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Guideline Summary
Guideline Title
Sepsis syndrome in urology (urosepsis). In: Guidelines on urological infections.
Bibliographic Source(s)
Sepsis syndrome in urology (urosepsis). In: Grabe M, Bjerklund-Johansen TE, Botto H, Wullt B, Çek M, Naber KG, Pickard RS, Tenke P, Wagenlehner F. Guidelines on urological infections. Arnhem, The Netherlands: European Association of Urology (EAU); 2011 Mar. p. 33-9. [18 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Sepsis syndrome in urology (urosepsis). In: Grabe M, Bishop MC, Bjerklund-Johansen TE, Botto H, Çek M, Lobel B, Naber KG, Palou J, Tenke P, Wagenlehner F. Guidelines on urological infections. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. p. 67-72. [18 references]

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

Drug Withdrawal

  • October 25, 2011 – Xigris [drotrecogin alfa (activated)]: The U.S. Food and Drug Administration (FDA) notified healthcare professionals and the public that on October 25, 2011, Eli Lilly and Company announced a worldwide voluntary market withdrawal of Xigris [drotrecogin alfa (activated)]. In a recently completed clinical trial (PROWESS-SHOCK trial), Xigris failed to show a survival benefit. Xigris failed to show a survival benefit for patients with severe sepsis and septic shock. Xigris treatment should not be started in new patients. Xigris treatment should be stopped in patients being treated with Xigris. All remaining Xigris product should be returned to the supplier from whom it was purchased.

Scope

Disease/Condition(s)

Urosepsis

Guideline Category
Diagnosis
Evaluation
Management
Prevention
Treatment
Clinical Specialty
Critical Care
Infectious Diseases
Surgery
Urology
Intended Users
Advanced Practice Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To provide guidelines on the diagnosis, prevention, and treatment of urosepsis
  • To provide both the urologist and the physician from other medical specialties in their daily practice, with the aim of reducing the misuse of antibiotics
Target Population

Patients with or at risk for urosepsis

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Assessment for symptoms of systemic inflammatory response syndrome (SIRS)
  2. Physical examination
  3. Sonographic and radiological examination
  4. Laboratory tests, including testing for bacteriuria and leukocyturia
  5. Microbiology of urine/blood

Treatment/Management

  1. Removal of any obstruction in the urinary tract
  2. Goal directed antimicrobial therapy
  3. Life-support care
  4. Adjunctive measures (e.g., sympathomimetic amines, hydrocortisone, blood glucose control)
  5. Collaborative management among specialists in urology, intensive care, and infectious diseases

Prevention

  1. Isolation of patients infected with multiresistant organisms
  2. Prudent use of antimicrobials
  3. Reduction in length of hospital stay
  4. Proper catheter use, including early removal
  5. Attention to daily asepsis techniques
Major Outcomes Considered
  • Mortality and morbidity
  • Rate of urinary tract infection developing into urosepsis
  • Response rate to therapy

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

General Search Strategy

A structured literature search is performed for all guidelines but this search is limited to randomized controlled trials and meta-analyses, covering at least the past three years, or up until the date of the latest text update if this exceeds the three-year period. Other excellent sources to include are other high-level evidence, Cochrane review and available high-quality guidelines produced by other expert groups or organizations. If there are no high-level data available, the only option is to include lower-level data. The choice of literature is guided by the expertise and knowledge of the Guidelines Working Group.

Specific Strategy for This Guideline

For literature review, PubMed was searched for published meta-analyses, which were used as far as available. Otherwise there was a non-structured literature review process by the guidelines group members. Each member was responsible for one chapter (reporter).

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

1a Evidence obtained from meta-analysis of randomised trials

1b Evidence obtained from at least one randomised trial

2a Evidence obtained from one well-designed controlled study without randomisation

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies, and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus (Consensus Development Conference)
Description of Methods Used to Formulate the Recommendations

Methods Used to Formulate the Recommendations

  • The first step in the European Association of Urology (EAU) guidelines procedure is to define the main topic.
  • The second step is to establish a working group. The working groups comprise about 4-8 members, from several countries. Most of the working group members are academic urologists with a special interest in the topic. Specialists from other medical fields (radiotherapy, oncology, gynaecology, anaesthesiology etc.) are included as full members of the working groups as needed. In general, general practitioners or patient representatives are not part of the working groups. Each member is appointed for a four-year period, renewable once. A chairman leads each group.
  • The third step is to collect and evaluate the underlying evidence from the published literature.
  • The fourth step is to structure and present the information. All main recommendations are summarized in boxes and the strength of the recommendation is clearly marked in three grades (A-C), depending on the evidence source upon which the recommendation is based. Every possible effort is made to make the linkage between the level of evidence and grade of recommendation as transparent as possible.

