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Management of Urosepsis in 2018

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Management of Urosepsis in 2018 EUF-633; No. of Pages 5 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 18) X X X – X X X ava ilable at www.sciencedirect.com journa l homepage: www.europeanurology.com/eufocus Guidelines CME article Management of Urosepsis in 2018 a, b c d Gernot Bonkat *, Tomasso Cai , Rajan Veeratterapillay , Franck Bruye`re , e f g h Riccardo Bartoletti , Adrian Pilatz , Be´la Ko¨ves , Suzanne E. Geerlings , d i f Benjamin Pradere , Robert Pickard , Florian M.E. Wagenlehner a b alta uro AG, Merian Iselin Klinik, Center of Biomechanics & Calorimetry, University Basel, Basel, Switzerland; Department of Urology, Santa Chiara, Reg. c d Hospital, Trento, Italy; Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK; Academic Department of Urology, Pitié-Salpêtrière Hospital, e f Assistance-Publique Hôpitaux de Paris, Paris, France; Department of Urology, University of Florence, Florence, Italy; Clinic for Urology, Pediatric Urology g h and Andrology, Justus-Liebig-University, Giessen, Germany; Department of Urology, South-Pest Teaching Hospital, Budapest, Hungary; Department of Internal Medicine, Division of Infectious Diseases, Center for Infection and Immunity Amsterdam, Academic Medical Center, Amsterdam, The Netherlands; i Newcastle University, Newcastle upon Tyne, UK Article info Abstract Article history: Despite optimal treatment, urosepsis has still high morbidity and mortality rates. An fi fi Accepted November 7, 2018 updated de nition and classi cation system for sepsis have recently been introduced. Management of urosepsis comprises four major aspects: (1) early diagnosis, (2) early fi Associate Editor: empiric intravenous antimicrobial treatment, (3) identi cation and control of compli- cating factors, and (4) specific sepsis therapy. The quick sequential organ failure Christian Gratzke assessment is replacing the systemic inflammatory response syndrome scoring for rapid identification of patients with urosepsis. Keywords: Patient summary: Urosepsis is a serious, life-threatening complication of infections Urosepsis originating from the urinary tract. As urosepsis has a very high mortality rate, it is important that is quickly spotted and that appropriate treatment is swiftly begun. Antimicrobial therapy Imaging of urinary tract disorders has been shown to be useful in decreasing mortality Urological infections from urosepsis, and in the future microbiology techniques may also prove useful. Given Prevention measures the severity of urosepsis and the associated risks, large efforts need to be made to prevent high-risk infections in hospitals with appropriate prevention measures, such as the early removal of catheters used whenever possible. © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. alta uro AG, Merian Iselin Klinik, Center of Biomechanics & Calorimetry, University Basel, Centralbahnplatz 6, 4051 Basel, Switzerland. Tel.: +41 61 2263000. E-mail address: [email protected] (G. Bonkat). upmost importance. For example, careful choice of prophy- 1. Introduction laxisand treatmentantimicrobialsiscrucial to avoid selection of resistant strains. Similarly, shorter hospital stays before Urosepsis is a life-threatening organ dysfunction caused by a surgery will help to decrease the risk of nosocomial infec- dysregulated host response to infection originating from the tions. In addition, early removal of indwelling urethral cathe- urinary tract and/or male genital organs. From the perspec- ters helps in decreasing the rate of nosocomial infections and tive of both patients and urologists, the best (uro)sepsis is thus reduces nosocomial urosepsis. Finally, attention to sim- undoubtedly the sepsis that can be prevented. In this context ple everyday techniques to assure asepsis, including routine it has to be highlighted that prevention measures are of https://doi.org/10.1016/j.euf.2018.11.003 2405-4569/© 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved. Please cite this article in press as: Bonkat G, et al. Management of Urosepsis in 2018. Eur Urol Focus (2018), https://doi.org/10.1016/ j.euf.2018.11.003 EUF-633; No. of Pages 5 2 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 8 ) X X X – X X X use of protective disposable gloves, frequent hand disinfec- and damage-associated molecular pattern receptors and tion, and application of infectious disease control measures results in the secretion of large amounts of pro-inflamma- can prevent cross-infections [1]. tory cytokines (eg, IL-1 and IL-6). The initial pro- inflammatory phase is followed by a counter-regulatory 1.1. Sepsis-3 definitions anti-inflammatory response, leading to an immunosup- pressive state. In urosepsis, as in other types of sepsis, The previous iteration of sepsis definitions (Sepsis-2) dates the host response determines the severity and clearly influ- back to 2001. Apart from an additional list of signs and ences the outcome [5]. symptoms possibly indicating sepsis, the