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Nine cases of urosepsis registered between 1986 and 1990 are analyzed. Authors intended to find out practical conclusions which can improve the prognosis of urosepsis. Risk factors are considered advanced age, preoperative disorders (diabetes, malnutrition), preexistent end organ failure (kidney, liver, lung) and urinary infection. Early diagnosis, emergency restoration of urinary flow, suppression of primary focus of infection, intravenous antibiotherapy and energetic intensive care measures are necessary for the outcome of patients.
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PMID:Urosepsis. Clinical aspects--therapy--results. 141 19

Over a period of 6 years 192 cases of urosepsis have been recorded and managed in our urological department. In almost all cases (97%) the primary focus of infection was the urinary tract and the responsible microorganisms were Gram-negative rods, in order Enterobacter, B. Proteus, E. Coli, Klebsiella and others. Clinical features were dominated by symptoms related to failure or insufficiency of end organs (fever, hypotension, oliguria, mental disorders, respiratory distress etc.). Bacteremia was diagnosed with an incidence of 66%, septic shock 12% and MSOF 20%. Negative bacteriological tests do not rule out the diagnosis of systemic infection. Risk factors are considered advanced age, uremia, diabetes, malnutrition and extensive surgery.
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PMID:Clinical comments on management of urosepsis in a general urological department. 141 20

In 98 patients undergoing elective vascular surgery, specimens for bacterial cultures were obtained from urine, ischaemic ulcers, incisional wounds and the implanted grafts. Wound and graft infections were registered and compared with the results of these cultures and suspected risk factors in an attempt to find the source of infections. Antibiotic prophylaxis with cefuroxime was given for 24 h beginning at the start of surgery. Patients with ischaemic ulcers also received "spread prophylaxis", directed against isolated bacteria, for ten days. Three cases of graft infection and twelve cases of wound infection occurred. Positive postoperative cultures from wounds did not correlate with pre- or peroperative cultures. Peroperative cultures revealed small numbers of staphylococcus epidermidis in eleven patients, and none of them developed graft infection. Ischaemic ulcers, diabetes or re-do procedures were not accompanied by a significantly increased frequency of wound or graft infection, although each of three patients with graft infection had one of these risk factors. Bacteria, sensitive to cefuroxime, were found in one graft infection, six wound infections, and in two patients with urosepsis, whereas cefuroxime resistant organisms were isolated from one graft infection and three infected wounds. One of the three graft infections was probably caused by bacteria originating from the patient's ischaemic ulcer. In the other two patients the source of bacteria could not be determined. Cefuroxime seems to be an adequate alternative for prophylaxis of vascular graft infection, but in some patients with bacteriuria or indwelling catheters, a one day regimen may be too short.
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PMID:Infections and antibiotic prophylaxis in reconstructive vascular surgery. 276 53

A prospective study evaluated the utility of renal computed tomography (CT) and ultrasonography in 35 patients hospitalized for treatment of urinary tract infection. Renal computed tomograms were abnormal in 18 of 28 patients with acute pyelonephritis and three of four patients with urosepsis, showing findings consistent with pyelonephritis in 17 patients and intrarenal abscess or focal bacterial nephritis in four patients. Renal sonograms were abnormal in only eight patients, showing findings compatible with pyelonephritis in four and intrarenal abscess or focal bacterial nephritis in the other four. Flank tenderness was absent in only four patients with CT findings of pyelonephritis, of whom three were diabetic. We therefore found that (1) renal CT is a sensitive test for acute upper urinary tract infection, (2) ultrasonography detects focal bacterial nephritis and abscesses but is insensitive to uncomplicated upper urinary tract infection, and (3) painless pyelonephritis may be more common in patients with diabetes mellitus.
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PMID:Ultrasonography and computed tomography in severe urinary tract infection. 388 34

