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Prevention and management of urosepsis

triggered by ureteroscopy

This article was published in the following Dove Press journal:

Research and Reports in Urology

Kymora B Scotland Abstract: Urosepsis is a potentially life-threatening phenomenon that may occur after an
Dirk Lange ureteroscopic procedure. With the increasingly widespread adoption of ureteroscopy, there is a
concern that the rates of urosepsis may increase. This review examines the current work being
Department of Urologic Sciences,
University of British Columbia, undertaken to minimize postprocedure infections both in the field of device development and
Vancouver, BC, Canada in clinical care. Guidelines for the diagnosis and management of urosepsis will be discussed.
Keywords: urosepsis, sepsis, urinary tract infection, ureteroscopy, ureteroscope, ureteral stent

Introduction
Urosepsis is a systemic response to and potentially life-threatening sequela of urogenital
tract infection. It often results secondary to urinary tract obstruction associated with
phenomena such as urolithiasis, tumor and stenosis, but it may also occur after urinary
tract manipulation such as ureteroscopy. The development of bacteremia resulting from
the dissemination of uropathogenic bacteria into the bloodstream marks the movement
of the infection from a localized insult to systemic disease.

Defining urosepsis
The systemic inflammatory response syndrome (SIRS) is a collection of symptoms that
have been used to identify patients at high risk for rapid development of sepsis. These
symptoms include fever, tachycardia, tachypnea, and elevated white blood cell count.1
In recent years, the diagnosis of sepsis has been less dependent on these SIRS
criteria. However, they continue to be useful warning signs. There is currently no
specific definition of sepsis. This has led to consensus definitions incorporating various
laboratory and physiologic parameters.2,3 The Third International Sepsis Consensus
Definition Task Force defines sepsis as “life threatening organ dysfunction due to
dysregulated host response to infection”.4 Sepsis has also been classified based on the
level of severity with patient outcomes worsening as they develop associated organ
dysfunction and shock. Patients with refractory septic shock have mortality rates ~50%.5

Causes of urosepsis
Correspondence: Dirk Lange Urinary tract infections (UTIs) result from the activity of pathogenic microbes within
Department of Urologic Sciences, the urinary system and may be secondary to chronic or acute colonization of the system.
University of British Columbia,
Vancouver, BC, Canada
The most common uropathogen is Escherichia coli, which is responsible for ~80%
Email [email protected] of uncomplicated UTIs or pyelonephritis.6 Complicated UTIs such as those resulting

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after ureteroscopy are caused by a more diverse range of Clinical presentation

