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Urosepsis is defined as sepsis caused by an infection in the urogenital tract. In approximately 30% of all septic patients the infectious focus is localized in the urogenital tract, mainly due to obstructions at various levels, such as ureteral stones. Urosepsis may also occur after operations in the urogenital tract. In urosepsis, complete bacteri...
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Context 1
... may be appropriate. In case of no or partial response in secondary urosepsis, i.e., after nosocomial UTI (especially after urological interventions or in pa- tients with long-term indwelling urinary catheters), an antipseudomonal, 3 rd -generation cephalosporin or piperacillin and BLI in combination with an amino- glycoside or a carbapenem may be necessary to cover a broader bacterial spectrum, including multirestistant pathogens (Tables 3 and 4). If the pretreatment history is known, the same group of antimicrobials should be avoided. ...
Citations
... Urosepsis is sepsis caused by urinary tract infections (UTI). Of the total cases of sepsis, urosepsis represents 9-31% [3,4]. ...
Purpose
To evaluate the impact of severe acute kidney injury (AKI) on short-term mortality in patients with urosepsis.
Methods
This prospective cohort study evaluated 207 patients with urosepsis. AKI was diagnosed in accordance with the Kidney Disease Improving Global Outcomes criteria, and severe AKI was defined as stage 2 or 3 AKI. Patients were divided into two groups: patients who developed severe AKI (severe AKI group) and patients who did not (control group). The primary endpoint was all-cause mortality within 30 days. The secondary endpoints were 90-day mortality and in-hospital mortality. The exploratory outcomes were the risk factors for severe AKI development.
Results
The median patient age was 79 years. Of the 207 patients, 56 (27%) developed severe AKI. The 30-day mortality rate in the severe AKI group was significantly higher than that in the control group (20% vs. 2.0%, respectively; P < 0.001). In the multivariable analysis, performance status and severe AKI were significantly associated with 30-day mortality. The in-hospital mortality and 90-day mortality rates in the severe AKI group were significantly higher than those in the control group (P < 0.001 and P < 0.001, respectively). In the multivariable analysis, age, urolithiasis-related sepsis, lactate values, and disseminated intravascular coagulation were significantly associated with severe AKI development.
Conclusions
Severe AKI was a common complication in patients with urosepsis and contributed to high short-term mortality rates.
... The lithotripsy intervention should be postponed if infection is present in the obstructed collecting system. An appropriate antibiotic regimen and decompression of the obstructed collecting system by a ureteral JJ stent or a percutaneous nephrostomy tube should be performed [11,12]. ...
... Moreover, NCCT signs may include a thickened renal pelvic wall, inflammatory alterations in the parenchyma or perinephric region, and the presence of gas-fluid or fluid-fluid levels in the urinary collecting system [13]. However, symptom-free infected hydronephrosis with non-specific findings on CT are always observed [11,12]. Because in the early stage of infected hydronephrosis, abnormal findings may not be detected on NCCT. ...
... Individuals suffering from pyonephrosis usually exhibit signs and symptoms of acute infection with pain, fever, and abnormal results from blood or urine tests. Nevertheless, it is worth noting that up to 15% of patients may not exhibit any feature of acute infection [11,12]. These patients are highly susceptible to experiencing SIRS, sepsis, and sepsis-related mortality after lithotripsy treatment. ...