original sepsis definition (the Bone criteria, Sepsis-1) dating from 2.2. Pathogens 1991 remained practically unchanged. This original concept of sepsis was based on a model consisting of four phases in a In urosepsis, as opposed to other type of sepsis, the most continuum. The first phase is an infection that can progress commonly isolated pathogen is Escherichia coli, followed by into the second phase called sepsis (combining infection other Enterobacteriaceae. In contrast to pulmonary or with at least two of the four systemic inflammatory abdominal sepsis, most cases of urosepsis are caused by a response syndrome [SIRS] criteria [2]) that can deteriorate single microorganism. At present, extended-spectrum towards severe sepsis (organ dysfunction) and ultimately to b-lactamase (ESBL) Enterobacteriaceae (including E. coli) septic shock. The new definition states that sepsis is a life- pose a serious threat to patients. Such bacteria (multiple threatening organ dysfunction caused by a dysregulated drug–resistant Enterobacteriaceae) can account for up to host response to infection. An important aim of this change 45% of all Enterobacteriaceae [6]. In such cases, initial was to differentiate sepsis (“bad infection”) from uncom- empiric therapy is often inappropriate. It is therefore crucial plicated infection. Three new aspects are thus added to the to rapidly isolate the microbial pathogen, as an appropriate previous definition. First, sepsis is life-threatening, imply- definitive treatment significantly improves the chances of ing a need for prompt recognition and intervention. Second, survival in cases of ESBL infection [7]. there is a dysregulated host response, which underlines the importance of both pro- and anti-inflammatory and other 3. Recognizing urosepsis processes. Third, sepsis is more severe than an uncompli- cated infection, meaning that organ dysfunction needs to be 3.1. Clinical recognition using sequential organ failure present. The new sepsis (infection with organ dysfunction) assessment definition thus makes the old severe sepsis term redundant. Patients with sepsis may show many different clinical 1.2. Epidemiology symptoms and signs. The task force evaluated those that best identify organ dysfunction. The electronic health care Urosepsis accounts for up to 20–30% of sepsis cases and can records for 1.3 million patients in the 12 hospitals of the potentially lead to septic shock, a more severe illness than University of Pittsburgh Medical Center conglomerate was sepsis alone and associated with high morbidity and mortality used as the discovery database. To characterize the possi- [2]. It is crucial to recognize urosepsis rapidly and to provide bility of sepsis, three different scores were evaluated: the timely effective treatment, as delayed treatment results in a systemic inflammatory response syndrome (SIRS) criteria, 7.6% increase in mortality after the onset of hypotension the logistic organ dysfunction system (LODS) score, and [3]. Sepsis and urosepsis are not uncommon. Overall, it is the sepsis-related organ failure assessment (SOFA) score estimated that sepsis represents 31.5 million cases per year, (Table 1). Importantly, the SIRS and SOFA scores offer with fatal outcome for 5.3 million of those cases. Furthermore, comparable discriminative value for non-intensive care approximately 20% of sepsis survivors will have cognitive or unit (ICU) patients. However, for ICU patients, SOFA and physical disabilities. Among all sepsis cases, an estimated LODS were superior to SIRS. A SOFA score 2 was associ- 9–31% are urosepsis, representing 2.8–9.8 million cases and ated with a 10% risk of hospital mortality among patients up to 1.6 million deaths [4]. As a result, sepsis and urosepsis with suspected infection; these patients had a two- to have become a priority for many hospitals and are recognized 25-fold higher risk of dying compared with patients with by the World Health Organization as a serious problem. a SOFA score of <2. 2. Pathogenesis 3.2. Quick SOFA score (qSOFA) The complex pathogenesis of urosepsis starts when uro- pathogens or their products stimulate the host innate The qSOFA consists of three variables: abnormal mentation immune system. (ie, new-onset agitation, altered mentation with Glasgow Coma Scale score 14, drowsiness, confusion, or coma), 2.1. Host response to pathogen invasion respiratory rate (22 breaths/min), and systolic blood pres- sure (100 mm Hg). When two of the three variables were Stimulation of the host immune system involves pattern present in a ward or emergency department patient, this recognition receptors such as toll-like receptors (eg, TLR-4) equated to a risk of dying of approximately 8%, whereas Please cite this article in press as: Bonkat G, et al. Management of Urosepsis in 2018. Eur Urol Focus (2018), https://doi.org/10.1016/ j.euf.2018.11.003 EUF-633; No. of Pages 5 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 8 ) X X X – X X X 3 Table 1 – Comparison of sepsis assessment instruments.
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