microbes encompassing E. coli, Proteus, and Pseudomo- Urosepsis is a clinical syndrome. It can present with various
nas species, Serratia and group B Streptococci, as well as symptoms including fever and tachypnea as well as acute
nonbacterial pathogens including various Candida species. multiorgan dysfunction and hypotension requiring pharmaco-
There is also the worsening spread of multidrug-resistant logic support (Table 1). It is important to note that urosepsis
infections, particularly in patients with recurrent UTI and can progress rapidly in severity and must be aggressively
treatment histories.7 UTIs account for 40% of the cases of managed.9
sepsis secondary to nosocomial infections.8 The initiating insult for urosepsis is a local infection of
Urosepsis typically begins with a UTI and most often the genitourinary tract. Sepsis results from an uncontrolled
follows pyelonephritis.9 It may also result from infection systemic response to that infection. The early clinical pre-
originating in the male genital tract, particularly the pros- sentation may involve temperature extremes (fever or hypo-
tate. The severity of urosepsis will be primarily dependent thermia), tachycardia, or altered mental status. Patients may
upon the host response. Patients with risk factors for UTI develop respiratory alkalosis secondary to tachypnea. Those
formation include immunocompromised patients such as with worsening symptoms often demonstrate oliguria, hypo-
post-transplantation, diabetic, or otherwise immunosup- tension, laboratory abnormalities including elevated white
pressed individuals. Elderly patients are also vulnerable. blood cells, and coagulation dysfunction. If not controlled,
Patients who are particularly susceptible to infection patients may develop multiorgan dysfunction, which can
include those with anatomic abnormalities within the col- eventually prove fatal.
lecting system, chronic drains including Foley catheters,
nephrostomy tubes and ureteral stents as well as patients Pathogenesis
with a history of infectious calculi or prior urologic The triggering event for urosepsis has been postulated
interventions.9 to be the prompting of the host inflammatory response
by the presence of intact bacteria or bacterial cell wall
Cost of urosepsis
The patient and economic costs of sepsis are substantial.
Table 1 Clinical presentation of urosepsis
Mortality rates range from 20% to 50% with septic shock
Documented urinary tract Infection or pyuria
being the major cause of patient demise in intensive care units
Appearance
as well as the primary reason for admission to these units.9,10
• Fever (temperature >38.5°C)
Sepsis is an expensive health care issue with costs >$24 • Hypothermia (temperature <36°C)
billion per year in the USA.11 A more recent statistical brief • Tachypnea
from the Healthcare Cost and Utilization Project revealed that • Altered mental status
Inflammatory response
sepsis accounted for 6.2% of all hospital costs.12 Urosepsis
• Leukocytosis (WBC count >11000/μL)
accounts for 25% of all adult septic episodes. It can lead to • Leukopenia (WBC count <4000/μL)
septic shock in a minority of cases.13 While there is a dearth • Normal WBC count with greater than 10% immature forms
of data on the rate of ureteroscopy-triggered urosepsis to date, Hemodynamic dysfunction
• Hypotension (SBP <90 mmHg, MAP <70 mmHg)
a previous retrospective study of patients treated for uroseptic • Tachycardia (heart rate >90/min)
shock revealed that urosepsis followed urologic interventions Organ dysfunction
in 17% of patients.14 The risk of infectious complications • Hypoxemia (Pao2/Fio2 <300)
following ureteroscopy has been documented and ranges • Oliguria (urine output <0.5 mL/kg/hr for ≥ 2 hours despite sufficient
fluid resuscitation)
from 2.2% to 20% in several studies.15–18 Although mortality • Elevated creatinine (increase >0.5 mg/dL from baseline)
following ureteroscopy is rare, a recent multi-institutional • Disordered coagulation (INR >1.5)
case report of six postureteroscopy mortalities revealed that Tissue malperfusion
• Elevated lactate (>2 mmol/L)
four of those patients died as a result of urosepsis.19 This
• Prolonged capillary refill time
underscores the seriousness of an episode of urosepsis when • Skin mottling
it occurs. The concerted effort required for the diagnosis and Note: Data from Wagenlehner et al.13
Abbreviations: MAP, mean arterial pressure; WBC, white blood cells; INR,
effective management of urosepsis accounts for the signifi- international normalized ratio; aPTT, activated partial thromboplastin time; SBP,
cant economic cost. systolic blood pressure.

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Dovepress Prevention and management of urosepsis

