Skip to Main Content




  • 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 ß-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, then colistin and a carbapenem 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 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 catheter-associated bacteriuria and treated only after exclusion of other potential causes of infection.


Community-acquired pyelonephritis sometimes leads to sepsis syndrome and intensive care unit (ICU) admission, especially when it arises in an obstructed urinary tract or when the host defense is compromised by poorly controlled diabetes. 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%.1 Urinary tract infection (UTI) is also a common sequel of ICU, because of the use of urinary catheters for in excess of 70% of ICU patient days2 and ranks in the top three or four of ICU-acquired infections.3,4 Although older data suggested that catheter-associated UTI caused mortality,5,6 more recent studies that control for confounding factors show no such link.7-10 In addition the evidence that bacteriuria prolongs ICU stay or increases cost has also been challenged.11 Unfortunately asymptomatic bacteriuria is frequently screened for and treated, resulting in harmful and unnecessary antimicrobial therapy.


Quantitative culture methods distinguish true bacterial multiplication within the urinary tract from a false result due to procurement contamination. 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.12 In a catheterized patient ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.