Infectious Diseases in Critical Care Medicine

be available for some time, the Gram stain of the urine provides immediate microbiologic

information regarding the likely cause of the patient’s UTI/urosepsis (1–5,13,14).

Patients with acute pyelonephritis have fever> 1028 F, pyuria with bacteriuria, and

unilateral costovertebral angle (CVA) tenderness or bladder/renal abnormalities. Urosepsis

due to cystitis in compromised hosts has no localizing signs (1,4,5) (Table 4).

Table 3 Catheter-Associated Bacteriuria (CAB) and Urosepsis

Clinical CAB setting

GU host

factors

Risk of

urosepsis

Preferred

approach Comments

.Indwelling (short-term)
non-obstructed Foley
catheter

Normal Low No antibiotics Remove Foley catheter as
soon as possible. No
antibiotics.
.Indwelling (short- or
long-term) obstructed
Foley catheter

Normal High Correction of

obstruction

IV/PO antibiotics until

obstruction relieved.

.Indwelling (short- or
long-term non-obstructive)
Foley catheter
in non-leukopenic compromised
hosts (SLE,
DM, multiple myeloma,
steroids, cirrhosis)

Abnormal High If possible,

avoid Foley

catheter

PO antibiotic prophylaxis.

Not septic Normal Low No antibiotics PO chronic antibiotic

suppressive therapy

(optional).

Septic Abnormal High IV/PO

antibiotics

First, treat urosepsis IV/

PO then follow with PO

suppressive therapy.

Abbreviations: CAB, catheter-associated bacteriuria; DM, diabetes mellitus; GU, genitourinary; IV/PO, intrave-
nous/by mouth; SLE, systemic lupus erythematosus.

Table 4 Differential Diagnosis of Acute Cystitis, Rental Stone, Acute Pyelonephritis

Clinical findings Acute cystitis Rental stone Acute pyelonephritis

.Symptoms
Abdominal pain
Dysuria

Suprapubic discomfort

þ

Unilateral back pain



Unilateral back pain
þ
.Signs
Fever> 1028 F
CVA tenderness









þ

þ

.Laboratory tests
Leukocytosis
:ESR
Urine tests
Urinalysis
Pyuria
Microscopic
hematuria
Bacteruria
Blood cultures

þ



þ



þ

a

þ   þ  

þ þ þ  þ þ

.Imaging studies
Abdominal
ultrasound
Abdominal CT
scan







Hydroureter/hydronephrosis



Hydroureter/hydronephrosis



Cortical abnormalities

Acute pyelonephritis (distorted

cortical contour/scarring)

aOnly in compromised hosts with urosepsis, e.g., SLE, systemic lupus erythematosus, DM, diabetes mellitus, MM,

multiple myeloma, cirrhosis, etc.
Abbreviations: CT, computed tomography; CVA, cerebrovascular accident; ESR, erythrocyte sedimentation rate.

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