New findings show that urosepsis is associated with lower mortality than sepsis derived from other sites, but if appropriate measures are not taken, 10-15% will develop a recurrent urosepsis.
Dr. Zafer Tandoğdu (University College London, UK) presented data derived from the SERPENS study1. This prospective observational study of approximately 600 patients specifically looks at outcomes for urosepsis.
Defining diagnostic criteria in the sepsis field has been problematic, but most researchers now agree that a suspicion of infection, coupled with a mental state assessment, and either the Systemic Inflammatory Response Syndrome (SIRS) or the National Early Warning Score (NEWS) constitute the best approach for the identification of severe sepsis and septic shock. The susceptibility profile of each patient should be carefully evaluated at the baseline evaluation (diagnosis of urosepsis).
Most patients will develop urosepsis within 10 days of intervention. Many patients will have had previous urosepsis, previous hospitalization, or are diabetic, and 43% will have had a recent urinary tract infection. Overall, about half of urosepsis patients have >1 comorbidity. The baseline catheter burden should be evaluated as well.
The 30-day outcomes from the SERPENS database indicate that mortality is reduced in urosepsis, at only 2.8% versus 20% other-source mortality. This reduction may be attributed to the fact that urosepsis is a less aggressive septic condition as compared with other septic sources because we have the ability to gain local control relatively quickly. Among the patients who died, 75% had severe sepsis and 25% had SIRS/sepsis.
The clinical failure rate was 15%, of whom 77% had severe sepsis. There is a high burden of disease on the urosepsis patient, including local and distant damage, and 10-15% of patients will acquire a recurrent infection. The main determinants of clinical failure are age and comorbidities (e.g. Parkinson’s disease), catheter burden, acute kidney injury and resting respiratory rate, previous admissions and antibiotics, and previous urinary tract infection burden.
Dr. Tandoğdu commented on the current discussion in sepsis management is personalization versus protocolization. Although the concept “each hour saves lives” has led to early administration of antibiotics, only 57% -80% of patients with suspicion of sepsis were proven to actually have sepsis2.
In non-septic shock patients, there is a window of time to identify the pathogen and apply specific treatments. In a prospective observational study (n=67) 34% of patients received inappropriate antibiotics. Despite the overuse of antibiotics, there was no impact on mortality, and individual patient characteristics turned out to be more relevant to patient outcomes3. Dr. Tandoğdu’s take-home message was ”Don’t delay antibiotics, but do use them cautiously and selectively.”
References:
1. Tandoğdu Z, et al. Urosepsis: Hot data from the SERPENS study. EAU20 Virtual Congress, 17-26 July 2020, Plenary Session 02: New frontiers in infections.
2. Klein Klouwenberg PM, et al. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study. Crit Care. 2015;19(1):319. Published 2015 Sep 7.
3. Fitzpatrick JM, et al. Gram-negative bacteraemia; a multi-centre prospective evaluation of empiric antibiotic therapy and outcome in English acute hospitals. Clin Microbiol Infect. 2016;22(3):244-251.