Infectious Diseases in Critical Care Medicine

diagnostic and surgical drainage may be required. Epididymitis in elderly may occasionally
present as urosepsis, and the usual pathogens are aerobic GNBs, particularlyP. aeruginosa
(6,7,13,14).

EMPIRIC ANTIMICROBIAL THERAPY
Empiric antibiotic therapy of urosepsis depends on the likely pathogen, which is related to
whether urosepsis is community or nosocomially acquired. The causative microorganisms in
community-acquired urosepsis are aerobic GNBs or group B or D streptococci. The Gram stain
of the urine rapidly differentiates gram-positive cocci in pairs/chains from aerobic GNBs,
which is sufficient to base initial empiric therapy. Gram-positive cocci in chains are group B or
D streptococci, since gram-positive cocci in clusters representS. aureus, not a uropathogen
(16,17). In terms of GNBs, coverage should be directed against community-acquired
uropathogens. Antibiotics effective againstK. pneumoniaewill almost always also be effective
againstE. coli, Proteus,etc. With the exception of epididymitis in the elderly, community-
acquired urosepsis does not require P. aeruginosa coverage. Antibiotics effective against
group D streptococci (VSE/VRE) will also be effective against group B streptococci (5,14,16–21)
(Table 6 and 7).
Nosocomial urosepsis is caused by aerobic GNBs and empiric therapy is based on the
Gram stain and recent past medical urologic history. Coverage should be directed against
P. aeruginosa, which will also cover other aerobic nosocomial GNBs. If recent PMH
indicated recurrent UTI/procedures due to multidrug resistant (MDR) GNBs, the coverage
should be directed against the most recent MDR GNB, i.e., MDRP. aeruginosa,MDR
K. pneumoniae, or MDRAcinetobacterspecies. If urine/blood cultures have grownS. maltophilia
orB. cepacia,treat with trimethoprim-sulfamethoxazole (TMP-SMX) or minocycline respec-
tively (16,21–33).

Table 6 Community-Acquired Urosepsis: Therapeutic Approach

Urosepsis-
associated syndrome Microorganisms Urine Gram stain Empiric coverage

.Acute epididymitis
(elderly males)

P. aeruginosa GNBs Meropenem
Amikacin
Antipseudomonal penicillin (APP)
Antipseudomonal third-generation
cephalosporin (APC)
Cefepime
Aztreonam
.Acute epididymitis
(young males)

C. trachomatics No bacteria Quinolonea
Doxycycline
.Acute prostatitis Common coliforms GNBs Quinolonea
Group D enterococci
E. faecalis(VSE)

Gram-positive cocci

in pairs/chains

Ampicillin
Vancomycin
Meropenem
E. faecium(VRE) Linezolid
.Acute pyelonephritis E. coli,
P. mirabilis,
K. pneumoniae

GNBs Meropenem

Quinolonea

Aztreonam

Aminoglycoside

Third-generation cephalosporin

aLevofloxacin or ciprofloxacin.

Abbreviations: GNBs, gram-negative bacilli; Q/D, quinupristin/dalfopristin; VRE, vancomycin-resistant enterococci;
VSE, vancomycin-susceptible enterococci.

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