Finding reliable and easy-to-obtain predictors of severe infectious complications after shock wave lithotripsy (SWL) is a major clinical need, particular in symptom-free hydronephrosis. Therefore, we aim to prospectively investigate the predictive value of Hounsfield units (HU) in renal pelvis urine for the risk of severe infectious complications in patients with ureteral stones and symptom-free hydronephrosis after SWL. This multi-center prospective study was conducted from June 2020 to December 2023. The HU of renal pelvis urine was measured by non-enhanced computed tomography. The severe infectious complications included systemic inflammatory response syndrome, sepsis, and septic shock. Binary logistic regression models assessed the odds ratios (ORs) and 95% confidence intervals (CIs). Finally, 1,436 patients with ureteral stones were enrolled in this study. 8.9% (128/1,436) of patients experienced severe infectious complications after SWL treatment. After adjusting confounding variables, compared with the patients in the lowest renal pelvis urine density quartile, the OR (95% CI) for the highest quartile was 32.36 (13.32, 78.60). There was a positive linear association between the HU value of renal pelvis urine and the risk of severe infectious complications after SWL (P for trend < 0.001). Furthermore, this association was also observed stratified by age, gender, BMI, stone size, stone location and hydronephrosis grade (all P for interaction > 0.05). Additionally, the nonlinear association employed by restricted cubic splines is not statistically significant (nonlinear P = 0.256). The AUROC and 95%CI of renal pelvis urine density were 0.895 (0.862 to 0.927, P value < 0.001). The cut-off value was 12.0 HU with 78.59% sensitivity and 85.94% specificity. This multi-center prospective study demonstrated a positive linear association between HU in renal pelvis urine and the risk of severe infectious complications in patients with ureteral stones and symptom-free hydronephrosis after SWL, regardless of age, gender, BMI, stone size, stone location, and hydronephrosis grade. These findings might be helpful in the SWL treatment decision-making process.
... This drug has also been recommended for empiric treatment in UTI in the guidelines released by Indian Council of Medical Research 37 . Left untreated or inadequately treated UTI can lead to sepsis in 30% cases particularly in geriatric population 38,39 . ...
Patients reporting to the outpatient departments of peripheral health care settings in India with symptoms of urinary tract infection (UTI) receive one or the other antibiotic before culture confirmation and out of the total culture confirmed UTI cases, in less than one third cases the prescribed antibiotics matches to the antibiotic sensitivity test result. Hence, in this study, an indigenous point-of-care (POCT) rapid diagnostic kit (Rapidogram) for UTI was validated against conventional urine culture and sensitivity to understand its possible applicability at peripheral health care settings. This cross-sectional study was conducted during November 2021 to June 2022 in OPDs of two peripheral hospitals. A sample size of 300 was calculated using prevalence of urinary tract infection (UTI) as 33% for sensitivity and specificity using Buderer’s formula. Urine specimens were collected following standard aseptic procedures from the recruited suspected UTI cases and transferred to laboratory maintaining the cold chain. The validation work up was done in two sections: lab validation and field validation. Out of 300 urine samples, 29 were found positive for the growth of UTI pathogen by both methods and 267 were found negative by both methods. Thus, the kit shows very high specificity (99.6%; 97.9–99.9%) and considerably high sensitivity (90.6%; 74.9–98.0%). We also observed higher PPV, NPV, test accuracy (> 96%). Diagnostic Odds Ratio and Youden index were respectively 2581 and 0.89. Clinical data showed that 44% of the suspected UTI cases were prescribed at least one antibiotic before urine test. Mostly they received Norfloxacin whereas the mostly identified organism E.coli was sensitive to Nitrofurantoin. In the context of absence of microbiology facility at peripheral setting and rampant empirical use of antibiotics in UTI, this highly specific and sensitive POCT for UTI may be used as it not only identifies the organism, also shows the antibiotic sensitivity pattern.
... Active treatment is essential because the response to antibiotic treatment is poor before the obstruction is relieved, and sepsis can occur if the infection worsens. If a urinary tract infection occurs because of acute urinary tract obstruction and progresses to urosepsis [3], it is essential to remove stones reliably to prevent the progression to infection, sepsis, and deterioration of renal function [4]. In particular, in the case of the elderly or those with underlying diseases, such as diabetes, sepsis can occur easily, even with local infection. ...
... Urosepsis, distinguishable from sepsis of other origins by basic diagnostic evaluation encompassing physical examination, urinalysis, laboratory blood tests, and ultrasonography [23], often permits early detection and prompt treatment, thereby diminishing mortality. Effective life-support measures, judicious antibiotic therapy involving optimized dosing, and minimally invasive clearance of infectious sources yield optimal conditions for enhancing patient survival [24]. ...
