尿源性脓毒症的研究进展
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摘要
尿源性脓毒症是指由于泌尿系统或者男性生殖器官的感染引起的脓毒症。近年来随着腔镜泌尿外科的发展,尿源性脓毒症的发病率和相关死亡人数逐年上升。作为泌尿外科风险最大、预后最差的并发症之一,尿源性脓毒症病情进展迅速,如对其未能早期诊断并及时正确处理,易迅速进展为脓毒症休克,危及患者生命。因此,早期识别及正确诊治尿源性脓毒症对降低相关病死率和改善预后具有重要意义。尿源性脓毒症的治疗关键在于早期液体复苏、早期使用抗生素及控制和消除易感因素,其围手术期处理需要外科,ICU,感染科及麻醉科医生之间的多学科协作及共同管理。本文就尿源性脓毒症的诊断标准及流行病学、病因及发病机制、危险因素和围手术期处理等相关研究进展作一综述。
Urosepsis refers to sepsis induced by infection of the urinary tract and/or male reproductive system.Recently,with the development of endoscopic urology,the incidence of urosepsis and related deaths have been increasing year over year.As one of the most risky and poorest prognosis complications in urology,urosepsis progresses rapidly.If it is not diagnosed early and treated promptly,urosepsis is easy to develop into septic shock and pose a serious threat to patients' life.Therefore,early identification and correct diagnosis and treatment of urosepsis are of great significance to reduce the mortality and improve the prognosis.The key to treat urosepsis is early fluid resuscitation,early antibiotic use,as well as control and elimination of susceptibility factors.The perioperative management of urosepsis requires the multidisciplinary collaboration of surgeons,ICU clinicians,infectious physicians,and anesthesiologists.This review summarizes the diagnostic criteria,epidemiology,etiology,pathogenesis,risk factors,and perioperative management of urosepsis.
Urosepsis refers to sepsis induced by infection of the urinary tract and/or male reproductive system.Recently,with the development of endoscopic urology,the incidence of urosepsis and related deaths have been increasing year over year.As one of the most risky and poorest prognosis complications in urology,urosepsis progresses rapidly.If it is not diagnosed early and treated promptly,urosepsis is easy to develop into septic shock and pose a serious threat to patients' life.Therefore,early identification and correct diagnosis and treatment of urosepsis are of great significance to reduce the mortality and improve the prognosis.The key to treat urosepsis is early fluid resuscitation,early antibiotic use,as well as control and elimination of susceptibility factors.The perioperative management of urosepsis requires the multidisciplinary collaboration of surgeons,ICU clinicians,infectious physicians,and anesthesiologists.This review summarizes the diagnostic criteria,epidemiology,etiology,pathogenesis,risk factors,and perioperative management of urosepsis.
引文
[1]Stoller J,Halpin L,Weis M,et al.Epidemiology of severe sepsis:2008-2012[J].J Crit Care,2016,31(1):58-62.
[2]Paoli CJ,Reynolds MA,Sinha M,et al.Epidemiology and costs of sepsis in the United States-An analysis based on timing of diagnosis and severity level[J].Crit Care Med,2018,46(12):1889-1897.
[3]Gadre SK,Shah M,Mireles-Cabodevila E,et al.Epidemiology and predictors of 30-day readmission in patients with sepsis[J].Chest2019,155(3):483-490.
[4]Tuzel E,Aktepe OC,Akdogan B.Prospective comparative study of two protocols of antibiotic prophylax is in percutaneous nephrolithotomy[J].J Endourol,2013,27(2):172-176.
[5]Wagenlehner FM,Weidner W,Naber KG.Optimal management of urosepsis from the urological perspective[J].Intern J Antimicrob Agents,2007,30(5):390-397.
[6]Bone RC,Balk RA,Cerra FB,et al.Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis The ACCP/SCCM Consensus Conference Committee.American College of Chest Physicians/Society of Critical Care Medicine[J]Chest,1992,101(6):1644-1655.
[7]Singer M,Deutschman CS,Seymour CW,et al.The Third International Consensus Definitions for Sepsis and Septic Shock(Sepsis-3)[J].JAMA,2016,315(8):801-810.
[8]Levy MM,Artigas A,Phillips GS,et al.Outcomes of the surviving sepsis campaign in intensive care units in the USA and Europe:Aprospective cohort study[J].Lancet Infect Dis,2012,12(12):919-924.
