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  • Empiric antimicrobial therapy for acute severe urosepsis should initially include two agents with activity against gram-negative bacilli, such as a third- or fourth-generation cephalosporin, aztreonam, or extended-spectrum penicillin in combination with either a fluoroquinolone or an aminoglycoside.

  • Where local epidemiology indicates significant prevalence of extended-spectrum β-lactamases among Enterobacteriaceae, then a carbapenem such as imipenem, meropenem, ertapenem, or doripenem is preferred while awaiting definitive cultures.

  • Where local epidemiology indicates significant prevalence of carbapenem-resistant Enterobacteriaceae (CRE), then colistin and a carbapenem or newer combination agents with activity against CRE should be chosen while awaiting definitive cultures.

  • Urine and blood cultures should be obtained prior to the first antimicrobial doses, which should be given without delay.

  • Once the pathogen is identified by a positive urine or blood culture, the antimicrobial regimen should be tailored to a single, least toxic agent with the narrowest spectrum, based on susceptibility data.

  • Patients with severe urosepsis requiring ICU admission should have imaging of the urinary tract on an urgent basis, preferably by computed tomography with intravenous contrast, because suppurative complications require drainage as a priority.

  • Percutaneous drainage by an interventional radiologist is generally preferred to drain definitively or stabilize temporarily a patient with suppurative complications.

  • Urinary catheters cause a high incidence (3%-7% per day) of bacteriuria and candiduria; the latter associated with broad-spectrum antimicrobial therapy.

  • Asymptomatic catheter–associated bacteriuria (CAB) or candiduria should not be treated; the only exceptions are transplant and neutropenic patients, and before instrumentation of the urinary tract.

  • The continued usefulness of a urinary catheter should be reassessed on a regular basis, and removal in selected patients should be considered.

  • Fever or sepsis should only be attributed to CAB and treated only after exclusion of other potential causes of infection.


Urinary tract infection (UTI) can range from uncomplicated cystitis to severe uroseptic shock.1 It is estimated that urosepsis accounts for up to 30% of sepsis cases.2 Bacteremia arises in about 15% of cases, at a rate of 50 per 100,000 person years, with a 28-day mortality of about 5%.3 UTI is also a common sequel of ICU, because of the use of urinary catheters for in excess of 70% of ICU patient days and ranks in the top three or four of ICU-acquired infections.4,5 Unfortunately, asymptomatic bacteriuria is frequently screened for and treated, resulting in harmful and unnecessary antimicrobial therapy.

A UTI should be differentiated from the mere detection of bacteria or white blood cells in the urinary tract using quantitative culture methods. Significant bacteriuria is defined as ≥105 organisms/mL. In the presence of urinary symptoms, a count of ≥102 organisms/mL from a woman with pyuria represents true infection.6 In a catheterized patient with symptoms or signs of UTI without other explanation, a criterion of ≥103 organisms/mL represents catheter-associated urinary tract infection (CAUTI).7 Pyuria, the presence of white blood cells in urine, ...

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