Chapter 56

• All patients with severe urosepsis requiring admission to the intensive care unit should have immediate imaging of the urinary tract preferably by computed tomography with contrast because suppurative complications are common and require drainage as a priority.
• Percutaneous drainage can be used to drain definitively or stabilize temporarily a patient with suppurative complications.
• Empiric antimicrobial therapy for acute complicated urosepsis should include two agents with activity against gram-negative bacilli, such as a combination of ciprofloxacin or piperacillin/tazobactam with an aminoglycoside, until the pathogen is isolated and antimicrobial sensitivities are known.
• Urinary catheters are associated with a high incidence, 1% to 5% per day, of bacteriuria. Patients are also predisposed to candiduria, especially those receiving broad-spectrum antibacterial therapy.
• Asymptomatic bacteriuria should be treated in all patients before instrumentation of the urinary tract to avoid the development of gram-negative bacteremia.
• The continued usefulness of a urinary catheter needs to be reassessed on a regular basis, and removal in selected awake stable patients needs to be considered.
• Treatment of bacteriuria without local signs of infection should be considered only in patients with fever or sepsis after exclusion of other potential causes of infection.

At the beginning of the 21st century, urinary tract infection (UTI) remains one of the commonest nosocomial infections, giving rise to prolonged hospitalization and additional cost. Eighty percent of nosocomial UTIs follow urinary catheterization, bacteremia arises in 1% to 3% of these, and the attributed mortality rate is then 13%.1 Community-acquired pyelonephritis occasionally causes sepsis syndrome, especially when it arises in an obstructed urinary tract or when the host defense is compromised by poorly controlled diabetes. Urinary tract infection is thus an important initiating event for admission to the intensive care unit (ICU). Because of the almost universal insertion of urinary catheters in critically ill patients, UTI is a common sequel of intensive care and ranks in the top four of ICU-acquired infections. Bacteriuria, acquired through urinary catheterization in the ICU, constitutes a reservoir of resistant pathogens, which occasionally gives rise to epidemic spread of infection within the hospital.

Bacteriuria simply means the presence of bacteria in the urine. Significant bacteriuria implies the presence of at least 105 organisms per milliliter by a quantitative method. However, a count of at least 102 aerobic gram-negative organisms per milliliter from a woman with pyuria and symptoms of lower UTI represents true infection.2 Low-level bacteriuria (or candiduria) of any quantity in a hospitalized, catheterized patient rapidly advances to significant bacteriuria, provided the patient is not receiving antimicrobial agents to which the organism is susceptible.3,4 Thus, any level of bacteriuria in a catheterized ICU patient is worthy of consideration as a cause of sepsis.

Pyuria, the presence of white blood cells in urine, is commonly measured by counting the number of cells per microscopic high-power field in a centrifuged urine specimen. Using the criterion of five cells per microscopic high-powered field, pyuria, when present, ...

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