[9]Bonkat G,Cai T,Veeratterapillay R,et al.Management of urosepsis in 2018[J].Eur Urol Focus,2019,5(1):5-9.
[10]Wagenlehner FM,Pilatz A,Naber KG,et al.Therapeutic challenges of urosepsis[J].Eur J Clin Invest,2008,38(Suppl 2):45-49.
[11]Hofmann W.Urosepsis and uroseptic shock[J].Z Urol Nephrol1990,83(6):317-324.
[12]Bjerklund Johansen TE,Cek M,Naber K,et al.Prevalence of hospital-acquired urinary tract infections in urology departments[J]Eur Urol,2007,51(4):1100-1112.
[13]Bouza E,San Juan R,Munoz P,et al.A European perspective on nosocomial urinary tract infections II.Report on incidence,clinical characteristics and outcome(ESGNI-004 study).European Study Group on Nosocomial Infection[J].Clin Microbiol Infect,20017(10):532-542.
[14]Astiz ME,Rackow EC.Septic shock[J].Lancet,1998,351(9114):1501-1505.
[15]Kumar S,Bag S,Ganesamoni R,et al.Risk factors for urosepsis following percutaneous nephrolithotomy:role of 1 week of nitrofurantoin in reducing the risk of urosepsis[J].Urol Res,201240(1):79-86.
[16]Liu C,Zhang X,Liu Y,et al.Prevention and treatment of septic shock following mini-percutaneous nephrolithotomy:a single-center retrospective study of 834 cases[J].World J Urol,2013,31(6):1593-1597.
[17]Singh I,Gupta NP,Hemal AK,et al.Efficacy and outcome of surgical intervention in patients with nephrolithiasis and chronic renal failure[J].Int Urol Nephrol,2001,33(2):293-298.
[18]Korets R,Graversen JA,Kates M,et al.Post-percutaneous nephrolithotomy systemic inflammatory response:a prospective analysis of preoperative urine,renal pelvic urine and stone cultures[J].J Urol,2011,186(5):1899-1903.
[19]McAleer IM,Kaplan GW,Bradley JS,et al.Endotoxin content in renal calculi[J].J Urol,2003,169(5):1813-1814.
[20]Draga RO,Kok ET,Sorel MR,et al.Percutaneous nephrolithotomy:factors associated with fever after the first postoperative day and systemic inflammatory response syndrome[J].J Endourol,200923(6):921-927.
[21]Wang Y,Jiang F,Wang Y,et al.Post-percutaneous nephrolithotomy septic shock and severe hemorrhage:a study of risk factors[J].Urol Int,2012,88(3):307-310.
[22]Troxel SA,Low RK.Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever[J].J Urol,2002,168(4 Pt 1):1348-1351.
[23]Chen L,Xu QQ,Li JX,et al.Systemic inflammatory response syndrome after percutaneous nephrolithotomy:an assessment of risk factors[J].Int J Urol,2008,15(12):1025-1028.
[24]Kizilbash QF,Petersen NJ,Chen GJ,et al.Bacteremia and mortality with urinary catheter-associated bacteriuria[J].Infect Cont Hosp Epidemiol,2013,34(11):1153-1159.
[25]Shigemura K,Tanaka K,Osawa K,et al.Clinical factors associated with shock in bacteremic UTI[J].Int Urol Nephrol,2013,45(3):653-657.
[26]van Nieuwkoop C,Bonten TN,van't Wout JW,et al.Procalcitonin reflects bacteremia and bacterial load in urosepsis syndrome:a prospective observational study[J].Crit Care,2010,14(6):R206.
[27]Blackmur JP,Maitra NU,Marri RR,et al.Analysis of factors association with risk of postoperative urosepsis in patients undergoing ureteroscopy for treatment of stone disease[J].JEndourol,2016,30(9):963-969.
[28]Shoshany O,Margel D,Finz C,et al.Percutaneous nephrolithotomy for infection stones:what is the risk for postoperative sepsis?Aretrospective cohort study[J].Urolithiasis,2015,43(3):237-242.
[29]Rivers E,Nguyen B,Havstad S,et al.Early goal-directed therapy in the treatment of severe sepsis and septic shock[J].New Engl J Med2001,345(19):1368-1377.
[30]Yealy DM,Kellum JA,Huang DT,et al.A randomized trial of protocol-based care for early septic shock[J].New Engl J Med,2014370(18):1683-1693.
