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Urosepsis

Urosepsis is a systemic inflammatory response due to an infection affecting the urogenital tract.


Presentation

Lower urinary tract infection presents with frequent urination, especially during the acute phase of the infection, which often results in urethra irritation. Furthermore, urination is painful due to the irritation and inflammation of the urethra, usually associated with a burning sensation as urine passes through the urethra itself. In the urine itself can be observed the presence of blood, indicating that the infection has reached upper parts of the urinary tract. In any case, the quantity of urine markedly decrease, as the kidneys become unable to perform their function.

When kidneys are reached by the inflammation, a severe sensation of pain begins to spread locally, which ends up affecting the area of the flank and the lower back. Fever, instead, may be seen since the onset of urinary tract infection, but when the infection spreads into the blood stream, fever becomes persistent.

As previously stated, after spreading through the circulatory system the infection ends up effecting the heart as well, which begins to increase its beating rate in a state of tachycardia. The breathing rate increases as well, in a general state of the subject characterized by hypotension and hypothermia. Furthermore, mental status can be impaired as consequence of thecirculation.

So, the major signs of UTI can be summarized as follows:

Moreover, it is possible to understand when urosepsis has begun due to the following signs:

  • High grade fever above 101.3 f or below 95F
  • Increased heart beating rate, above 90 beats per minute
  • Rapid breathing rate, above 20 breaths per minutes
  • Verified infections through urinalysis
  • Decreased urine output
  • Impaired mental status

If in addition to these symptoms, it is possible to observe an extremely low blood pressure, this means that urosepsis has triggered a septic shock.

Fever
  • A 91-year-old man with chronic incontinence managed by indwelling catheter was hospitalized for investigation of fever, hypotension, and cloudy urine.[ncbi.nlm.nih.gov]
  • Gender, age, blood pressure, fever, malignant disease, liver disease, neurological disease, prostatic disease, chronic indwelling urinary catheter, C-reactive protein, and white blood cell count did not show a statistically significant association with[ncbi.nlm.nih.gov]
  • We attempted to differentiate pyelonephritis, defined as upper urinary tract parenchymal infection, from fever due to other sources in patients with spinal cord injury by radioisotope renal scintigraphy.[ncbi.nlm.nih.gov]
  • FeverFever is a classic sign of infection that may be experienced after the onset of UTI. Persistent high fever occurs when the infection has spread to the blood stream.[healthzene.com]
Chills
  • The authors present a case of a 72-year-old diabetic male s/p pelvic irradiation for prostate carcinoma who arrived in the emergency department with complaints of shaking chills.[ncbi.nlm.nih.gov]
  • […] in temperature Absence of chills and diaphoresis Pulse and respiratory rate within Normal range for client WBC and differential counts Returning to normal Negative blood culture results.[prezi.com]
  • ChillsChills along with very high fever are also experienced. Chills are a sign of systemic infection. Tachycardia or increased heart rate – Tachycardia is experienced by patients with urosepsis due to affectation of the organ.[healthzene.com]
  • As a person's body tries to fight the infection, it can cause a rapid heartbeat, as well as fever, chills, and confusion, and ultimately organ failure or even death. Knowing the risk factors and recognizing early symptoms can be vital.[urologists.org]
Rigor
  • Other features of lower UTI may be present e.g. frequency, dysuria etc Fever can often be high enough to cause rigors Other systemic features may also be present e.g. nausea/vomiting, anorexia, malaise and occasionally diarrhoea Investigations Urinalysis[dundeemedstudentnotes.wordpress.com]
  • Patients with urosepsis need to be hospitalized for rigorous treatment measures as mortality is very high. What Is The Cause Of Urosepsis Infection? As mentioned earlier, urosepsis is secondary to urinary tract infection.[tandurust.com]
  • Discussion In this study, we developed and rigorously validated a novel multiplex PCR assay for 29 putative VF gene regions of extraintestinal E. coli .[jid.oxfordjournals.org]
High Fever
  • Hypothermia – When septic shock occurs, very high fever is usually followed by hypothermia due to severe dilation of the blood vessels, which allows heat to escape from the body.[healthzene.com]
  • High fever with chills. The infection can spread into the bloodstream particularly if the condition is not treated or if the person has low immune level.[tandurust.com]
  • Signs and symptoms of Urosepsis in the early phase or the sepsis phase include the following: Onset of high fever which is more than 101 degrees F A rapid heart rate of about 90 or more beats per minute An increased respiratory rate of about 20 or more[healthh.com]
Flushing
  • Fluids help flush the renal system and prevent accumulation of bacteria and germs that cause the infection. Reduce the intake of spicy and pungent foods.[simple-remedies.com]
  • Intravenous fluids are administered to flush the urine so that the germs may not remain adhered to the walls of urinary bladder. It also helps to increase blood pressure and for electrolyte balance.[tandurust.com]
  • They include: Drinking plenty of water every day, to help flush out your urinary tract. Don’t hold your urine. Empty your bladder as frequently as is realistic and possible.[sepsis.org]
Intracranial Hemorrhage
  • Spontaneous psoas hematoma requiring blood transfusion and intracranial hemorrhage developed after antiplatelet and anticoagulant therapies, even in therapeutic doses.[ncbi.nlm.nih.gov]
Flank Pain
  • Symptoms of urosepsis include fever, chills, flanking pain, frequent urination, increased respiratory rate and hypotension.[invokanaclaim.com]
  • I was in deep trouble due to the increased frequency of urination, burning sensation on urination, flank pain, and at times blood was seen in my urine along with the fever plus increased heart rate.[forerunnershealthcare.com]
  • Flank pain – Pain may be felt in the lower back or the flank area due to underlying inflammation of the kidneys, distending the space that radiates to the back.[healthzene.com]
  • Signs and symptoms of urinary tract infections include: Frequent urge to urinate but in small quantity only Burning sensation with every urination Urine is cloudy in appearance Urine has a strong foul smell Pelvic pain and flank pain Onset of high grade[hubpages.com]

