Urosepsis is one of my favorite ICU diagnoses. In almost all cases, patients will improve dramatically within 12-24 hours and leave the ICU with minimal sequelae. But that shouldn't lull us into a false sense of security: careful antibiotic selection, aggressive resuscitation, and (in some cases) emergent drainage may be required for a good outcome.
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Hi Josh
I often cannot get a timely urinary microscopy to assist clinical decision making.
Does microscopy add anything over and above the simple urine dipstick in ruling in or ruling out urosepsis?
Some remarks regarding antibiotic choice (this is necessarily based on geography – I live in Belgium) : – For community-acquired urosepsis, gram+ organisms are rarely the cause in patients without a urological history. Gram+ coverage is generally not necessary. For those with a history, past culture results can be invaluable. – Consider gram+ coverage in those with an indwelling catheter. – Vancomycin does make sense if a lot of your enterococci are E. faecium – which is naturally resistant to meropenem (unless you see a lot of VRE) . – 3rd Gen cephalosporins are okay if your lab keeps tabs… Read more »
We even do have a recommendation for ceftriaxone in urosepsis in germany, but i never got the thought behind that. Ceftriaxone is known and used for its hepatic elimination (great choice in cholangitis), but that also means urinary concentration is going to be low. I don’t see it indicated in uronary infection even if it fits from resistogram, especially when patients receive i.v. fluids, you never know if MIC is met in urin. Thanks for your great blog!