Diagnosis and treatment of sepsis syndrome in urology

Sepsis syndrome in urology is a serious problem, as this condition is associated with a high level of patient mortality. At the same time, early diagnosis of sepsis symptoms can reduce the mortality rate, provided that violations in the urinary tract are corrected in a timely manner.

Urosepsis should be diagnosed early, especially in patients with complicated urinary tract infections (UTIs). Systemic inflammatory response syndrome (SIRS), characterized by fever or hypothermia, hyperleukocytosis or leukopenia, tachycardia, tachypnea, is the first link in the cascade of multiple organ failure.

With the development of severe sepsis or septic shock, the mortality of patients increases significantly, however, the prognosis for the life of patients with urosepsis is generally more favorable compared to sepsis against the background of infectious foci of other localizations.

Treatment of urosepsis should include life support, appropriate and timely antibiotic therapy, a range of ancillary treatments (sympathomimetics, hydrocortisone, glycemic control), and correction of urinary tract abnormalities (Level of Evidence (LE) 1a; Grade of Recommendation (GR) ) BUT). Restoration of urinary tract patency is the mainstay of first-line therapy for urosepsis (LE: 1b, RG A). In addition, patients with urosepsis should be treated by a urologist in collaboration with a resuscitator and an infectious disease specialist (LE: 2a, RG B).

Urosepsis can develop both against the background of community-acquired and nosocomial infections. At the same time, most cases of nosocomial urosepsis can be prevented by measures aimed at preventing the persistence of nosocomial infection, for example, reducing the length of stay of patients in the hospital, early removal of the catheter from the bladder, reducing the number of episodes of unnecessary catheterization, rational use of closed-type drainage systems and compliance with simple rules of daily asepsis to avoid cross-infection (LE: 2a, RG B).

Prerequisites for the development of urosepsis

UTIs can manifest as bacteriuria with limited clinical symptoms, sepsis, or severe sepsis, depending on the extent of the infection. The diagnosis of "sepsis" is stated in cases where the clinical signs of an infectious lesion are accompanied by symptoms of systemic inflammation (fever or hypothermia, tachycardia, tachypnea, leukocyturia or leukopenia). Severe sepsis is defined by the presence of symptoms of organ dysfunction, and septic shock is defined by persistent hypotension associated with tissue hypoxia.

Mortality in severe sepsis reaches 20-42% (according to the literature, this pathology is most often associated with pulmonary (50%) or abdominal (24%) infections), while UTIs account for only 5% of cases of this disease. It has also been found that sepsis is more common among males. Despite the fact that in recent years the incidence of sepsis has increased by 8.7% per year, the mortality rates caused by it have decreased, which indicates the improvement of patient management tactics (in total, from 1995 to 2000, mortality in the hospital decreased from 27.8 to 17.9 %). With the exception of urosepsis, in general, there is an increase in the incidence of septic conditions caused by fungal flora, and gram-positive bacteria began to dominate in the etiological structure in the septic process, despite the fact that

The severity of urosepsis, like other types of sepsis, depends mainly on the body's response. Most often, urosepsis occurs in elderly patients, people with diabetes mellitus, immunocompromised people receiving chemotherapy or corticosteroids, AIDS patients.

The course of urosepsis also depends on the individual characteristics of the patient, such as stones in various parts of the urinary system, obstruction of the urinary tract at any level, the presence of congenital uropathy, neurogenic bladder disorders or endoscopic manipulations. At the same time, it is affected by the specificity of pathogens that can induce inflammation in the urinary tract. In addition, it has been proven that SIRS can develop without the participation of an infectious factor (against the background of pancreatitis, burns or nonseptic shock).

Definition and clinical signs of sepsis in urology

In addition to identifying symptoms of the disease, the diagnosis of UTI is based on physical, ultrasound, and x-ray examinations, as well as laboratory results indicating the presence of bacteriuria and leukocyturia. The following definitions are used:

Sepsis is the body's systemic response to infection. Symptoms of SIRS, which were originally considered pathognomonic for this condition, are now considered to be signal. Most other clinical or biological signs of sepsis require clarification.

Severe sepsis is associated with organ dysfunction.

Septic shock is manifested by persistence of hypoperfusion or hypotension despite fluid therapy.

Refractory septic shock is characterized by a lack of positive response to therapy.

Clinical and diagnostic criteria for sepsis and septic shock are given in Table 1.

Physiological and biochemical markers of urosepsis

Microorganisms reach the urinary tract via the ascending route, as well as through hematogenous and lymphogenous drift.

In the case of urosepsis, pathogens must enter the bloodstream. The risk of bacteremia is increased in severe UTIs such as pyelonephritis and acute bacterial prostatitis, which alleviate urinary tract obstruction. E. coli remains the most common causative agent of sepsis in urology. In some countries, some bacterial strains may be resistant to quinolones or third-generation cephalosporins. Some microorganisms (methicillin-resistant Staphylococcus aureus (MRSA), P. aeruginosa, Serratia spp., etc.) are multidrug resistant and difficult to treat. Most often they occur in compromised patients (people with diabetes mellitus or immunosuppression), causing the appearance of typical symptoms of generalized sepsis, combined with local signs of infection.

Cytokines as a marker of septic response

Cytokines are peptides that regulate the amplitude and duration of the persistence of the inflammatory response in the body. They are produced by various cells, including monocytes, macrophages, and endotheliocytes, in response to infectious stimuli. In severe sepsis, an imbalance is formed in the work of the pro- and anti-inflammatory systems of the body. Cytokines such as interleukins 1, 6, 8 and tumor necrosis factor are involved in the development of sepsis. Sepsis is an indicator of serious disorders in the immune system, in particular, its inability to provide eradication of the pathogen and / or adequate control over the severity of the inflammatory response. In some cases, severe sepsis can be explained by a genetic predisposition.

