CURRENT Essentials of Critical Care.pdf

158 Current Essentials of Critical Care■■■UrosepsisEssentials of Diagnosis• Urinary tract infection with secondary sepsis; ascending routeof infection most common• Vesiculoureteral reflux and renal transplant (short ureter withhigh risk of reflux) predispose to pyelonephritis; women higherrisk for cystitis secondary to short urethra• E coli most common pathogen but multidrug-resistant gramnegativerods, candida, coagulase negative staphylococci maycause nosocomial urosepsis• Complications: intrarenal or perinephric abscess, obstruction,and infected renal stones; emphysematous pyelonephritis rarecomplication of elderly women with diabetes mellitus, chronicurinary tract infection, underlying renal vascular disease; organismtypically E coliDifferential Diagnosis• Sepsis from other sources• Simple acute pyelonephritis or cystitisTreatment• Systemic antibiotics targeting most likely pathogen (urine Gramstain may guide empiric therapy)• If negative urine Gram stain, empiric therapy with aminoglycoside,extended-spectrum penicillin, third-generation cephalosporin,or fluoroquinolone• Obtain imaging studies (ultrasound examination, computed tomography,or CT urogram) to evaluate possible complications• Emphysematous pyelonephritis requires immediate nephrectomy■ PearlIn uroseptic patient, urine culture growing S aureus should promptwork up for S aureus bacteremia (eg, infective endocarditis).ReferenceParadisi F: Urosepsis in the critical care unit. Crit Care Clin 1998;14:165.[PMID: 9561812]