components within the urogenital tract.14 They may be patients at highest risk for urosepsis status post ureteroscopy
present secondary to manipulation during ureteroscopy but are those with preoperative positive urine samples. This cor-
have also been thought to be associated with the presence relation maintained significance on multivariable analysis.16
of ureteral stents placed at the conclusion of the procedure. The association held irrespective of preoperative antibiotic
The formation of biofilm on urinary drainage devices such treatment or whether the patient was asymptomatic. This
as ureteral stents and Foley catheters is thought to play result was corroborated by another group who found an
a role in the genesis of urosepsis. Biofilm is a thin layer association between preoperative pyuria and postoperative
formed by the accumulation of microbes and bacterial febrile UTIs.17 Recent work from the Clinical Research
cell wall portions as well as extracellular biopolymers Group of the Endourological Society (CROES) study also
establishing a matrix.20 The first step of biofilm formation provided data demonstrating that cardiovascular disease and
is the development of the conditioning film.21 This layer ASA score were significantly associated with postoperative
coats foreign bodies placed in the body including ureteral UTI. This prospective multi-institutional study also showed
stents. Biofilm formation is thought to exacerbate urothe- that preoperative prophylactic antibiotics in patients with a
lial irritation, leading to an inflammatory response.21 The negative baseline urine culture do not reduce postoperative
development of biofilm has also been postulated to attract febrile UTIs.18 Given these data, potential risk factors for this
further bacterial adhesion, possibly leading to infection22 or phenomenon of urosepsis following ureteroscopy are a posi-
predisposing patients undergoing subsequent ureteroscopic tive preoperative urine culture, stone burden, and comorbid
intervention to infection.23 However, we and others have conditions. However, there are several inconsistencies in the
shown no statistically significant association between bio- findings of various similar studies to date. Blackmur found
film formation and increased bacterial adhesion in vitro24 an association between same session bilateral ureteroscopy
or postoperative infection in patients.25 These data suggest and urosepsis, a finding which is in direct contrast to work
that the presence of biofilm may not necessarily result in presented by Hollenbeck et al.29 Similarly, Mitsuzuka et al17
the development of an UTI, particularly in those patients proposed that preoperative acute pyelonephritis played a role
with intact immune systems. in postoperative febrile UTI, while the opposite was found
The colonization of ureteral stents by bacteria occurs by Blackmur. This lack of consensus in results of the studies
in 42%–90% of patients.23 Bacteria will adhere to stents in done may be due to the fact that they are primarily small or
both the presence and absence of conditioning film.24 The single-institution reports. A prospective multi-institutional
subsequent development of UTIs was shown to be dependent study would help to clarify this issue.
on stent dwell time.26 However, stent colonization tends to The pathogenesis of urosepsis is not simply that of a
be polymicrobial while UTIs generally result from a single worsening UTI. It is indeed complex with a series of interac-
strain of bacteria, implying that stent-associated infection tions beginning with an initial inflammatory response and a
is likely not a straightforward process, potentially resulting subsequent anti-inflammatory counter regulatory response
from contamination during the insertion.27 resulting in an eventual overwhelming immunosuppression.13
We have championed the use of coated biodegradable The overall patient response incorporates the autonomic
stents as a mean of addressing the issue of stent-associated nervous system, coagulatory pathway, and endocrine system.
UTIs. One benefit of stent degradation would be the ease of The complex interregulatory processes involved in urosepsis
disposal via the urine. The concept of the drug-eluting or continue to be elucidated, and a discussion of the various
coated stent holds that altering the surface of the stent would pathways is beyond the scope of this review.
modify its resistance to bacterial adhesion, therefore decreas-
ing the chance of infection.28 Work is ongoing to develop suit- Management
able coated stents using biomaterials, which would combat Diagnosis of urosepsis
infection without inducing antibiotic resistance. As mentioned earlier, there is no specific definition of
There is a paucity of systematic reviews of ureteroscopy- urosepsis. The Sepsis Consensus Definition Task Force
triggered urosepsis. A recent prospective study by Blackmur introduced the sequential (sepsis-related) organ failure
et al demonstrated a statistically significant association assessment (SOFA) as a mean of operationalizing this most
between urosepsis and a history of diabetes, ischemic heart recent consensus definition of sepsis and provided the quick
disease, American Society of Anesthesia (ASA) score, and SOFA (qSOFA) scoring system, which facilitates the bedside
stone volume on univariable analysis. The study found that diagnosis of sepsis.4 However, early attempts at the validation

