Urgent considerations

See Differentials for more details

Dysuria in isolation rarely warrants emergency action, but accompanying red-flag features require investigation.

Malignancy

Hematuria should be investigated to exclude malignancy. Malignancy should be assumed until shown otherwise. Signs such as pneumaturia (i.e., passage of gas or air in urine) should lead to investigation of possible malignancy or inflammatory bowel disease (colovesical fistula).

Sepsis

Sepsis is a spectrum of disease, where there is a systemic and dysregulated host response to an infection.[22] Presentation ranges from subtle, nonspecific symptoms (e.g., feeling unwell with a normal temperature) to severe symptoms with evidence of multiorgan dysfunction and septic shock. Patients may have signs of tachycardia, tachypnea, hypotension, fever or hypothermia, poor capillary refill, mottled or ashen skin, cyanosis, newly altered mental state or reduced urine output.[23] Sepsis and septic shock are medical emergencies.

Risk factors for sepsis include: age under 1 year, age over 75 years, frailty, impaired immunity (due to illness or drugs), recent surgery or other invasive procedures, any breach of skin integrity (e.g., cuts, burns), intravenous drug misuse, indwelling lines or catheters, and pregnancy or recent pregnancy.[23]

Early recognition of sepsis is essential because early treatment - when sepsis is suspected but is yet to be confirmed - is associated with significant short- and long-term benefits in outcome.[23] However, detection can be challenging because the clinical presentation of sepsis can be subtle and nonspecific. A low threshold for suspecting sepsis is therefore important. The key to early recognition is the systematic identification of any patient who has signs or symptoms suggestive of infection and is at risk of deterioration due to organ dysfunction. Several risk stratification approaches have been proposed. All rely on a structured clinical assessment and recording of the patient's vital signs.[23][24][25]​​​[26] It is important to check local guidance for information on which approach your institution recommends. The timeline of ensuing investigations and treatment should be guided by this early assessment.[26]

Treatment guidelines have been produced by the Surviving Sepsis Campaign and remain the most widely accepted standards.[27][28] Recommended treatment of patients with suspected sepsis is:

  • Measure lactate level, and remeasure lactate if initial lactate is elevated (>2 mmol/L).

  • Obtain blood cultures before administering antibiotics.

  • Administer broad-spectrum antibiotics (with methicillin-resistant Staphylococcus aureus [MRSA] coverage if there is high risk of MRSA) for adults with possible septic shock or a high likelihood for sepsis.

  • For adults with sepsis or septic shock at high risk of fungal infection, empiric antifungal therapy should be administered.

  • Begin rapid administration of crystalloid fluids for hypotension or lactate level ≥4 mmol/L. Consult local protocols.

  • Administer vasopressors peripherally if hypotensive during or after fluid resuscitation to maintain MAP ≥65 mm Hg, rather than delaying initiation until a central venous access is secured. Norepinephrine (noradrenaline) is the vasopressor of choice.

  • For adults with sepsis-induced hypoxemic respiratory failure, high flow nasal oxygen should be given.

Ideally these interventions should all begin in the first hour after sepsis recognition.[28]

For adults with possible sepsis without shock, if concern for infection persists, antibiotics should be given within 3 hours from the time when sepsis was first recognized.[27] For adults with a low likelihood of infection and without shock, antibiotics can be deferred while continuing to closely monitor the patient.[27]

Pyelonephritis and other considerations

Lower urinary tract infection (UTI) may develop into pyelonephritis, particularly in patients with diabetes or those who are immunosuppressed. Patients with pyelonephritis have symptoms of fever, flank pain, and nausea or vomiting. Assess the patient for signs of sepsis, collect a midstream urine specimen (for dipstick analysis, microscopy, and culture), and then administer empiric antibiotic therapy.​[12][29]​​​ If sepsis is suspected, take two sets of blood cultures and then administer empiric antibiotic therapy.[12]

Untreated sexually transmitted infections may result in complications such as pelvic inflammatory disease, epididymitis, prostatitis, sexually acquired reactive arthritis, and infertility.

Pregnancy should be excluded in women, as an untreated UTI is associated with premature labor and low-birthweight babies.[30]

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