The global incidence of sepsis worldwide is estimated to be 31.5 million cases per year, resulting in 5.3 million deaths. Detection and management of sepsis has become a top priority for many hospitals, and the World Health Organization recognizes sepsis as a serious problem. It is crucial to differentiate between sepsis and septic shock due to the high mortality rate in the latter.
Urinary tract infection (UTI) is the source of approximately 10-30% of all sepsis cases, with high morbidity and mortality. Complicated UTI (cUTI) is the most common cause of urosepsis in adults over 65 years of age. It is essential to diagnose urosepsis promptly and provide time-sensitive antibiotic treatment, supportive therapy, and source control.
Conditions that predispose to febrile UTI include any structural, anatomical and/or functional abnormality that impedes urine flow and the main reason for uroseptic shock is urinary tract obstruction. Therefore, patients with urosepsis generally require early radiological evaluation to rule out any obstructive urinary tract disorders.
As a clinician facing a patient with suspected or proven urosepsis, there are two critical issues.
- The first is the choice of appropriate empiric antibiotic treatment and dosage, taking into account the patient’s general condition, comorbidity, and the expected pathogen, especially in view of increasing antibiotic resistance among Enterobacteriaceae.
- The second is the timing of imaging for diagnosis and possible source control to rule out obstruction requiring decompression.
In this study on patients with community-onset bloodstream infection (CO-BSI) during 2019 and 2020, a well-defined retrospective cohort was selected to determine risk factors for urosepsis-related mortality within 30 days of infection. date on which the first positive blood culture was performed.
Background
Urosepsis is a life-threatening condition that must be addressed without delay. Two critical aspects in its management are:
(1) Appropriate empirical antibiotic therapy, considering the patient’s general condition, comorbidity and the expected pathogen.
(2) Timing of imaging to identify obstruction requiring decompression.
Goals
Identify risk factors associated with 30-day mortality in patients with urosepsis.
Methods
From a cohort of 1605 community-onset bloodstream infections (CO-BSIs), 282 patients with urosepsis were identified in one Swedish county 2019-2020. Mortality risk factors with crude and adjusted odds ratios were analyzed using logistic regression.
Results
Urosepsis was found in 18% (n = 282) of all community-onset bloodstream infections (CO-BSI).
All-cause mortality at 30 days was 14% (n = 38 ) .
After multivariate analysis, radiologically detected urinary tract disorder was the predominant risk factor for mortality (OR = 4.63, 95% CI = 1.47–14.56), followed by microbiologically inappropriate empiric antibiotic therapy (OR = 4.19, 95% CI = 1.41–12.48).
Time to radiological diagnosis and decompression of obstruction for source control were also important prognostic factors for survival.
Interestingly, 15% of blood cultures showed gram-positive species associated with a high 30-day mortality rate of 33%.
Conclusion
The 30-day all-cause mortality for urosepsis was 14%. The two main risk factors for mortality were hydronephrosis caused by obstructive stones in the ureter and inadequate empiric antibiotic therapy .
Therefore, early detection of any urinary tract disorder by imaging followed by source control as necessary, and antibiotic coverage of gram-negative pathogens and gram-positive species such as E. faecalis to optimize management, is likely to improve survival. in patients with urosepsis.
Discussion
Several independent risk factors were associated with 30-day mortality in patients with community-onset bloodstream infections (CO-BSI) with urosepsis during the 2-year study period. In a multivariable logistic regression model, urinary tract disorder, inadequate empiric antibiotic treatment, and disease severity (In-SOFA score and 24-hour SOFA) were associated with a significantly increased risk of all-cause mortality at the 30 days.
The covariate that showed the strongest association with 30-day mortality was urinary tract disorder , the most common being hydronephrosis caused by an obstructive stone in the ureter, renal abscess, urologic malignancy, and displaced nephrostomy.
Clinically important associations between the presence of urinary tract disorders and urosepsis have been previously reported, and several studies recommend radiology in patients at risk or with poor response to initial treatment. In most previous studies, all patients with febrile UTI have been studied, not just those with urosepsis. In the present study on a selected retrospective cohort with urosepsis, a strong correlation between urinary tract disorder and 30-day mortality was observed, clearly justifying early radiology to evaluate the urinary tract.
The second most important risk factor was inadequate empirical antibiotic treatment according to the cultured pathogen and its susceptibility pattern. It is crucial to recognize urosepsis as early as possible and initiate timely sensitive antibiotic treatment. The overall 30-day mortality rate was 14%, and of these, 61% had gram-negative urosepsis . The most common pathogen isolated was E. coli followed by other Enterobacteriaceae spp. There is growing concern about the global increase in the prevalence of ESBL-producing Enterobacteriaceae. In this study, 4% of cases were caused by ESBL E. coli, which caused 11% of deaths.
An interesting finding was the high percentage of gram-positives (37%) associated with 30-day mortality, particularly E. faecalis observed in 21% of deaths. This could possibly have been the consequence of the lack of coverage of Enterococcal in the Swedish empiric treatment recommendations.
The third and fourth most important risk factors were disease severity (In-SOFA and maximum 24-hour SOFA scores), as expressed by the SOFA score. This may be due to patient delay or delay in prehospital care. Studies show that sepsis is difficult to diagnose in the early stages and this may explain the severity of illness in non-survivors upon arrival to the emergency department, although more virulent pathogens or patient-specific factors could also have played a role.
Time to decompression by ureteral stent placement or percutaneous nephrostomy were important factors in increasing survival in urosepsis. In this study, significant delays in renal decompression were observed in nonsurvivors. The delay may be due to the complexity of the procedure or the time of day the need for decompression was discovered (limited access to staff and facilities for emergency decompression at night), or because seriously ill patients have a greater need stabilization and optimization before intervention.
Age is a well-known risk factor for BSI, sepsis, urosepsis and mortality which was also the case in this study . Previous studies have shown a significant association between the number of comorbidities and mortality. Diabetes, kidney disease and cancer were the comorbidities that had the greatest association with non-survival in this study. Diabetes has previously been shown to increase the risk of urinary tract disease. Inadequate empiric antibiotic treatment, kidney disease, and cancer can override any patient-specific factors that would otherwise increase the chance of survival.
Final message
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