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45
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Scotland and Lange Dovepress

of this model have produced mixed results.30,31 Diagnosis pathogens.37 Organisms are rapidly developing resistance
continues to rely on recognition of the constellation of to even broad-spectrum antibiotics, resulting in a weakened
symptoms associated with sepsis (Table 1). In addition to armamentarium. Management of these infections will often
the discussion of subjective fevers, an adequate history must require a multidisciplinary approach involving infectious
query symptoms of suprapubic or flank discomfort, dysuria, disease specialists.
and irritative voiding. Management will also include aggressive resuscitation
and supportive care with close monitoring. This will likely
Treatment of urosepsis require a multidisciplinary approach. The Surviving Sepsis
The most commonly advocated treatment plan for urosepsis Campaign organized the management of sepsis into treatment
is the protocol for early recognition and immediate supportive bundles each with a timeframe for implementation.32 Hence,
and counter-infection activity advocated by the Surviving the treatment of urosepsis can be undertaken in a system-
Sepsis Campaign.32 Critical to the management of urosepsis atic fashion with special emphasis on early goal-directed
is the timeframe within which the initial diagnosis is reached therapy.40 This treatment paradigm advocates for the fluid
and treatment measures are undertaken. Patients presenting resuscitation of patients who are hypoperfused or present
with concerning symptoms status post ureteroscopy should with elevated serum lactic acid levels via a protocol aimed at
have microbiological sampling in the form of urine and blood maintaining several parameters within specific limits.13 The
cultures obtained immediately and supportive measures initi- key recommendations are presented in Figure 1.
ated. Serum procalcitonin may also be obtained at this point. A thorough history should reveal previous episodes of
Procalcitonin is a marker of inflammation, particularly in UTI with urine culture results and preprocedure antibiotic
response to a stimulus of bacterial origin.30 It is an acute phase use. A timeline of symptoms should be established for prompt
reactant that is often elevated during a systemic response to identification and treatment of sepsis. Patients must then be
infection as occurs in sepsis. Thus, it has been used as an monitored closely for the development of organ dysfunction.
early marker of severe bacterial infection33 and was recently Before attributing sepsis to a recently performed ureteros-
shown to have some utility as an indicator of urosepsis.34,35 copy, a thorough physical examination must be undertaken
Because rapid diagnosis of urosepsis is essential for effec-
tive therapy, procalcitonin levels may prove a useful tool for
focusing the differential diagnosis.
Blood, urine cultures
Increased rates of mortality are associated with delayed
initiation of antimicrobials.36 Hence, patients with a presen- Broad-spectrum antibiotics
1h
tation concerning for urosepsis should have early institution
of antibiotics. On initial patient presentation, there may be Cross-sectional imaging
an absence in previous pathogen speciation. Once culture
specimens are obtained, empiric treatment with suitably 6h Early resuscitation
broad-spectrum antibiotics should be started in the concern-
ing patient.13 This is done in an effort to combat as many Fluid challenge if hypoperfusin
likely pathogens as possible.37 Once the offending microbes
are known, more specific antibiotics can be given. Antibiotic Fluid resuscitation

choice should also be guided by preoperative antibiotic his-

tory and perioperative details as well as local and institutional Vasopressors if poor response to fluid

microbial susceptibility patterns. It is imperative that the

Blood glucose management
local antibiogram is consulted so that bacterial resistance
patterns are taken into consideration and ineffective anti-
12 h Source control
biotics are avoided.38 The use of appropriately dosed and
chosen antibiotics has been shown to improve outcomes
48 h Oral or enteral feedings
in patients with urosepsis and septic shock.39 Particularly
in the case of multidrug-resistant organisms, the choice Address goals of care in intensive care unit
72 h
of appropriate antibiosis will depend on an understanding
of common mechanisms of resistance of the most likely Figure 1 Clinical management of urosepsis.