Group B streptococcal infection has recently been recognised as an important and apparently increasingly common cause of invasive disease in nonpregnant adults. The annual incidence of invasive disease has been estimated at 4.4 per 100,000 nonpregnant adults and is highest among adults over 60 years of age. The most common clinical diagnoses include skin and soft-tissue infections, bacteraemia with no identified source, osteomyelitis, urosepsis and pneumonia. Other important but less common infections include peritonitis, infectious arthritis, meningitis and endocarditis. The majority of adults with group B streptococcal infections have underlying diseases including diabetes mellitus, malignant neoplasms and liver disease. Nosocomial infection and polymicrobial bacteraemia occur in a significant proportion of patients with invasive group B streptococcal disease. Mortality from invasive disease is particularly high in the elderly. For treatment of serious group B streptococcal infections, high doses of benzylpenicillin (penicillin G) are recommended because of the somewhat higher minimal inhibitory concentrations. In addition to parenteral antibiotic therapy surgical management may be required for successful treatment, particularly in the case of soft-tissue or bone infection. Invasive group B streptococcal infection is a major problem in elderly adults and those with chronic diseases, and efforts should be made to identify and treat such infections early. Future approaches may include vaccine prevention of serious group B streptococcal infection in adults at highest risk.
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PMID:Group B streptococcal infection in older patients. Spectrum of disease and management strategies. 761 18

Proteus penneri has been isolated from many different clinical sources, including surgical wound infections, urine, and blood. We describe the first reported case of P. penneri nosocomial urosepsis in a patient with diabetes. P. penneri was subsequently isolated from bronchoalveolar lavage fluid and a pulmonary artery catheter tip.
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PMID:Proteus penneri urosepsis in a patient with diabetes mellitus. 954 71

Although tens of thousands of Salmonella infections occur annually in this country, most involve the gastrointestinal tract with involvement of the urinary tract being quite infrequent.1-3 I would like to report a case of urosepsis due to Salmonella with eventual development of metastatic osteomyelitis of a rib that proved refractory to treatment. A 59-year-old Latin American male who resided in the Texas Rio Grande Valley presented to an emergency room with inability to void, having first noted a decreased urinary stream and dribbling a few months earlier. In-and-out bladder catheterization yielded 700 cc of urine, and he was sent out on co-trimoxazole one double-strength tablet twice daily. The patient returned within several hours, again unable to void, and a Foley catheter was inserted draining 1100 cc of urine. The patient was admitted for further evaluation. Past history was notable for long-standing inflammatory arthritis treated with injectable gold, hydroxychloroquine and nonsteroidal anti-inflammatory agents. He had previously undergone left shoulder replacement and synovectomy of both knees. Diabetes mellitus was diagnosed 6 years earlier and treated with oral hypoglycemic agents. The patient denied any gastrointestinal complaints. Examination was notable for a temperature of 102.4 degreesF and obvious sequelae of long-standing rheumatoid arthritis. The abdomen was entirely benign, but rectal examination revealed an enlarged, nontender prostate. White blood cell count was 11,200/mm3. Urinalysis revealed 10-12 white blood cells per high power field and 15-20 red blood cells per high power field. Two blood cultures from admission grew Salmonella species sensitive to all antibiotics. Urine cultured at the time of admission remained sterile. The patient was treated initially with tobramycin and ciprofloxacin and was changed to ceftriaxone 1 g intravenously every 12 hr when the Salmonella was identified. Ultrasound examination confirmed an enlarged prostate but disclosed no ureteral or renal abnormalities. Intravenous pyelogram also revealed the enlarged prostate but was otherwise unremarkable. On the ninth hospital day a transurethral resection of the prostate (TURP) was performed with histologic evidence of abscesses containing acute inflammatory cells in the resected tissue. The tissue itself was culture negative. He gradually defervesced and completed a 14-day course of parenteral therapy. The patient did well for about 6 months at which point he developed anterior chest wall pain for which he applied a heating pad. A second degree burn developed which ulcerated and began to drain. Culture revealed Salmonella species with a similar sensitivity pattern as the previous isolate. Local care as well as courses of oral ciprofloxacin and chloramphenicol failed to eradicate the drainage. The patient underwent surgical excision of the sinus tract 11 months after the initial bacteremia. Surgical specimens again grew Salmonella. Unfortunately, neither this nor the previous chest wall isolate was saved for further analysis. The area continued to drain and bone scan was consistent with osteomyelitis of the left sixth rib. Ceftriaxone 2 g intravenously per day was begun. The following month (16 months after the initial bacteremia) the patient underwent extensive debridement of the anterior chest wall with removal of the sixth and seventh ribs, and closure via a pectoralis myocutaneous flap. Forty-eight hours postoperatively, the patient suffered an acute myocardial infarction and expired. Postmortem revealed severe coronary artery disease. No additional focus of Salmonella infection was found.
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PMID:Salmonella Urosepsis Complicated by Metastatic osteomyelitis of the Chest Wall. 981 3

