Approach to managing sepsis and septic shock from a urinary tract source in adults
For advice on recognising sepsis or septic shock, see Identifying sepsis or septic shock, and for advice on early management, see Resuscitation of patients with sepsis or septic shock.
For adults with sepsis or septic shock from a urinary tract source, start antibiotic therapy within 1 hour of presentation to medical care or, for ward-based patients, development of sepsis or septic shock. Antibiotics should be administered immediately after blood samples are taken for culture. Collect a urine sample as soon as possible; however, do not delay antibiotic administration to do so1. Consider imaging to investigate for urinary obstruction or kidney stone disease.
Empirical regimens for adults with sepsis or septic shock from a urinary tract source should be based on local protocols, where available, and informed by susceptibilities of expected pathogens in the local antibiogramWorld Health Organization (WHO), 2022. Also consider the patient’s recent culture and susceptibility test results, and risk factors for infection with a multidrug-resistant gram-negative bacterium, including recent antibiotic useDuffy, 2013Nelson, 2024Osthoff, 2015Steinke, 2001.
Aminoglycosides continue to be recommended in these guidelines for empirical therapy for sepsis or septic shock from a urinary tract source in adults without risk factors for infection with multidrug-resistant gram-negative bacteria; rates of aminoglycoside resistance in community-associated gram-negative pathogens (eg Escherichia coli) are low and the balance of benefits and harms favours their use in life-threatening infectionAustralian Commission on Safety and Quality in Health Care (ACSQHC), 2023. An aminoglycoside in combination with amoxicillin or ampicillin is recommended for pregnant patients with sepsis from a urinary tract source because of the increased risk of invasive infection with Streptococcus agalactiae (group B streptococcus [GBS])Bowyer, 2017Hall, 2017. An aminoglycoside in combination with ceftriaxone is recommended to treat septic shock from a urinary tract source, to broaden the spectrum of empirical therapy while awaiting susceptibility resultsWorld Health Organization (WHO), 2022.
There is worldwide emergence of multidrug-resistant E. coli, particularly extended-spectrum beta-lactamase (ESBL)-producing strains, causing urinary tract infections (UTIs) and associated bacteraemias. Data from 2023 suggest that the rate of ESBL-producing E. coli strains among isolates from blood samples varies significantly across Australia (eg from 6% in Tasmania to 25% in the Northern Territory)Australian Group on Antimicrobial Resistance (AGAR), 2024. Infection with susceptible ESBL-producing E. coli isolates can be treated with an aminoglycoside; however, susceptibility is variable, and the choice of aminoglycoside should be informed by susceptibilities in the local antibiogram. Meropenem is recommended in these guidelines for empirical therapy for adults with sepsis or septic shock from a urinary tract source who are at risk of infection with multidrug-resistant gram-negative bacteriaNelson, 2024.
Carbapenemase-producing Enterobacterales (eg E. coli) remain uncommon in Australia but are a growing concernAustralian Group on Antimicrobial Resistance (AGAR), 2024CDC, 2019. If infection with a carbapenem-resistant organism is suspected or confirmed, seek expert advice. See Antimicrobials with and without activity against carbapenemase-producing Enterobacterales for information on the effectiveness of various antimicrobials against bacteria that produce these enzymes.
Empirical regimens for sepsis and septic shock from a urinary tract source in adults are included in this topic; see:
- Empirical therapy for sepsis without septic shock from a urinary tract source in nonpregnant adults
- Empirical therapy for sepsis without septic shock from a urinary tract source in pregnancy
- Empirical therapy for septic shock from a urinary tract source in adults.
The empirical regimens in this topic may not be appropriate for adults with hospital-acquired infection; follow local protocols, or advice from clinical microbiologists or infectious diseases specialists.
The empirical regimens in this topic are intended for initial therapy only (up to 48 hours). Modify therapy as soon as additional information is available (eg results of Gram stain, culture and susceptibility testing of urine or blood samples). Evaluate appropriateness of antibiotic therapy daily, with consideration given to the patient’s clinical status and the principles of antimicrobial stewardship.
For adults with sepsis or septic shock from a urinary tract source who have an indwelling urinary catheter, remove or replace the catheter. Antibiotic therapy is often only transiently effective if the catheter is not removed or replaced, because most antibiotics penetrate poorly into catheter biofilm.