Objective
The aim of this study is to develop and validate a multivariate prediction model for mortality risks at 28, 42, and 56 days in patients with sepsis in the intensive care units (ICUs) by utilizing locally sourced datasets, eschewing reliance on open-source clinical databases in developing nations.
Methods
A retrospective cohort study was conducted on 2389 sepsis patients admitted to ICUs across two campuses of a tertiary hospital from January 1, 2020, to June 30, 2022. An independently developed clinical decision support system captured electronic data. Enrolled patients were randomly divided into a training set (n = 1673) and a validation set (n = 716) in a 7:3 ratio. Variables identified through Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis were integrated into a multivariate Cox proportional hazards regression model to construct a nomogram. Model accuracy was assessed using the area under the receiver operating characteristic curve (AUROC). Nomogram performance was evaluated for discrimination, calibration, and clinical utility in both sets.
Results
The risk score was developed based on 9 independent predictive factors from an original pool of 32 potential predictors. Notably, the prognostic nomogram revealed the minimum APACHE II score's paramount influence on prognosis, followed by days of mechanical ventilation, number of vasopressors, maximum and minimum SOFA scores, infection sources, gram-positive or gram-negative bacteria, and malignancy. A publicly accessible online calculator implementing this nomogram is available at (https://tingyutongji.shinyapps.io/Nomogram/). The nomogram demonstrated superior discriminative ability, with AUROC values of 0.882 (95%CI, 0.855–0.909) and 0.851 (95%CI, 0.804–0.899) at 4 weeks; 0.836 (95%CI, 0.798–0.874) and 0.820 (95%CI, 0.761–0.878) at 6 weeks; and finally, at week 8, it achieved AUROC values of 0.843 (95%CI, 0.800-0.887) and 0.794 (95%CI, 0.720–0.867) in both training and validation sets. Furthermore, both sets exhibited strong discrimination and calibration, supported by C-indexes of 0.872 and 0.839, respectively, confirmed through decision curve analysis, highlighting the significant net clinical benefit provided by the developed nomogram.
Conclusion
A risk assessment model and web-based calculator have been devised to predict in-hospital mortality among ICU sepsis patients. Targeting factors identified as relevant in the model could potentially enhance survival rates for critically ill patients during their hospital stay.
... Several studies reveal that sepsis due to bacterial infections emanates from urinary tract infections which are more prevalent in women [19][20][21]. So, we expected to observe the similar trend in this study. ...
Background
Multidrug resistance (MDR) is a global problem that require multifaceted effort to curb it. This study aimed to evaluate the antibiotic susceptibility patterns of routinely isolated bacteria at Livingstone Central Hospital (LCH).
Methods
A retrospective study was performed on all isolated organisms from patient specimens that were processed from January 2019 to December 2021. Specimens were cultured on standard media and Kirby-Bauer disc diffusion method was employed for susceptibility testing following the Clinical and Laboratory Standard Institute’s recommendations.
Results
A total of 765 specimens were processed and only 500 (65.4%) met the inclusion criteria. Of the 500, 291(58.2%) specimens were received from female and from the age-group 17–39 years (253, 50.6%) and 40–80 years (145, 29%) in form of blood (331, 66.2%), urine (165, 33%) and sputum (4, 0.8%). Amongst the bacterial isolates, Staphylococcus aureus (142, 28.4%) was the commonest followed by Escherichia coli (91, 18.2%), and Enterobacter agglomerans (76, 15.2%), and Klebsiella pneumoniae (43, 8.6%). The resistance pattern revealed ampicillin (93%) as the least effective drug followed by oxacillin (88%), penicillin (85.6%), co-trimoxazole (81.5%), erythromycin (71.9%), nalidixic acid (68%), and ceftazidime (60%) whereas the most effective antibiotics were imipenem (14.5%), and piperacillin/tazobactam (16.7%). The screening of methicillin resistant Staphylococcus aureus (MRSA) with cefoxitin showed 23.7% (9/38) resistance.
