transducer

Sterile US probe cover and gel

Fluoroscopy equipment

CT equipment

Radiopaque grid


21- to 22-gauge Chiba needle

0.018″ guidewire

5- to 6-Fr coaxial dilator-sheath assembly

0.035″ 3-J guidewire

8- to 10-Fr dilator as appropriate

8- to 10-Fr locking pigtail catheter


0.035″ Amplatz guidewire

8-Fr, 20- to 24-cm nephroureteral catheter


0.035″ Amplatz guidewire

8-Fr, 20- to 24-cm double pigtail (J) ureteral stent

Whitaker t est

18- to 22-gauge needle

(Video) Sepsis and Septic Shock are MUST KNOW topics - Learn Sepsis with a Surgeon

Manometer or pressure transducer

Power injector/infusion pump

Bladder catheter (e.g., Foley)

2 individual 3-way stopcocks and connecting tubing


Transurethral catheter if possible

19-gauge needle if not possible

Trocar technique

Stiffening inner cannula

Sharp trocar

8- to 16-Fr Foley catheter

Seldinger technique

5-Fr Longdwell needle (20 cm)

0.035″ Amplatz wire

Sequential dilators

8- to 14-Fr locking pigtail catheter

(Video) Septic Shock Nursing (Sepsis) Treatment, Pathophysiology, Symptoms Distributive

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Solid Renal Mass

In Expertddx: Abdomen and Pelvis (Second Edition), 2017

Key Differential Diagnosis Issues

Solid, expansile mass in adult is usually renal cell carcinoma, unless

Mass contains fat (probably angiomyolipoma)

Patient has fever, urosepsis (consider pyelonephritis and renal abscess)

Patient is immunocompromised (consider lymphoma, posttransplant lymphoproliferative disorder)

Patient has known other primary cancer (consider metastases)

Role of biopsy is evolving but definitely has role in diagnosing renal lymphoma and metastases

Useful in diagnosing oncocytoma, angiomyolipoma (AML)

Morphology and immunohistochemical features are key pathologic findings

Routinely performed prior to percutaneous ablation: ~ 20% of small (< 4 cm) enhancing renal masses are benign (i.e., non-fat-containing AML, oncocytoma)

Morphology of lesion also aids diagnosis: “beans” vs. “balls”

Infiltrating tumor maintains reniform (“bean”) shape: Consider urothelial carcinoma, collecting duct carcinoma, medullary carcinoma

Well-circumscribed (“ball”) tumor: Consider renal cell carcinoma (RCC) (clear cell, papillary, chromophobe)

Clinical history is key in diagnosing renal trauma, infection, metastases, lymphoma

Not usually helpful in diagnosing primary renal tumors

CT or MR evaluation of renal mass must include nonenhanced and parenchymal phase images

Arterial phase good for diagnosing column of Bertin; pyelographic phase essential for diagnosing transitional cell cancer

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