Investigations to Rule Out Urosepsis

Initial Clinical Assessment

The Infectious Diseases Society of America recommends assessing for symptoms and signs of urosepsis, including fever, shaking chills, hypotension, and delirium, especially in the context of recent catheter obstruction or change 1, 2
Evaluate for UTI-associated symptoms such as dysuria, gross hematuria, and new or worsening urinary incontinence, as suggested by the American Geriatrics Society 1, 3

Perform urinalysis for determination of leukocyte esterase and nitrite level by dipstick, as recommended by the Infectious Diseases Society of America 1, 2
Pyuria is defined as ≥10 WBCs/high-power field or a positive leukocyte esterase test, according to the American Geriatrics Society 2, 3

Only order urine culture if pyuria is present or if there is strong clinical suspicion of urosepsis, as suggested by the Infectious Diseases Society of America 1, 2

Complete blood cell (CBC) count with differential should be performed within 12-24 hours of symptom onset, as recommended by the Infectious Diseases Society of America and the American Geriatrics Society 1, 3
Pay particular attention to elevated WBC count (≥14,000 cells/mm³) and left shift (percentage of band neutrophils ≥16% or total band neutrophil count ≥1,500 cells/mm³), as suggested by the Infectious Diseases Society of America 1, 7

If urosepsis is suspected, obtain paired blood and urine specimens for culture and antimicrobial susceptibility testing, as recommended by the Infectious Diseases Society of America 1, 2

Consider imaging studies if there is failure to respond to appropriate antimicrobial therapy within 72 hours or deterioration in clinical status despite treatment, as suggested by the European Association of Urology 8
Ultrasound is the preferred initial imaging modality to rule out obstruction or stone disease, according to the European Association of Urology 8

For patients with indwelling catheters, evaluation is indicated if there is suspected urosepsis, especially in the context of recent catheter obstruction or change, as recommended by the Infectious Diseases Society of America 1, 2
In the absence of fever, leukocytosis, left shift, or specific clinical manifestations of focal infection, additional diagnostic tests may not be indicated due to low potential yield, as suggested by the Infectious Diseases Society of America 1, 9

Do not perform urinalysis and urine cultures for asymptomatic patients, as recommended by the Infectious Diseases Society of America and the American Geriatrics Society 1, 10
Avoid attributing nonspecific symptoms to UTI without specific urinary symptoms, as suggested by the American Geriatrics Society 6
Remember that bacteriuria is common in elderly patients and does not necessarily indicate infection requiring treatment, according to the American Geriatrics Society 6