The members of the Urinary Tract Infection (UTI) Working Group of the EAU Health Care Office established the first version of these guidelines in several consensus conferences. A second Working Group updated the guidelines and added several chapters. The first draft of each chapter was sent to the committee members asking for comments, which were then considered, discussed and incorporated accordingly.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendation

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial
  2. Based on well-conducted clinical studies, but without randomised clinical trials
  3. Made despite the absence of directly applicable clinical studies of good quality

It should be noted that when recommendations are graded, the link between the level of evidence and grade of recommendation is not directly linear. Availability of randomised controlled trials (RCTs) may not necessarily translate into a grade A recommendation where there are methodological limitations or disparity in published results. Alternatively, absence of high level evidence does not necessarily preclude a grade A recommendation, if there is overwhelming clinical experience and consensus.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

The formal agreement to each updated chapter was achieved by the European Association of Urology (EAU) working group in a series of meetings.

There is no formal external review prior to publication.

The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used to analyse and assess a range of specific attributes contributing to the validity of a specific clinical guideline.

The AGREE instrument, to be used by two to four appraisers, was developed by the AGREE collaboration (www.agreetrust.org External Web Site Policy) using referenced sources for the evaluation of specific guidelines (see the "Availability of Companion Documents" field for further methodology information).

Recommendations

Major Recommendations

Note from the European Association of Urology (EAU) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of March 2011. However, because the European Association of Urology updates their guidelines frequently, users may wish to consult the European Association of Urology Web site External Web Site Policy for the most current version available.

Levels of evidence (LE) (1a-4) and grades of recommendation (GR) (A-C) are defined at the end of the "Major Recommendations" field.

Patients with urosepsis should be diagnosed at an early stage, especially in the case of a complicated urinary tract infection (UTI). The systemic inflammatory response syndrome, known as SIRS (fever or hypothermia, hyperleukocytosis or leukopenia, tachycardia, tachypnoea), is recognised as the first event in a cascade to multi-organ failure. Mortality is considerably increased when severe sepsis or septic shock are present, although the prognosis of urosepsis is globally better than sepsis due to other infectious sites.

The treatment of urosepsis calls for the combination of adequate life-supporting care, appropriate and prompt antibiotic therapy, adjunctive measures (e.g., sympathomimetic amines, hydrocortisone, blood glucose control) and the optimal management of urinary tract disorders (LE: 1a, GR: A). The drainage of any obstruction in the urinary tract is essential as first-line treatment (LE: 1b, GR: A). Urologists are recommended to treat patients in collaboration with intensive care and infectious diseases specialists (LE: 2a, GR: B).

Urosepsis is seen in both community-acquired and healthcare associated infections. Most nosocomial urosepsis can be avoided by measures used to prevent nosocomial infection (e.g., reduction of hospital stay, early removal of indwelling urethral catheters, avoidance of unnecessary urethral catheterisations, correct use of closed catheter systems, and attention to simple daily asepsis techniques to avoid cross-infection). (LE: 2a, GR: B).

Definitions:

Levels of Evidence

1a Evidence obtained from meta-analysis of randomised trials

1b Evidence obtained from at least one randomised trial

2a Evidence obtained from one well-designed controlled study without randomisation

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies, and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Grades of Recommendation

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial
  2. Based on well-conducted clinical studies, but without randomised clinical trials
  3. Made despite the absence of directly applicable clinical studies of good quality
Clinical Algorithm(s)

A clinical algorithm for the management of urosepsis is available in the original guideline document.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for most of the recommendations (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis, management, and prevention of urosepsis

Potential Harms

Side effects of treatment

Qualifying Statements

Qualifying Statements
  • The aim of clinical guidelines is to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgement, knowledge, and expertise. A guideline is not intended to take the place of physician judgment in diagnosing and treatment of particular patients.
  • Guidelines may not be complete or accurate. The European Association of Urology (EAU) and their Guidelines Office, and members of their boards, officers and employees disclaim all liability for the accuracy or completeness of a guideline, and disclaim all warranties, express or implied to their incorrect use.
  • Guidelines users always are urged to seek out newer information that might impact the diagnostic and treatment recommendations contained within a guideline.
  • Due to their unique nature – as international guidelines, the EAU Guidelines are not embedded within one distinct healthcare setting - variations in clinical settings, resources, or common patient characteristics, are not accounted for.