[31]Peake SL,Delaney A,Bailey M,et al.Goal-directed resuscitation for patients with early septic shock[J].New Engl J Med,2014,371(16):1496-506.
[32]Mouncey PR,Osborn TM,Power GS,et al.Trial of early,goaldirected resuscitation for septic shock[J].New Engl J Med,2015372(14):1301-1311.
[33]Angus DC,Barnato AE,Bell D,et al.A systematic review and metaanalysis of early goal-directed therapy for septic shock:the ARISE,ProCESS and ProMISe Investigators[J].Intens Care Med,201541(9):1549-1560.
[34]Guidet B,Martinet O,Boulain T,et al.Assessment of hemodynamic efficacy and safety of 6%hydroxyethylstarch 130/0.4 vs.0.9%NaCl fluid replacement in patients with severe sepsis:the CRYSTMASstudy[J].Crit Care,2012,16(3):R94.
[35]Serpa Neto A,Veelo DP,Peireira VG,et al.Fluid resuscitation with hydroxyethyl starches in patients with sepsis is associated with an increased incidence of acute kidney injury and use of renal replacement therapy:a systematic review and Meta-analysis of the literature[J].J Crit Care,2014,29(1):185.e1-7.
[36]Rhodes A,Evans LE,Alhazzani W,et al.Surviving sepsis campaign:international guidelines for management of sepsis and septic shock:2016[J].Intens Care Med,2017,43(3):304-377.
[37]Semler MW,Rice TW.Sepsis resuscitation:Fluid choice and dose[J].Clin Chest Med,2016,37(2):241-250.
[38]Kumar A,Roberts D,Wood KE,et al.Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock[J].Crit Care Med2006,34(6):1589-1596.
[39]Wagenlehner FM,Pilatz A,Weidner W.Urosepsis-from the view of the urologist[J].Int J Antimicrob Agents,2011,38(Suppl):51-57.
[40]Naber KG,Bergman B,Bishop MC,et al.EAU guidelines for the management of urinary and male genital tract infections.Urinary Tract Infection(UTI)Working Group of the Health Care Office(HCO)of the European Association of Urology(EAU)[J].Eur Urol2001,40(5):576-588.
[41]Annane D,Sebille V,Charpentier C,et al.Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock[J].JAMA,2002,288(7):862-871.
[42]Gibbison B,Lopez-Lopez JA,Higgins JP,et al.Corticosteroids in septic shock:a systematic review and network Meta-analysis[J].Crit Care,2017,21(1):78.
[43]Annane D,Renault A,Brun-Buisson C,et al.Hydrocortisone plus fludrocortisone for adults with septic shock[J].New Engl J Med2018,378(9):809-818.
[44]Venkatesh B,Finfer S,Cohen J,et al.Adjunctive glucocorticoid therapy in patients with septic shock[J].New Engl J Med,2018378(9):797-808.
[45]Dellinger RP,Levy MM,Rhodes A,et al.Surviving sepsis campaign:international guidelines for management of severe sepsis and septic shock:2012[J].Crit Care Med,2013,41(2):580-637.
[46]Bernard GR,Vincent JL,Laterre PF,et al.Efficacy and safety of recombinant human activated protein C for severe sepsis[J].New Engl J Med,2001,344(10):699-709.
[47]Kalil AC,LaRosa SP.Effectiveness and safety of drotrecogin alfa(activated)for severe sepsis:a Meta-analysis and metaregression[J]Lancet Infect Dis,2012,12(9):678-686.
[48]Annane D,Timsit JF,Megarbane B,et al.Recombinant human activated protein C for adults with septic shock:a randomized controlled trial[J].Am J Respir Crit Care Med,2013,187(10):1091-1097.
[2]Paoli CJ,Reynolds MA,Sinha M,et al.Epidemiology and costs of sepsis in the United States-An analysis based on timing of diagnosis and severity level[J].Crit Care Med,2018,46(12):1889-1897.
[3]Gadre SK,Shah M,Mireles-Cabodevila E,et al.Epidemiology and predictors of 30-day readmission in patients with sepsis[J].Chest2019,155(3):483-490.
[4]Tuzel E,Aktepe OC,Akdogan B.Prospective comparative study of two protocols of antibiotic prophylax is in percutaneous nephrolithotomy[J].J Endourol,2013,27(2):172-176.
[5]Wagenlehner FM,Weidner W,Naber KG.Optimal management of urosepsis from the urological perspective[J].Intern J Antimicrob Agents,2007,30(5):390-397.