Conclusion
Increased levels of MDR strains and rising numbers of MRSA strains were detected. Therefore, re-establishing of the empiric therapy is needed for proper patient management, studies to determine the levels of extended spectrum beta lactamase- and carbapenemase-producing bacteria are warranted.
... [16] Patients were classified as positive for infective complications if there was leukocytosis (total white cell count ˃12,000/mm 3 on full blood count), positive urine culture (≥10 5 colony-forming units per ml) with symptoms (UTI) or without symptoms (asymptomatic bacteriuria), and systemic inflammatory response syndrome with positive urine culture (urosepsis). [17,18] Data obtained from the study were analyzed using the IBM SPSS Statistics for Windows, Version 21.0. (Armonk, NY: IBM Corp). ...
Aims: The purpose of this study is to determine whether bisacodyl rectal suppository can reduce infective complications postprostate biopsy.
Patients, Materials and Methods: This was a comparative cross-sectional study done at the urology unit of a tertiary hospital over 12 months.
A sample size of 56 was determined using Fisher’s formula. Both groups had tablets of ciprofloxacin 500 mg and metronidazole 400 mg at
induction of anaesthesia and continued for three days postbiopsy at a dose of 500 mg twice daily and 400 mg thrice daily, respectively. In
addition to antibiotics, those in Group 1 had 20 mg of bisacodyl (Dulcolax) suppositories given at night, starting two days before the procedure.
The patients underwent digitally guided 10-core transrectal prostate biopsy on an outpatient basis. Blood and urine samples were taken for
full blood count and urine culture, respectively, before surgery and three days after the biopsy. Statistical analysis was performed using the
SPSS version 21.0. The level of significance was set at P < 0.05. Results: The mean age was 69.64 ± 9.31 with a range of 52–90 years. The
peak age distribution was 70–79. In Group 1, two patients had urosepsis, one patient had urinary tract infection (UTI), and seven patients had
bacteriuria, while in Group 2, four patients had urosepsis, four patients had UTI, and ten patients had bacteriuria. Conclusions: The addition of
bisacodyl rectal suppository to antibiotics reduced the frequency of infective complications following prostate biopsy. The observed difference,
however, was not statistically significant.
Keywords: Bisacodyl suppository, postprostate biopsy infection, prostate biopsy
... Urinary tract infections (UTIs) are among the most frequent bacterial infections confronted by clinicians worldwide and represent a huge burden on the health care system due to a high likelihood of recurrence and increasing antibiotic resistance among uropathogens [11]. Sepsis caused by UTIs is urosepsis, a systemic response triggered by an infection originating in the urogenital system [363]. ...
... Sepsis is a systemic, life-threatening medical emergency, caused by dysregulated host response to an infection [378]. Sepsis emerging from the urinary tract is known as urosepsis [363]. Approximately 31% of all sepsis cases are urosepsis [364] and is associated with significant morbidity and mortality in ICU patients [1]. ...
The β-lactamase enzymes produced by Escherichia coli are responsible for much β-lactam antibiotic resistance. These enzymes can effectively hydrolyse β-lactam antibiotics. Extended-spectrum β-lactamase (ESBL) is a class of β-lactamases cause resistance to many β-lactam antibiotics, including expanded-spectrum cephalosporins and monobactams, but not carbapenems. Carbapenems such as meropenem are stable against ESBL-mediated hydrolysis and are recommended for the treatment of infections caused by ESBL-producing E. coli including infections with a urinary tract source. Overuse of carbapenems may select for more carbapenem-resistant pathogens representing a major healthcare problem, given carbapenems can be last resort antibiotics. Therefore, there is an imperative to identify effective carbapenem-sparing treatment options. The β-lactam/β-lactamase inhibitors, such as piperacillin/tazobactam, generally retains adequate in vitro activity against most ESBL enzymes by tazobactam-mediated ESBL inhibition profiles.
