Urosepsis Management (EAU 2024 + SSC 2021)

Algorithm Steps

1. ▶

   Start

   Suspected Urosepsis

   UTI with systemic inflammatory response

   1. ⚠

      Warning

      ⚠️ RECOGNIZE SEPSIS - TIME CRITICAL

      qSOFA: RR≥22, SBP≤100, altered mental status

      • qSOFA ≥2 = high mortality risk
      • SOFA score for organ dysfunction
      • Fever, rigors, flank pain, pyuria
      • Signs of shock: hypotension, tachycardia, mottling
      • Altered mental status = late sign
      • High index of suspicion in elderly/immunocompromised
      1. ●

         Action

         SSC Hour-1 Bundle - START IMMEDIATELY

         Do all within 1 hour of recognition

         • 1. Measure lactate (repeat if >2)
         • 2. Blood cultures BEFORE antibiotics
         • 3. Broad-spectrum IV antibiotics
         • 4. 30mL/kg crystalloid if hypotensive/lactate≥4
         • 5. Vasopressors if MAP<65 despite fluids
         • NEVER delay antibiotics for cultures
         1. ●

            Action

            Empiric Antibiotic Selection (EAU 2024)

            Broad coverage, adjust based on cultures

            • Community: Ceftriaxone 2g IV + Aminoglycoside
            • OR Piperacillin-tazobactam 4.5g IV q6h
            • Healthcare-associated: Add MRSA/Pseudomonas coverage
            • Carbapenem if ESBL risk or severe
            • Meropenem 1g IV q8h
            • De-escalate based on culture results
            1. ◆

               Decision

               Obstructed Infected System?

               Critical decision - source control needed

               1. ⚠

                  Warning

                  ⚠️ URGENT SOURCE CONTROL

                  Decompression saves lives (EAU Strong Rec)

                  • Antibiotics CANNOT sterilize obstructed system
                  • Must decompress to survive
                  • Options: Nephrostomy tube OR Ureteral stent
                  • Choice depends on patient stability and expertise
                  • Do within hours, not days
                  • Definitive stone treatment LATER
                  1. ●

                     Action

                     Percutaneous Nephrostomy

                     Often preferred in unstable patients

                     • US or CT guided
                     • Local anesthesia usually sufficient
                     • Avoids general anesthesia
                     • Direct decompression of renal pelvis
                     • Send pus for culture
                     • Higher success in dilated system
                     1. ●

                        Action

                        ICU-Level Care

                        For septic shock or organ dysfunction

                        • Vasopressors: Norepinephrine first-line
                        • Target MAP ≥65 mmHg
                        • Central venous access
                        • Arterial line for BP monitoring
                        • Lactate clearance as marker
                        • Consider stress-dose steroids if refractory
                        1. ●

                           Action

                           Ongoing Monitoring

                           Track response to treatment

                           • Serial lactate (should decrease)
                           • Urine output (target >0.5mL/kg/hr)
                           • Mental status improvement
                           • Temperature trending down
                           • WBC and inflammatory markers
                           • Culture results - narrow antibiotics
                           1. ●

                              Action

                              Definitive Treatment

                              After stabilization

                              • Stone removal once sepsis resolved
                              • Typically wait 2-4 weeks
                              • Transition to oral antibiotics
                              • Total duration: 7-14 days
                              • Address underlying cause
                              • Evaluate for structural abnormalities
                              1. ✓

                                 Outcome

                                 Outcomes

                                 Mortality 20-40% if delayed treatment

                                 • Early recognition + treatment: <10% mortality
                                 • Delayed decompression: 20-40% mortality
                                 • Key: antibiotics + source control FAST
                                 • Long-term: address stone/obstruction cause
                  2. ●

                     Action

                     Retrograde Ureteral Stent

                     Alternative decompression

                     • Requires cystoscopy (brief GA/sedation)
                     • May not pass if stone impacted
                     • Internal drainage
                     • Less invasive long-term
                     • Consider if stable and experienced OR
               2. ●

                  Action

                  Non-Obstructed Urosepsis

                  Antibiotics and supportive care

                  • Continue IV antibiotics
                  • Aggressive fluid resuscitation
                  • ICU if hemodynamically unstable
                  • Look for other sources (prostatitis, abscess)
                  • Renal/perinephric abscess may need drainage
                  • Emphysematous pyelonephritis high mortality
         2. ●

            Action

            Urgent Imaging

            Identify obstructed system

            • CT abdomen/pelvis (non-contrast OK for obstruction)
            • US if CT not immediately available
            • Look for: hydronephrosis, stone, abscess
            • Pyonephrosis = purulent obstructed system
            • Air in collecting system concerning
            • Do NOT delay source control for imaging