[6]Bone RC,Balk RA,Cerra FB,et al.Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis The ACCP/SCCM Consensus Conference Committee.American College of Chest Physicians/Society of Critical Care Medicine[J]Chest,1992,101(6):1644-1655.
[7]Singer M,Deutschman CS,Seymour CW,et al.The Third International Consensus Definitions for Sepsis and Septic Shock(Sepsis-3)[J].JAMA,2016,315(8):801-810.
[8]Levy MM,Artigas A,Phillips GS,et al.Outcomes of the surviving sepsis campaign in intensive care units in the USA and Europe:Aprospective cohort study[J].Lancet Infect Dis,2012,12(12):919-924.
[9]Bonkat G,Cai T,Veeratterapillay R,et al.Management of urosepsis in 2018[J].Eur Urol Focus,2019,5(1):5-9.
[10]Wagenlehner FM,Pilatz A,Naber KG,et al.Therapeutic challenges of urosepsis[J].Eur J Clin Invest,2008,38(Suppl 2):45-49.
[11]Hofmann W.Urosepsis and uroseptic shock[J].Z Urol Nephrol1990,83(6):317-324.
[12]Bjerklund Johansen TE,Cek M,Naber K,et al.Prevalence of hospital-acquired urinary tract infections in urology departments[J]Eur Urol,2007,51(4):1100-1112.
[13]Bouza E,San Juan R,Munoz P,et al.A European perspective on nosocomial urinary tract infections II.Report on incidence,clinical characteristics and outcome(ESGNI-004 study).European Study Group on Nosocomial Infection[J].Clin Microbiol Infect,20017(10):532-542.
[14]Astiz ME,Rackow EC.Septic shock[J].Lancet,1998,351(9114):1501-1505.
[15]Kumar S,Bag S,Ganesamoni R,et al.Risk factors for urosepsis following percutaneous nephrolithotomy:role of 1 week of nitrofurantoin in reducing the risk of urosepsis[J].Urol Res,201240(1):79-86.
[16]Liu C,Zhang X,Liu Y,et al.Prevention and treatment of septic shock following mini-percutaneous nephrolithotomy:a single-center retrospective study of 834 cases[J].World J Urol,2013,31(6):1593-1597.
[17]Singh I,Gupta NP,Hemal AK,et al.Efficacy and outcome of surgical intervention in patients with nephrolithiasis and chronic renal failure[J].Int Urol Nephrol,2001,33(2):293-298.
[18]Korets R,Graversen JA,Kates M,et al.Post-percutaneous nephrolithotomy systemic inflammatory response:a prospective analysis of preoperative urine,renal pelvic urine and stone cultures[J].J Urol,2011,186(5):1899-1903.
[19]McAleer IM,Kaplan GW,Bradley JS,et al.Endotoxin content in renal calculi[J].J Urol,2003,169(5):1813-1814.
[20]Draga RO,Kok ET,Sorel MR,et al.Percutaneous nephrolithotomy:factors associated with fever after the first postoperative day and systemic inflammatory response syndrome[J].J Endourol,200923(6):921-927.
[21]Wang Y,Jiang F,Wang Y,et al.Post-percutaneous nephrolithotomy septic shock and severe hemorrhage:a study of risk factors[J].Urol Int,2012,88(3):307-310.
[22]Troxel SA,Low RK.Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever[J].J Urol,2002,168(4 Pt 1):1348-1351.
[23]Chen L,Xu QQ,Li JX,et al.Systemic inflammatory response syndrome after percutaneous nephrolithotomy:an assessment of risk factors[J].Int J Urol,2008,15(12):1025-1028.
[24]Kizilbash QF,Petersen NJ,Chen GJ,et al.Bacteremia and mortality with urinary catheter-associated bacteriuria[J].Infect Cont Hosp Epidemiol,2013,34(11):1153-1159.
[25]Shigemura K,Tanaka K,Osawa K,et al.Clinical factors associated with shock in bacteremic UTI[J].Int Urol Nephrol,2013,45(3):653-657.
[26]van Nieuwkoop C,Bonten TN,van't Wout JW,et al.Procalcitonin reflects bacteremia and bacterial load in urosepsis syndrome:a prospective observational study[J].Crit Care,2010,14(6):R206.