At Asama General Hospital, we experienced six cases of urosepsis with septic shock during a period of five years between 1989 and 1993. All six patients, whose average age was 74 years old, recovered. In four patients, the condition was caused by obstructive uropathy. The remaining two cases were caused by renal inflammatory disease, which was complicated by diabetes mellitus. One of them was renal abscess with renal papillary necrosis, and the other was emphysematous pyelonephritis. The patients, who exhibited symptoms such as gram-negative bacteremia, severe hypotension, tachycardia, decrease of urine volume and mental disturbance, were diagnosed with urosepsis with septic shock. In all cases, symptoms such as a high fever of over 39 degrees C, hypoxemia and thrombocytopenia were observed. Renal dysfunction was found in 67%, and both liver dysfunction and disseminated intravascular coagulation (DIC) were found in 50% of the cases. Since no patients suffered from adult respiratory distress syndrome, a high survival rate was apparent. Anti-shock therapy and anti-coagulation therapy were ineffective for the patients who had septic shock due to urinary tract obstruction. Urinary tract drainage was required to treat the latter patients. Nephrectomy could not be avoided in renal parenchymatous inflammatory disease. In the future, what might be essential in therapeutics against urosepsis with septic shock, particularly to avoid nephrectomy, are the treatments such as immunotherapy against endotoxins and their mediators, and hemoperfusion for the removal of endotoxins.
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PMID:[Clinical study on 6 cases of urosepsis associated with septic shock]. 989 24

Using the UBC test, the specificity, sensitivity and prognostic information were evaluated in patients with recently diagnosed transitional cell carcinoma (TCC) and in a control group consisting of apparently healthy individuals and individuals with benign disorders. Frozen urine samples from the 485 individuals in the control group and 100 newly diagnosed TCC patients were analyzed with the UBC test, specific for epitopes on cytokeratin fragments released from the urothelial cells. All the samples were analyzed and corrected for creatinine. No significant concentration difference was found between males and females (p=0.65) and there was no age dependent relation. The median concentration for the entire control group was estimated at 3.7 microg/g and the 95th percentile was calculated at 53.0 microg/g. The apparently healthy individuals in the control group had a median value of 3.4 microg/g with a 95th percentile of 24.3 microg/g. An increased frequency of elevated UBC concentrations was found in some benign disorders e.g., anemia, thyroid disorders, diabetes mellitus, hyperlipemia, urosepsis and cystitis. Patients with superficial tumors exhibited a 66% sensitivity (at 95% specificity), and the UBC concentrations did not differ statistically (p=0.16) from those patients with muscle invasive lesions with a 52% sensitivity. When the UBC concentrations were related to histopathological grade, a significant concentration difference (p<0.004) was found between low grade tumors (sensitivity 41%) and high grade tumors (sensitivity 72%). Survival analysis showed that patient with muscle invasive tumors, high-grade tumors and high UBC concentrations have a significantly reduced survival (five-year survival was estimated to 30%, 35% and 30% respectively) compared to patients with superficial tumors, low-grade tumors or low UBC concentrations (five-year survival, 60%, 85% and 75% respectively). The UBC test showed good accuracy and repeatability. Clinically the test could assist in tumor grading and the detection of recurrent disease, which in turn could assist in treatment selection for the individual patient and possibly improve prognosis.
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PMID:Evaluation of the UBC test in the urine of healthy individuals, patients with benign disorders and urinary bladder cancer. 1103 28

Hospital-acquired urinary tract infections have a great impact on clinical medicine. They are almost exclusively complicated urinary tract infections. Clinical diagnosis in some patients. (e.g., sedated patients, paediatric or geriatric patients) might be delayed for the lack of symptoms. About 80% of urinary tract infections are catheter-associated. However, certain diseases favour urinary tract infections: diabetes mellitus or cystic renal diseases, amongst others. Each specialist field (e.g., geriatrics, gynaecology, paediatrics) encounters its own problems concerning diagnosis and treatment of urinary tract infections. Hospital-acquired urinary tract infections can merge into severe infections such as urosepsis and septic shock. The microbiological spectrum encompasses multi-resistant bacteria, thus microbiological sampling prior to therapy is mandatory. Additionally the complicating factors must be diagnosed and treated adequately. The best prophylaxis is to minimize the duration of the urinary catheter and to employ general hygienic procedures.
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PMID:Hospital-acquired urinary tract infections. 1107 25


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