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Dovepress Prevention and management of urosepsis

including a digital rectal examination in males to rule out have been shown to decrease UTI in patients undergo-
acute prostatitis and palpation of the testes to rule out ing ureteroscopy44 and have since been recommended by
epididymoorchitis. All patients should undergo palpation American Urological Association practice statements.45 We
of suprapubic and flank regions. Patients should undergo have recently demonstrated that a single dose of antibiotic is
cross-sectional imaging in order to query the presence of generally sufficient to achieve this.25 These data suggest that
urinary tract injury or postprocedural collections as a source preoperative urine cultures are imperative and that positive
of infection after ureteroscopy. For urosepsis in particular, cultures must be adequately treated. Furthermore, patients
the ability to decompress the urinary system with the use of with positive preoperative cultures should be more closely
stents, percutaneous nephostomy tubes, or urinary catheters monitored postoperatively.
in the event of obstructive uropathy is critical.9 Intraoperative stone cultures have also proven useful
The issue of source control must also be considered. in identifying the microbial source of urosepsis in patients
The development of urosepsis following ureteroscopy may who have undergone lithotripsy for endoscopic stone treat-
occur in patients with ureteral stents placed periopera- ment.46 A retrospective study by Eswara et al46 revealed that
tively.28 Discussions should be undertaken with respect to 73% of patients who developed sepsis after ureterscopy or
the timely removal or exchange of foreign bodies such as percutaneous nephrolithotomy had positive stone cultures
stents and Foley catheters. Patients with chronic urinary in the absence of positive preoperative urine cultures. This
system drainage as provided by ureteral stents and bladder supports the notion that stone cultures should be routinely
catheters are predisposed to bacteriuria and funguria. The sent in ureteroscopy patients.
subset of patients with chronic funguria may be susceptible There has been increasing concern over the possibility
to the development of urosepsis status postureteroscopy. This of infections due to ureteroscopes themselves. In the case
funguria will be more often seen in patients with some level of reusable endoscopes, this may be due to problems with
of immune system compromise such as diabetics or patients reprocessing as well as ureteroscope defects.47,48 A recent
who have received extended antimicrobial therapy. Patients prospective study demonstrated multiple instances of con-
with urosepsis secondary to fungemia require antifungal tamination even when institutional reprocessing protocols
treatment in the form of azoles or systemic amphotericin B were designed to be consistent with guidelines.49 Several
in azole-refractory infection.41 incidents of deviation from guideline recommendations were
noted. Safe decontamination of reusable ureteroscopes will
Prevention require mandatory adherence to guidelines for reprocess-
Urosepsis prevention involves identifying comorbidities ing.50 In addition, protocols should be instituted that include
or genitourinary abnormalities that predispose a patient to repeated evaluations of reprocessing practices and routine
infection. Patients with diabetes and other diseases or treat- examination of ureteroscopes for infectious material. Con-
ment regimens causing immunosuppression must be closely cerns for persistent contamination even in institutions with
monitored in the intraoperative and early postoperative peri- strict adherence to guidelines have led to the championing
ods. Congenital malformations such as ureteropelvic junction of disposable uereteroscopes.51 Infection prevention may be
obstruction or presentations such as neurogenic bladder with improved with the adoption of these sterile single use devices.
often concomitant bladder dysfunction and vesicoureteral Several intraoperative practices such as the use of ure-
reflux are also associated with an increased risk of UTIs.42,43 teral access sheaths and low pressure irrigation devices
Appropriate perioperative antimicrobials should be used, and have been proposed anecdotally to decrease postoperative
postureteroscopy Foley catheters should be placed with cau- complications. However, to our knowledge, there are few
tion and kept only as long as they are necessary for urinary peer-reviewed English language studies supporting these
tract drainage. practices.52 In fact, a systematic review of ureteral access
Ureteroscopy and other procedures that involve instru- sheaths reports an association with increased risk of post-
mentation of the genitourinary tract have an elevated risk operative complications.53 The concern for renal pelvic
of postoperative UTI development.44 This risk is even more pressures stems from the notion that persistent pressures in
elevated in patients with positive preoperative urine cultures, excess of normal range may be attained during ureteroscopy
the presence of foreign bodies within the urinary tract, and that this may increase the risk of postoperative infection.
obstruction, history of urinary diversion and comorbidities Although there are currently no systematic studies supporting
such as diabetes and paraplegia.25 Periprocedural antibiotics these practices, we propose that it is good clinical practice