Procalcitonin as a potential marker of sepsis

Procalcitonin is a calcitonin propeptide lacking hormonal activity. As a rule, in healthy people, its level cannot be determined. During severe generalized infections (bacterial, parasitic and fungal) with systemic manifestations, the level of procalcitonin can rise to more than 100 ng / ml. In contrast, with severe viral infection or non-infectious inflammatory reactions, the level of procalcitonin does not change or slightly increases.

Monitoring of procalcitonin concentration is advisable to be carried out in a group of patients who are at risk of developing SIRS of infectious etiology. High levels of this propeptide or a sharp increase in its concentration in the blood in such patients are the basis for clarifying the localization of the focus of infection in the body. At the same time, determining the concentration of procalcitonin can help in establishing the nature (infectious or non-infectious) of a severe inflammatory reaction.

Prophylaxis of urosepsis

Septic shock is the most common cause of death in patients hospitalized for community-acquired and nosocomial infections (20-40%). Sepsis initiates a cascade of reactions that cause the development of severe forms of SIRS, including septic shock. In the treatment of urosepsis, an integrated approach is used, involving the impact on the cause of the disease (obstruction of the urinary tract), measures aimed at maintaining the life support of the body, and appropriate antibiotic therapy. In this situation, in addition to the urologist, it is recommended to involve a resuscitator and an infectious disease specialist in the supervision of the patient.

Prophylactic measures with proven or probable effectiveness

The most effective methods to prevent nosocomial urosepsis are similar to those used to prevent other nosocomial infections and are as follows:

isolation of all patients infected with multidrug-resistant strains of microorganisms in order to prevent cross-infection;

• Rational use of antimicrobials for the prevention and treatment of established infections to prevent the selection of resistant strains. The choice of antibiotic should depend on the characteristics of the microorganism prevalent in the site of infection;
• reduction of the length of stay of patients in the hospital (it has been proven that a long stay of patients in the hospital before surgery leads to an increase in the incidence of nosocomial infections);
• remove the catheter from the bladder as early as possible. As is known, nosocomial UTIs are often caused by bladder catheterization, as well as ureteral stenting. Antibiotic prophylaxis does not prevent stent infection, which occurs in 100% of patients with a permanent ureteral stent and in 70% of patients who have undergone temporary stenting;
• Use closed drainage systems and minimize the risk of their integrity being compromised, including when taking urine samples for analysis or bladder lavage;
• use the least invasive methods to relieve urinary tract obstruction until the patient's condition stabilizes;
• Attention to simple asepsis routines, including regular use of protective disposable gloves, frequent hand disinfection to prevent cross-infection.

Perioperative antibiotic prophylaxis

Potential side effects of antibiotics should be considered before prescribing them. Recommendations for the use of antibacterial drugs in the perioperative period are presented in Table 2.

Preventive measures, the effectiveness of which is discussed:

Instillation of antibiotics or antiseptics into catheters and drainage bags.

• Use of urinary catheters coated with antibiotics or silver.
Ineffective measures:

Continuous or intermittent irrigation of the bladder with antibiotics or antiseptics, which increase the risk of infection with antibiotic-resistant bacteria.

• Routine administration of antibacterial drugs to catheterized patients, which reduces the incidence of bacteriuria for several days and increases the risk of infection with multidrug-resistant bacteria.

Algorithms for the treatment of urosepsis

Primary goals of targeted therapy are presented in Table 3.

Relief of obstruction in the urinary tract

Removal of any urinary tract obstruction with removal of foreign bodies such as catheters or stones should result in resolution of symptoms and recovery. Restoration of urinary tract patency is a key component of the urosepsis management strategy.

Antimicrobial therapy

Initial empiric antibiotic therapy should cover a wide range of potential septic pathogens. Later it is modified depending on the results of the culture study. The dosage of antimicrobials is of paramount importance in patients with sepsis syndrome, in whom it is usually high, with the exception of people with renal insufficiency. Antimicrobial agents should be prescribed to the patient no later than 1 hour after the provisional diagnosis of sepsis was made.

The criteria for diagnosing UTIs, modified according to the recommendations of the American Society for Infectious Diseases / European Society for Clinical Microbiology and Infectious Diseases, are shown in Table 4.

Concomitant Therapy

The control of fluid and electrolyte balance is one of the most important aspects of the care of patients with sepsis syndrome, especially complicated by shock. The feasibility of using human albumin remains controversial. It has been proven that early targeted therapy leads to a decrease in patient mortality. Correction of the volume of circulating blood and the appointment of vasopressor drugs have a significant impact on the outcome of the disease. Early intervention in the processes of tissue perfusion and oxygen transport with the help of timely infusion therapy and stabilization of blood pressure are very effective.

Hydrocortisone (optimum dosage TBD) appears to be useful in patients with relative insufficiency of the pituitary-adrenal cortex.

Tight blood glucose control with insulin at doses up to 50 U/h is associated with reduced mortality.

Available evidence does not support the use of human recombinant activated protein C in adults and children with severe sepsis and septic shock.

Thus, when studying the problem of urosepsis, we can come to the following conclusions.

1. Sepsis syndrome in urology is a serious problem, as this condition is associated with a high mortality rate (20-40% of patients).

2. Early diagnosis of the symptoms of sepsis can reduce the mortality rate from this pathology, provided that disorders in the urinary tract, such as obstruction or urolithiasis, are corrected in a timely manner.

3. Rational use of life support approaches and adequate antibiotic therapy create the most favorable conditions for improving patient survival.

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