Workup

It is important to determine the onset of the urinary tract infection, as it might spread to the blood stream causing urosepsis. An urinalysis is extremely useful in this regards, an urine sample is taken to be sent to the laboratory for testing. In the laboratory clinicians check for a series of parameters, such as the presence of key ions, traces of metals, proteins and enzymes, as well as blood cells and other molecules. The analysis can be performed through urine test strip, microscopic examination, and other methods like hemoglobin test. Apart from the presence of infection, urinalysis allows to detect clotting problems, impaired oxygen supplies, as well as imbalances in fluid and electrolytes.

ST Elevation
  • We present a 71-year-old woman with Escherichia coli urosepsis and sepsis-induced myocardial injury masquerading as non-ST elevated myocardial ischemia.[ncbi.nlm.nih.gov]
Corynebacterium Diphtheriae
  • Corynebacterium species other than Corynebacterium diphtheriae rarely cause infections in human but rather reside in flora, however they have been reported to cause opportunistic infections in both immunocompromised and immunecompetent patients.[ncbi.nlm.nih.gov]

Treatment

A regimen of antibiotics is the primary choice in the treatment of urosepsis. The choice of the antibiotics should be based on the underlying lesion, the causative microorganism and its resistance pattern [8] [9]. Furthermore, the therapy could be based on just one antibiotic or a combination of two or more of them [10]. In addition to these, medications against increased blood pressure can be prescribed to reduced hypertension, as well as supportive measures like intravenous fluid administration, whose primary aim is to adjust fluid and electrolytes physiological imbalance.

Due to the danger involved, the worst cases have to be treated in hospital and placed in intensive care units, where subjects can be constantly monitored. If septic shock occurs, patients have to undergo mechanical ventilation or other life-saving measures like this, to stabilize breathing and organic functions in general.

Prognosis

Prognosis of urosepsis is generally not good, as complications can be very frequent. The major complications include septic shock, disseminated intravascular coagulation, kidney failure or damage, scarring, and renal, perirenal, or prostatic abscesses.

Etiology

Sepsis does not occur randomly and is generally associated with another underlying condition such as a perforation or the rupture of an intraabdominal or pelvic structure [4]. As previously said, in the case of urosepsis the infection starts from the urinary tract to finally enter the blood stream and spread throughout the body. Usually, the infection has remained undiagnosed and untreated in the urinary tract for some time, before moving to other parts of the body. There are numerous risk factors implicated in the development of urosepsis, and these include:

  • Age, since the immune system is generally weaker in elderly.
  • Conditions of compromised immune systems, as a result of another disease.
  • Chronic conditions such as diabetes.
  • Objects blocking urinary tracks such as little stones, scarring, or prostate enlargement.
  • Sex, as females have a higher risk to develop this disease due to the closer proximity of the urinary tract to female genitalia and the outside environment.
  • Pregnancy, due to the softening and opening of the cervix.
  • The use of indwelling catheters.
  • Urinary retention.

The majority of the cases  are due to gram-negative bacilli such as Escherichia coli (50%), Proteus spp. (15%), Enterobacter, Klebsiella spp. (15%), and Pseudomonas aeruginosa (5%). However, the cases due to gram-positive organisms, such as Enterococcus, are not negligible, as they are responsible for the 21,2% of all the cases of hospital-acquired urinary tract infections.

Epidemiology

Urosepsis accounts for approximately 25% of all the sepsis cases. As previously stated, the risk of getting urosepsis multiplies in case of hospitalization and long-term care, due to the indwelling catheter treatment and the high risk of infection that this implies. According to a study conducted during 1990s, 23% of all cases of sepsis acquired in hospital were due to infections of urinary tract mostly seen in catheterized patients [5]. In 2001 a pan-European study reported an incidence of hospital-acquired urinary tract infection of 3.55 cases over 1000 patients [6]. According to two point-prevalence studies, instead, the Pan European Prevalence (PEP) study and the Pan EuroAsian Prevalence (PEAP) study, conducted in 2003 and 2004, the prevalence of the hospital-acquired urinary tract infection should range from 10% to 14%, 12% of which are accounted for by US [7].