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Scotland and Lange Dovepress

to limit operative time and to endeavor to maintain low irri- 15. Sohn DW, Kim SW, Hong CG, Yoon BI, Ha US, Cho YH. Risk factors
of infectious complication after ureteroscopic procedures of the upper
gation pressures as well as consistent decompression of the urinary tract. J Infect Chemother. 2013;19(6):1102–1108.
upper urinary tract. 16. Blackmur JP, Maitra NU, Marri RR, Housami F, Malki M, McIlhenny
C. Analysis of factors’ association with risk of postoperative urosepsis
in patients undergoing ureteroscopy for treatment of stone disease. J
Conclusion Endourol. 2016;30(9):963–969.
Ureteroscopy-associated urosepsis is a nosocomial infection. 17. Mitsuzuka K, Nakano O, Takahashi N, Satoh M. Identification of fac-
tors associated with postoperative febrile urinary tract infection after
With the increasing popularity of ureteroscopic procedures, it ureteroscopy for urinary stones. Urolithiasis. 2016;44(3):257–262.
is imperative that patients are administered appropriate peri- 18. Martov A, Gravas S, Etemadian M, et al; Clinical Research Office of
operative antimicrobial prophylaxis in order to decrease the the Endourological Society Ureteroscopy Study Group. Postoperative
infection rates in patients with a negative baseline urine culture under-
risk of postprocedure UTI and urosepsis. The development of going ureteroscopic stone removal: a matched case-control analysis on
urosepsis after ureteroscopy is a potentially life-threatening antibiotic prophylaxis from the CROES URS global study. J Endourol.
2015;29(2):171–180.
phenomenon, and suspected sepsis must be speedily and 19. Cindolo L, Castellan P, Scoffone CM, et al. Mortality and flex-
aggressively managed. ible ureteroscopy: analysis of six cases. World J Urol. 2016;34(3):
305–310.
20. Goto T, Nakame Y, Nishida M, Ohi Y. Bacterial biofilms and cath-
Disclosure eters in experimental urinary tract infection. Int J Antimicrob Agents.
The authors report no conflicts of interest in this work. 1999;11(3–4):227–231.
21. Zumstein V, Betschart P, Albrich WC, et al. Biofilm formation on ureteral
stents – incidence, clinical impact, and prevention. Swiss Med Wkly.
References 2017;147:w14408.
1. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ 22. Choong S, Whitfield H. Biofilms and their role in infections in urology.
failure and guidelines for the use of innovative therapies in sepsis. BJU Int. 2000;86(8):935–941.
The ACCP/SCCM Consensus Conference Committee. American Col- 23. Kehinde EO, Rotimi VO, Al-Hunayan A, Abdul-Halim H, Boland F,
lege of Chest Physicians/Society of Critical Care Medicine. Chest. Al-Awadi KA. Bacteriology of urinary tract infection associated with
1992;101(6):1644–1655. indwelling J ureteral stents. J Endourol. 2004;18(9):891–896.
2. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: 24. Elwood CN, Lo J, Chou E, et al. Understanding urinary condition-
international guidelines for management of sepsis and septic shock: ing film components on ureteral stents: profiling protein compo-
2016. Intensive Care Med. 2017;43(3):304–377. nents and evaluating their role in bacterial colonization. Biofouling.
3. Singer M. The new sepsis consensus definitions (Sepsis-3): the good, 2013;29(9):1115–1122.
the not-so-bad, and the actually-quite-pretty. Intensive Care Med. 25. Chew BH, Flannigan R, Kurtz M, et al. A single dose of intraopera-
2016;42(12):2027–2029. tive antibiotics is sufficient to prevent urinary tract infection during
4. Singer M, Deutschman CS, Seymour CW, et al. The Third International ureteroscopy. J Endourol. 2016;30(1):63–68.