Implementation of the Guideline

Description of Implementation Strategy

The European Association of Urology (EAU) Guidelines long version (containing all 19 guidelines) is reprinted annually in one book. Each text is dated. This means that if the latest edition of the book is read, one will know that this is the most updated version available. The same text is also made available on a CD (with hyperlinks to PubMed for most references) and posted on the EAU websites Uroweb and Urosource (http://www.uroweb.org/guidelines/online-guidelines/ External Web Site Policy & http://www.urosource.com/diseases/ External Web Site Policy).

Condensed pocket versions, containing mainly flow-charts and summaries, are also printed annually. All these publications are distributed free of charge to all (more than 10,000) members of the Association. Abridged versions of the guidelines are published in European Urology as original papers. Furthermore, many important websites list links to the relevant EAU guidelines sections on the association websites and all, or individual, guidelines have been translated to some 15 languages.

Implementation Tools
Clinical Algorithm
Foreign Language Translations
Pocket Guide/Reference Cards
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Sepsis syndrome in urology (urosepsis). In: Grabe M, Bjerklund-Johansen TE, Botto H, Wullt B, Çek M, Naber KG, Pickard RS, Tenke P, Wagenlehner F. Guidelines on urological infections. Arnhem, The Netherlands: European Association of Urology (EAU); 2011 Mar. p. 33-9. [18 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2008 Mar (revised 2011 Mar)
Guideline Developer(s)
European Association of Urology - Medical Specialty Society
Source(s) of Funding

European Association of Urology

Guideline Committee

Urinary Tract Infection Guidelines Working Group

Composition of Group That Authored the Guideline

Group Members: M. Grabe (Chairman); T.E. Bjerklund-Johansen; H. Botto; B. Wullt; M. Çek; K.G. Naber; R.S. Pickard; P. Tenke; F. Wagenlehner

Financial Disclosures/Conflicts of Interest

All members of the Urological Infections guidelines writing panel have provided disclosure statements of all relationships which they have and which may be perceived as a potential source of conflict of interest. This information is kept on file in the European Association of Urology (EAU) Central Office database. This guidelines document was developed with the financial support of the EAU. No external sources of funding and support have been involved. The EAU is a non-profit organisation and funding is limited to administrative assistance and travel and meeting expenses. No honoraria or other reimbursements have been provided.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Sepsis syndrome in urology (urosepsis). In: Grabe M, Bishop MC, Bjerklund-Johansen TE, Botto H, Çek M, Lobel B, Naber KG, Palou J, Tenke P, Wagenlehner F. Guidelines on urological infections. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. p. 67-72. [18 references]

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the European Association of Urology Web site External Web Site Policy. Also available in Russian External Web Site Policy and Spanish External Web Site Policy.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Availability of Companion Documents

The following are available:

  • Guidelines on urological infections. Pocket guideline. Arnhem, The Netherlands: European Association of Urology (EAU); 2010 Apr. 17 p. Electronic copies: Available in English External Web Site Policy, Spanish External Web Site Policy, Portuguese External Web Site Policy, and Russian External Web Site Policy from the European Association of Urology Web site.
  • EAU guidelines office template. Arnhem. The Netherlands: European Association of Urology (EAU); 2007. 4 p.
  • The European Association of Urology (EAU) guidelines methodology: a critical evaluation. Arnhem, The Netherlands: European Association of Urology (EAU); 2009. 6 p. Electronic copies: Available from the European Association of Urology Web site External Web Site Policy.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Also, Chapter 2 of the original guideline document External Web Site Policy presents a system of classification for urinary tract infection (UTI) being proposed by the EAU/International Consultation on Urological Diseases (ICUD) based on anatomical level of infection, grade of severity of infection, underlying risk factors, and microbiological findings.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on September 8, 2008. The information was verified by the guideline developer on December 8, 2008. This summary was updated by ECRI Institute on January 11, 2010. This NGC summary was updated by ECRI Institute on November 17, 2011. The updated information was verified by the guideline developer on December 23, 2011.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Downloads are restricted to one download and print per user, no commercial usage or dissemination by third parties is allowed.

Disclaimer

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