**8. Management of urosepsis**

Septic shock is the most severe complication of urinary tract infection.

### **8.1 Initial resuscitation**

Urosepsis patient will be dehydrated and febrile and may be in shock, hence initially resuscitating with fluid challenges. Fever is usually controlled by paracetamol. If after initial resuscitation, if their hemodynamic parameters is not improving, they should be started early on vasopressors. These uroseptic shock patients should be initially managed following sepsis protocols in the first hour. O2 supplementation, IV fluid and antibacterial administration and advanced hemodynamic monitoring are useful. With the goal of central venous pressure (CVP) 8–12, intrathoracic blood volume index (ITBV) and global end-diastolic index (GEDVI) within normal range. Cardiac contractility will be monitored by cardiac index (CI), cardiac functional index (CFI) and the isovolumic contraction of the heart (D/P max). Uroseptic shock patients may have respiratory distress, earlier intubation and maintain mixed O2 or saturation of 70% will improve the outcome [29]. Blood sugar should be maintained around 10 mmol/L. If these urosepsis patients had respiratory distress, they should be immediately intubated and ventilated. As a part of multi-organ dysfunction, these patients may be in disseminated intravenous coagulopathy and should be taken care and resuscitated with blood and blood products.

**9. Prevention**

*Urosepsis: Flow is Life*

*DOI: http://dx.doi.org/10.5772/intechopen.82262*

[36–37].

**10. Conclusion**

septic shock.

**185**

Community-acquired urosepsis can be prevented up to some extent by relieving the obstruction to the flow of urine or correction of the urinary tract abnormalities, whereas the hospital-acquired urosepsis can be prevented by following the CAUTI

Preventing the urinary tract infection in females, it can be done by following few general principles such as clean genitalia, drinking plenty of water particularly after

In elderly patients, the regular use of cranberry juice or capsule may be helpful.

Endo-urological procedure such as ureteroscopy involving instrumentation of the genitourinary tract which has a risk for postoperative urosepsis. The urinary tract interventions are more risky in patients with positive preoperative urine cultures or foreign bodies within the urinary tract causing obstruction. It has been demonstrated that perioperative antibiotics reduce urosepsis after uroendoscopy

Sepsis is a medical emergency; urosepsis is a sepsis originating from the urinary tract. Urosepsis contributes significantly to the overall epidemiology of sepsis. The common and most frequent aetiology of urosepsis is either congenital or acquired obstruction to the flow of urine. The risk factor for urosepsis varies from metabolic diseases to the renal calculi. Based upon the environment in which the patient gets infection, urosepsis is divided into community-acquired urosepsis and hospitalacquired urosepsis. In the diagnosis of urosepsis apart from monitoring blood count, acute-phase proteins and serum lactate and blood and urinary cultures, the imaging studies play an important role. If not treated early and managed properly, urosepsis can progress into pyelonephritis, renal and prostatic abscesses and

The cornerstones for the management of urosepsis are initial organ supportive resuscitation, appropriate early antibiotics, relieving obstruction to urinary flow and the source control. Obstruction to the urine flow is the important and most frequent factor for the urosepsis as it facilitates the bacterial growth and repeated sepsis. It is of vital importance to relieve the obstruction and restore the normal

flow of urine as soon as possible to reduce the morbidity and mortality. Prevention of urosepsis starts from well hydration to the clean genitalia, periurological procedure antibiotics, maintaining free flow of urine and strictly

following the CAUTI prevention bundle in the hospitalised patients.

In elderly postmenopausal patient, intravaginal oestriol therapy is useful in preventing UTI. In this group of patients, antibiotics highly effective. Other risk factor such as inconsistence, cystocele should be taken care. Elderly man, incontinence of the bladder and enlargement of prostate is risk, so they should be taken

bundle, removing urinary catheter and using the condom catheters.

intercourse, urinating frequently and wiping from front to back.

care condom catheter or surgical intervention.

In antibiotics and bacterial resistance, proper antibiotic administration in septic shock patients improve their outcome [30]**.**

Kumar et al. demonstrated that administration of an effective antimicrobial within the first hour of documented hypotension was associated with a survival rate of 80% [31]. Hence the initial antibiotic in these patients selected on the basis of local antibiogram and as soon as culture are available changed the antimicrobial to the narrow spectrum.

As the common bacteria is *E.coli* in the community-acquired urosepsis, the third generates cephalosporin and fluoroquinolones and combinations are a better choice where as in the hospital-acquired urosepsis, we should add an antipseudomonas antibiotics with combination with amino glucosides or should be initial antimicrobial therapy. Biofilm formation by microorganism is a vital factor in the progress of urosepsis, which is formed in association with urinary catheters, scar tissue and stones, and minimal inhibitory concentrations (MIC) in biofilm are increased up to 100-fold; hence, the high dosages of antibiotics needed in combination with the attempt to remove the biofilm should be considered [32].

Most of these patients' therapy for 2–3 weeks goes parallel with the relief of symptoms and sign with clinical improvement. The cultures should be repeated after 2–4 weeks of cessation of therapy [30]**.**

#### **8.2 Source control**

Obstruction to the urinary flow is one of the foremost causes and risks for community-acquired urosepsis. This obstruction should be cleared as soon as possible, either with endoscopic insertion of stent or image-guided percutaneous drainage. The endoscopic stenting is a minimally invasive procedure hence preferred in shock patients with coagulopathy. If the patient has hydronephrosis or renal abscesses, the choice is percutaneous drainage by nephrostomy [33]**.** In hospital-acquired urosepsis, the indwelling urinary catheter is the frequent cause of urosepsis. In all hospitalised patients with indwelling urinary catheters, catheter-associated urinary tract infection (CAUTI) bundles should be followed strictly. It should be removed as early as possible; if still required the condom catheter can be used, and an antipseudomonal antibiotic should be started [34, 35]**.**