Consensus Definitions for sepsis and septic shock (Sepsis-3). JAMA. 26. Kehinde EO, Rotimi VO, Al-Awadi KA, et al. Factors predispos-
2016;315(8):801–810. ing to urinary tract infection after J ureteral stent insertion. J Urol.
5. Caironi P, Tognoni G, Masson S, et al. Albumin replacement in patients with 2002;167(3):1334–1337.
severe sepsis or septic shock. N Engl J Med. 2014;370(15):1412–1421. 27. Lange D, Bidnur S, Hoag N, Chew BH. Ureteral stent-associated compli-
6. Dielubanza EJ, Schaeffer AJ. Urinary tract infections in women. Med cations – where we are and where we are going. Nat Rev Urol. 2015;12(1):
Clin North Am. 2011;95(1):27–41. 17–25.
7. Barber AE, Norton JP, Wiles TJ, Mulvey MA. Strengths and limitations 28. Lo J, Lange D, Chew BH. Ureteral stents and foley catheters-associated
of model systems for the study of urinary tract infections and related urinary tract infections: the role of coatings and materials in infection
pathologies. Microbiol Mol Biol Rev. 2016;80(2):351–367. prevention. Antibiotics (Basel). 2014;3(1):87–97.
8. Johansen TE, Cek M, Naber KG, Stratchounski L, Svendsen MV, Tenke 29. Hollenbeck BK, Schuster TG, Faerber GJ, Wolf JS Jr. Safety
P. Prevalence of hospital acquired urinary tract infections in urology and efficacy of same-session bilateral ureteroscopy. J Endourol.
departments. Eur Urol. 2007;51(4):1100–1112. 2003;17(10):881–885.
9. Wagenlehner FM, Pilatz A, Weidner W, Naber KG. Urosepsis: overview 30. Askim Å, Moser F, Gustad LT, et al. Poor performance of quick-SOFA
of the diagnostic and treatment challenges. Microbiol Spectr. 2015;3(5). (qSOFA) score in predicting severe sepsis and mortality – a prospective
10. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, study of patients admitted with infection to the emergency department.
Pinsky MR. Epidemiology of severe sepsis in the United States: analysis Scand J Trauma Resusc Emerg Med. 2017;25(1):56.
of incidence, outcome, and associated costs of care. Crit Care Med. 31. Burnham JP, Kollef MH. qSOFA score: predictive validity in Entero-
2001;29(7):1303–1310. bacteriaceae bloodstream infections. J Crit Care. 2017;43:143–147.
11. Lagu T, Rothberg MB, Shieh MS, Pekow PS, Steingrub JS, Lindenauer 32. Dellinger RP, Carlet JM, Masur H, et al; Surviving Sepsis Campaign
PK. Hospitalizations, costs, and outcomes of severe sepsis in the United Management Guidelines Committee. Surviving Sepsis Campaign
States 2003 to 2007. Crit Care Med. 2012;40(3):754–761. guidelines for management of severe sepsis and septic shock. Crit
12. Torio C (AHRQ), Moore B (Truven Health Analytics). National Inpa- Care Med. 2004;32(3):858–873. Review. Erratum in: Crit Care Med
tient Hospital Costs: The Most Expensive Conditions by Payer, 2013. 2004;32(10):2169–2170.
HCUP Statistical Brief #204. Rockville, MD: Agency for Healthcare 33. Aikawa N, Fujishima S, Endo S, et al. Multicenter prospective
Research and Quality; 2016. Available from: http://www.hcup-us.ahrq. study of procalcitonin as an indicator of sepsis. J Infect Chemother.
gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.pdf. 2005;11(3):152–159.
Accessed May 4, 2018. 34. Sugimoto K, Adomi S, Koike H, Esa A. Procalcitonin as an indicator
13. Wagenlehner FM, Lichtenstern C, Rolfes C, et al. Diagnosis and man- of urosepsis. Res Rep Urol. 2013;5:77–80.
agement for urosepsis. Int J Urol. 2013;20(10):963–970. 35. van Nieuwkoop C, Bonten TN, van’t Wout JW, et al. Procalcitonin
14. Wagenlehner FM, Pilatz A, Naber KG, Weidner W. Therapeutic chal- reflects bacteremia and bacterial load in urosepsis syndrome: a prospec-
lenges of urosepsis. Eur J Clin Invest. 2008;38(suppl 2):45–49. tive observational study. Crit Care. 2010;14(6):R206.

