Nosocomial urosepsis follows recent urologic instrumentation usually<72 hours. The
diagnosis should be considered when a patient becomes septic after a urologic procedure. A
patient in the critical care unit (CCU) with an indwelling Foley catheter, with bacteriuria and
pyuria, almost never has fever on the basis of urosepsis unless the he or she is a compromised
host, i.e., has diabetes mellitus, SLE, cirrhosis, or is on steroids/immunosuppressives (1,3,4,9)
(Table 3). In such cases, other sources of fever should be considered in the CCU setting, i.e., IV
line infections, Clostridium difficilediarrhea/colitis, intraabdominal peritonitis/abscess, or
acute pancreatitis (5,9–12,15).
Patients presenting from the community with urosepsis often have stone or structural
ureteral, bladder, or renal abnormality, acute prostatitis/prostatic abscess, or acute pyeloneph-
ritis. Acute pyelonephritis is diagnosed by a temperature of 1028 F, CVA tenderness, and
pyuria with bacteriuria. In acute pyelonephritis, the Gram stain provides a rapid, presumptive,
otherwise unexplained microbiologic diagnosis, which should guide antibiotic selection. A Gram
stain of the urine in acute pyelonephritis will reveal gram-positive cocci in pairs/chains, group B
streptococci or group D enterococci, or GNBs. In acute pyelonephritis GNBs are aerobic since
anaerobic GNBs do not cause UTIs/pyelonephritis (3–8).
Patients with acute prostatitis may become septic, but urosepsis often accompanies
prostatic abscesses (3–8) (Table 5). Prostatic abscess is a difficult diagnosis in a septic
patient without any localizing signs. “Fever everywhere,fever nowhere” suggests an occult
subdiaphragmatic abscess. Similarly, in a patient who has a history of prostatitis and no
other explanation for fever/hypotension sepsis, a prostatic abscess should be considered
in the differential diagnosis. A transrectal ultrasound or an abdominal CT scan areTable 5 Mimics of Pyelonephritis
Pyelonephritis mimics Distinguishing features
l Lower lobe community-acquired
pneumonial No true CVA tenderness
l Chest X ray: Lower lobe infiltrate/effusion
l UA/UC
l Abdominal CT scan
l BCs:Streptococcus pneumoniaeorHaemophilus influenzae
l Hepatic/splenic flexure diverticulitis l No true CVA tenderness
l UA/UC
l Abdominal CT scan diverticulitis:peridiverticular abscess
l BCs:coliforms/Bacteroides fragilis
l Regional enteritis l No true CVA tenderness
l UA:þ
l UC:
l Abdominal CT scan: ileitisabscess
l BCs:
l Lower rib plasmacytoma l No true CVA tenderness
l Tenderness/mass over rib
l UA/UC:
l Abdominal CT scan:
l SPEP: monoclonal gammopathy
l BCs:
l Costochondritis l No true CVA tenderness
l Point tenderness over one/more rib cartilages
l UA/UC:
l Abdominal CT scan:
l :Coxsackie B titers
l SPEP: No monoclonal gammopathy
l BCs:Abbreviations: BCs, blood cultures; CT, computed tomography; CVA, cerebrovascular accident; SPEP: serum
protein electrophoresis; UA, urinalysis; UC, urine culture.
Urosepsis in Critical Care 291