This thesis consists of six chapters and aims to evaluate the microbiological efficacy of piperacillin/tazobactam monotherapy, and in combination with the aminoglycoside antibiotic amikacin, versus meropenem monotherapy against ESBL-producing and non-producing E. coli clinical isolates. Chapter 1 presents an overview of the thesis context by outlining the key knowledge gaps and potential ESBL-producing E. coli treatments such as piperacillin/tazobactam alone, and in combination with amikacin to attain effective bacterial killing and suppress emergence of resistance for the treatment of urinary originated sepsis. Chapter 2 is a systematic review and meta-analysis that reports the prevalence of ESBL-producing E. coli in South Asia, the region which is postulated as the global epicentre for the emergence and spread of ESBLs. The prevalence of metallo-β-lactamase (MBL)-producing E. coli, is also reported as these pathogens are indicative of carbapenem overuse. Overall, the meta-analysis estimated that, the pooled prevalence of ESBL-producing E. coli was 33% and blaCTX-M-15 being the most prevalent (51%) ESBL variant in South Asia. The prevalence of blaCTX-M-15 type ESBL-producing E. coli was greater in Bangladesh (70%) relative to Pakistan (60%) and India (46%). A substantial unavailability of data was also identified for countries in South Asia. The MBL-producing E. coli was 17%. The blaNDM-1 was the most prevalent (33%) MBL variant in South Asia.
Chapter 3 evaluates the pharmacodynamic activity of piperacillin/tazobactam regimens (4.5 g, 6-hourly and 8-hourly, as 30 min infusion) against ESBL-producing versus non-producing E. coli clinical isolates in a dynamic in vitro hollow fibre infection model (HFIM). Bacterial killing was similar between two of three ESBL-producing (CTAP#168 and CTAP#169) and two non-ESBL-producing (CTAP#179 and CTAP#180) E. coli clinical isolates over the experiment. Piperacillin/tazobactam 4.5 g 6-hourly and 8-hourly regimens resulted in > 3 log10 CFU/mL bacterial kill against all ESBL-producing and non-ESBL-producing E. coli within 24 h without any emergence of resistance over the seven-day experiment.
Chapter 4 uses the HFIM to compare the pharmacodynamics of piperacillin/tazobactam versus meropenem against ESBL-producing and non-producing E. coli clinical isolates. Simulated piperacillin/tazobactam regimens (4.5 g, 6-hourly and 8-hourly, as 30 min infusion) attained ~4-5 log10 CFU/mL bacterial killing within 24 h and prevented emergence of resistance over seven days against ESBL-producing and non-producing E. coli. However, compared with 8-hourly meropenem, the 6-hourly piperacillin/tazobactam attained ~1 log10 lower bacterial kill against one of three ESBL-producing E. coli but comparable killing against other two ESBL-producing and two non-ESBL-producing E. coli.
Chapter 5 compares the pharmacodynamic activity of piperacillin/tazobactam and amikacin combination versus meropenem monotherapy against ESBL-producing, piperacillin/tazobactam-resistant E. coli in the HFIM. Piperacillin/tazobactam in combination with amikacin resulted in rapid bacterial killing of ~4-5 log10 CFU/mL within 24 h, which was comparable to the bacterial kill attained by meropenem monotherapy. Unlike piperacillin/tazobactam or amikacin monotherapy, their combination suppressed proliferation of resistant subpopulations as observed for meropenem over the seven-day experiment against ESBL-producing, piperacillin/tazobactam-resistant E. coli.
Finally, chapter 6 of this thesis summarises the important findings from the present research, discuss the key limitations and recommendations for future research investigations.
Overall, the mechanistic results produced by this thesis support the potential utility of piperacillin/tazobactam monotherapy as an alternative to meropenem against ESBL-producing, piperacillin/tazobactam susceptible E. coli. For ESBL-producing, piperacillin/tazobactam-resistant E. coli, piperacillin/tazobactam in combination with amikacin could be an effective carbapenem-sparing option.
