46 H. HASHIM AND J. REYNARD
approximately 1.5% of men undergoing TURP. Diabetic patients, patients in the intensive care units (ICU), and patients on chemotherapy and steroids are more prone to urosepsis.
The commonest causative organisms of urinary sepsis are Escherichia coli, enterococci (Streptococcus faecalis), sta-phylococci, Pseudomonas aeruginosa, Klebsiella, and Proteus mirabilis.
The principles of management include early recognition, resuscitation, localisation of the source of sepsis, early and appropriate antibiotic administration, and removal of the primary source of sepsis. The clinical scenario is usually a postoperative patient who has undergone TURP or surgery for stone. Having returned to the ward, the patient becomes pyrexial, starts to shiver and shake, is tachycardic, and may be confused. On inspection the patient may initially show signs of peripheral vasodilatation (may appear flushed and warm to the touch). Look for symptoms and signs of a non-urological source of sepsis such as pneumonia. If there are no indications of infection elsewhere, assume the urinary tract is the source of sepsis.
■ Urine culture. An immediate Gram stain may aid in deciding which antibiotic to use.
■ Full blood count. The white blood count is usually elevated. The platelet count may be low, a possible indication of impending disseminated intravascular coagulopathy (DIC).
■ Coagulation screen. This is important if surgical or radiological drainage of the source of infection is necessary.
■ Urea and electrolytes as a baseline determination of renal function.
■ Arterial blood gases to identify hypoxia and the presence of metabolic acidosis.
■ Blood cultures.
■ Chest x-ray (CXR), looking for pneumonia, atelectasis, and effusions.
Depending on the clinical situation, a renal ultrasound may be helpful to demonstrate hydronephrosis or pyonephrosis and CT urography (CTU) may be used to establish the presence or absence of a ureteric stone.