48 submit your manuscript | www.dovepress.com Research and Reports in Urology 2018:10

Dovepress
Dovepress Prevention and management of urosepsis

36. Ferrer R, Martin-Loeches I, Phillips G. Empiric antibiotic treatment 46. Eswara JR, Shariftabrizi A, Sacco D. Positive stone culture is associated
reduces mortality in severe sepsis and septic shock from the first hour: with a higher rate of sepsis after endourological procedures. Urolithiasis.
results from a guideline-based performance improvement program. Crit 2013;41(5):411–414.
Care Med. 2014;42(8):1749–1755. 47. Chang CL, Su LH, Lu CM, Tai FT, Huang YC, Chang KK. Outbreak of
37. Karam G, Chastre J, Wilcox MH, Vincent JL. Antibiotic strategies in ertapenem-resistant Enterobacter cloacae urinary tract infections due
the era of multidrug resistance. Crit Care. 2016;20(1):136. to a contaminated ureteroscope. J Hosp Infect. 2013;85(2):118–124.
38. Joshi S. Hospital antibiogram: a necessity. Indian J Med Microbiol. 48. Carey RI, Gomez CS, Maurici G, Lynne CM, Leveillee RJ, Bird VG.
2010;28(4):277–280. Frequency of ureteroscope damage seen at a tertiary care center. J Urol.
39. Elhanan G, Sarhat M, Raz R. Empiric antibiotic treatment and the 2006;176:607–610.
misuse of culture results and antibiotic sensitivities in patients with 49. Ofstead CL, Heymann OL, Quick MR, Johnson EA, Eiland JE, Wetzler
community-acquired bacteraemia due to urinary tract infection. J Infect. HP. The effectiveness of sterilization for flexible ureteroscopes: a real-
1997;35(3):283–288. world study. Am J Infect Control. 2017;45(8):888–895.
40. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy 50. AORN. Association of Perioperative Registered Nurses Guideline for
Collaborative Group. Early goal-directed therapy in the treatment of Processing Flexible Endoscopes Sterilization and Disinfection. Denver,
severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–1377. CO: AORN; 2016:675–758.
41. Kalra OP, Raizada A. Approach to a patient with urosepsis. J Glob Infect 51. Usawachintachit M, Isaacson DS, Taguchi K, et al. A prospective
Dis. 2009;1(1):57–63. case-control study comparing LithoVue, a single-use, flexible dispos-
42. Park JM, Bloom DA. The pathophysiology of ureteropelvic junction able ureteroscope, with flexible, reusable fiber-optic ureteroscopes. J
obstruction. Urol Clin North Am. 1998;25:161–169. Endourol. 2017;31(5):468–475.
43. Vigil HR, Hickling DR. Urinary tract infection in the neurogenic blad- 52. Auge BK, Pietrow PK, Lallas CD, Raj GV, Santa-Cruz RW, Preminger
der. Transl Androl Urol. 2016;5(1):72–87. GM. Ureteral access sheath provides protection against elevated renal
44. Knopf HJ, Graff HJ, Schulze H. Perioperative antibiotic prophylaxis in pressures during routine flexible ureteroscopic stone manipulation. J
ureteroscopic stone removal. Eur Urol. 2003;44(1):115–118. Endourol. 2004;18(1):33–36.
45. Wolf JS Jr, Bennett CJ, Dmochowski RR, et al. Urologic surgery 53. Huang J, Zhao Z, AlSmadi JK, et al. Use of the ureteral access sheath
antimicrobial prophylaxis best practice policy panel. Best practice during ureteroscopy: a systematic review and meta-analysis. PLoS One.
policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2018;13(2):e0193600.
2008;179(4):1379–1390.

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