Sex distribution
Age distribution

Pathophysiology

Urinary tract infection (UTI) as infection can occur everywhere in the urinary tract. Once it starts spreading, the infection moves towards the upper urinary tract, spreading through the bladder, ureters, and kidneys. Here it affects nephrons causing pyelonephritis, a pathological condition consisting in an intense pain in the flank and lower back. After reaching the kidneys, the infection may further progresses towards the blood and the circulatory system, triggering the classical systemic response, sepsis. The involvement of further organs causes the wide range of signs and symptoms.

Prevention

Preventive measures of urosepsis should largely be based on preventing the occurrence of infections in the urinary tract. Therefore, people at higher risk of developing UTI are recommended to frequently empty the bladder, and to avoid, at least as much as possible, holding urine for long periods of time. Furthermore, they should strictly follow hygiene measures, such as wipe and wash genitals after having bowel movement or a sexual intercourse.

Summary

The word sepsis refers to a whole-body inflammatory response caused by a particular infection [1] which then results into a systemic blood inflammation. The classical signs of this condition include fever, increased heart and breath rate as well as an impaired mental status [2], associated with a series of other signs which vary according to the particular infection. This condition is usually triggered by a bacterium, but sometime it can be caused by fungi, viruses and other parasites a well [3]. The site of the primary infection generally include lungs, brain, urinary tract, abdominal organs, and skin.

In the case of urosepsis the systemic infection starts in the urinary tract to spreads into the bloodstream. In particular, the bacteria responsible for this infection producing toxins, begin to damage internal vascular side of endothelial vessels, the endothelium. This condition is clinically very serious, and if left untreated it might lead to death in a few days. 

Patient Information

Urosepsis is an infectious condition due to an infection affecting the urogenital tract. The infection is usually caused by a bacterium, but sometime it can also be caused by fungi, viruses and other parasites a well. In urosepsis there is a spread from the urinary tract to the blood stream, causing a systemic infection that experts called sepsis.

Once inside the blood stream, the condition affects major systems such as the respiratory system and cardiovascular system. The major signs of urinary tract infection include:

When urosepsis has begun, it is possible to observe other signs such as:

  • High grade fever above 101.3 f or below 95F
  • Increased heart beating rate, above 90 beats per minute
  • Rapid breathing rate, above 20 breaths per minutes
  • Verified infections through urinalysis
  • Decreased urine output
  • Impaired mental status

When these are added by an extremely low blood pressure, a septic shock has started. The major treatment for urosepsis is an antibiotic therapy, which is usually planned based on the original site of infection, the nature of the pathogen responsible for the infection and its resistance to antibiotics.

Preventive measures of urosepsis should largely be based on preventing the occurrence of infections in the urinary tract. Therefore, people at higher risk of developing them are recommended to frequently empty the bladder, and to avoid, at least as much as possible, holding urine for long periods of time. Furthermore, they should strictly follow hygiene measures, such as wipe and wash genitals after having bowel movement or a sexual intercourse.

References

Article

  1. Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup; Dellinger, RP; Levy, MM; Rhodes, A et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2012. Critical Care Medicine 41 (2): 580–637. 
  2. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003 Apr. 31(4):1250-6. 
  3. Jui J. Ch. 146: Septic Shock. In Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM. et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide (7th ed.). 2011 New York: McGraw-Hill. pp. 1003–14. 
  4. Merrell RC. The abdomen as source of sepsis in critically ill patients. Crit Care Clin. Apr 1995;11(2):255-72. 
  5. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in combined medical surgical intensive care units in the United States. Infect Control Hosp Epidemiol. 2000;21:510–5. 
  6. Bouza E, San Juan R, Muñoz P, Voss A, Kluytmans J. Co-operative Group of the European Study Group on Nosocomial Infections. A European perspective on nosocomial urinary tract infections II: Report on incidence, clinical characteristics and outcome (ESGNI-004 study) Clin Microbiol Infect. 2001;7:532–42. 
  7. Gastmeier P, Kampf G, Wischnewski N, Hauer T, Schulgen G, Schumacher M, et al. Prevalence of nosocomial imfections in representative German hospitals. J Hosp Infect. 1998;38:37–49. 
  8. Singh N, Yu VL. Rational empiric antibiotic prescription in the ICU. Chest. 2000;117:1496–9. 
  9. Schwab U, Chernomas F, Larcom L, Weems J. Molecular typing and fluconazole susceptibility of urinary Candida glabrata isolates from hospitalized patients. Diagn Microbiol Infect Dis. 1997;29:11–7. 
  10. Safdar N, Handelsman J, Maki DG. Does combination antimicrobial therapy reduce mortality in Gram-negative bacteraemia? A meta-analysis. Lancet Infect Dis. 2004;4:519–27.

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Last updated: 2017-08-09 17:57