[27]Blackmur JP,Maitra NU,Marri RR,et al.Analysis of factors association with risk of postoperative urosepsis in patients undergoing ureteroscopy for treatment of stone disease[J].JEndourol,2016,30(9):963-969.
[28]Shoshany O,Margel D,Finz C,et al.Percutaneous nephrolithotomy for infection stones:what is the risk for postoperative sepsis?Aretrospective cohort study[J].Urolithiasis,2015,43(3):237-242.
[29]Rivers E,Nguyen B,Havstad S,et al.Early goal-directed therapy in the treatment of severe sepsis and septic shock[J].New Engl J Med2001,345(19):1368-1377.
[30]Yealy DM,Kellum JA,Huang DT,et al.A randomized trial of protocol-based care for early septic shock[J].New Engl J Med,2014370(18):1683-1693.
[31]Peake SL,Delaney A,Bailey M,et al.Goal-directed resuscitation for patients with early septic shock[J].New Engl J Med,2014,371(16):1496-506.
[32]Mouncey PR,Osborn TM,Power GS,et al.Trial of early,goaldirected resuscitation for septic shock[J].New Engl J Med,2015372(14):1301-1311.
[33]Angus DC,Barnato AE,Bell D,et al.A systematic review and metaanalysis of early goal-directed therapy for septic shock:the ARISE,ProCESS and ProMISe Investigators[J].Intens Care Med,201541(9):1549-1560.
[34]Guidet B,Martinet O,Boulain T,et al.Assessment of hemodynamic efficacy and safety of 6%hydroxyethylstarch 130/0.4 vs.0.9%NaCl fluid replacement in patients with severe sepsis:the CRYSTMASstudy[J].Crit Care,2012,16(3):R94.
[35]Serpa Neto A,Veelo DP,Peireira VG,et al.Fluid resuscitation with hydroxyethyl starches in patients with sepsis is associated with an increased incidence of acute kidney injury and use of renal replacement therapy:a systematic review and Meta-analysis of the literature[J].J Crit Care,2014,29(1):185.e1-7.
[36]Rhodes A,Evans LE,Alhazzani W,et al.Surviving sepsis campaign:international guidelines for management of sepsis and septic shock:2016[J].Intens Care Med,2017,43(3):304-377.
[37]Semler MW,Rice TW.Sepsis resuscitation:Fluid choice and dose[J].Clin Chest Med,2016,37(2):241-250.
[38]Kumar A,Roberts D,Wood KE,et al.Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock[J].Crit Care Med2006,34(6):1589-1596.
[39]Wagenlehner FM,Pilatz A,Weidner W.Urosepsis-from the view of the urologist[J].Int J Antimicrob Agents,2011,38(Suppl):51-57.
[40]Naber KG,Bergman B,Bishop MC,et al.EAU guidelines for the management of urinary and male genital tract infections.Urinary Tract Infection(UTI)Working Group of the Health Care Office(HCO)of the European Association of Urology(EAU)[J].Eur Urol2001,40(5):576-588.
[41]Annane D,Sebille V,Charpentier C,et al.Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock[J].JAMA,2002,288(7):862-871.
[42]Gibbison B,Lopez-Lopez JA,Higgins JP,et al.Corticosteroids in septic shock:a systematic review and network Meta-analysis[J].Crit Care,2017,21(1):78.
[43]Annane D,Renault A,Brun-Buisson C,et al.Hydrocortisone plus fludrocortisone for adults with septic shock[J].New Engl J Med2018,378(9):809-818.
[44]Venkatesh B,Finfer S,Cohen J,et al.Adjunctive glucocorticoid therapy in patients with septic shock[J].New Engl J Med,2018378(9):797-808.
[45]Dellinger RP,Levy MM,Rhodes A,et al.Surviving sepsis campaign:international guidelines for management of severe sepsis and septic shock:2012[J].Crit Care Med,2013,41(2):580-637.
[46]Bernard GR,Vincent JL,Laterre PF,et al.Efficacy and safety of recombinant human activated protein C for severe sepsis[J].New Engl J Med,2001,344(10):699-709.
[47]Kalil AC,LaRosa SP.Effectiveness and safety of drotrecogin alfa(activated)for severe sepsis:a Meta-analysis and metaregression[J]Lancet Infect Dis,2012,12(9):678-686.
[48]Annane D,Timsit JF,Megarbane B,et al.Recombinant human activated protein C for adults with septic shock:a randomized controlled trial[J].Am J Respir Crit Care Med,2013,187(10):1091-1097.