... Before starting empiric antibiotic therapy, the patient's risk factors for sepsis with E.coli resistant to 3rd generation cephalosporins should be evaluated and the empricial treatment chosen accordingly. Antibiotics choice is adjusted once the antibiogram is available [12]. ...
Background
The aim of this study was to compare short- and long-term mortality among patients with urosepsis caused by Escherichia coli susceptibile (EC-SC) and resistant (EC-RC) to 3rd generation cephalosporins.
Methods
A retrospective cohort study that included all patients with E. coli urosepsis admitted to a 700-bed hospital from January 2014 until December 2019. Mortality up to 30 days, 6 months and 1 year was assessed using logistic multivariate regression analysis and Cox regression analysis.
Results
A total of 313 adult were included, 195 with EC-SC and 118 patients with EC-RC. 205 were females (74%), mean age was 79 (SD 12) years. Mean Charlson score was 4.93 (SD 2.18) in the EC-SC group and 5.74 (SD 1.92) in the EC-RC group. Appropriate empiric antibiotic therapy was initiated in 245 (78.3%) patients, 100% in the EC-SC group but only 42.5% in the EC-RC group. 30-day mortality occurred in 12 (6.3%) of EC-SC group and 15 (12.7%) in the EC-RC group. Factors independently associated with 30-day mortality were Charlson score, Pitt bacteremia score, fever upon admission and infection with a EC-RC. Appropriate antibiotic therapy was not independently associated with 30-day mortality. Differences in mortality between groups remained significant one year after the infection and were significantly associated with the Charlson co-morbidity score.
Conclusions
Mortality in patients with urosepsis due to E. coli is highly affected by age and comorbidities. Although mortality was higher in the EC-RC group, we could not demonstrate an association with inappropriate empirical antibiotic treatment. Mortality remained higher at 6 months and 1 year long after the infection resolved but was associated mainly with co-morbidity.
... 1 Sepsis caused by UTIs is urosepsis, a systemic response triggered by an infection originating in the urogenital system. 2 It is a common cause of ICU admission. 3 The rate of urosepsis among all sepsis cases is approximately 31% and could potentially progress to severe sepsis or septic shock, which is associated with high morbidity and mortality. ...
Background
Urosepsis caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli is increasing worldwide. Carbapenems are commonly recommended for the treatment of ESBL infections; however, to minimize the emergence of carbapenem resistance, interest in alternative treatments has heightened.
Objectives
This study compared pharmacodynamics of piperacillin/tazobactam versus meropenem against ESBL-producing and non-producing E. coli clinical isolates.
Methods
E. coli isolates, obtained from national reference laboratory in Bangladesh, were characterized by phenotypic tests, WGS, susceptibility tests and mutant frequency analysis. Three ESBL-producing and two non-producing E. coli were exposed to piperacillin/tazobactam (4.5 g, every 6 h and every 8 h, 30 min infusion) and meropenem (1 g, every 8 h, 30 min infusion) in a hollow-fibre infection model over 7 days.
Results
Piperacillin/tazobactam regimens attained ∼4–5 log10 cfu/mL bacterial killing within 24 h and prevented resistance emergence over the experiment against ESBL-producing and non-producing E. coli. However, compared with 8 hourly meropenem, the 6 hourly piperacillin/tazobactam attained ∼1 log10 lower bacterial kill against one of three ESBL-producing E. coli (CTAP#173) but comparable killing for the other two ESBL-producing (CTAP#168 and CTAP#169) and two non-producing E. coli (CTAP#179 and CTAP#180). The 6 hourly piperacillin/tazobactam regimen attained ∼1 log10 greater bacterial kill compared with the 8 hourly regimen against CTAP#168 and CTAP#179 at 24 h.
Conclusions
Our study suggests piperacillin/tazobactam may be a potential alternative to carbapenems to treat urosepsis caused by ESBL-producing E. coli, although clinical trials with robust design are needed to confirm non-inferiority of outcome.
