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Editorial: Predicting sepsis after percutaneous nephrolithotomy

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In this month’s BJUI, Chen et al. [1] report on a large series of percutaneous nephrolithotomy (PCNL) procedures from Guangzhou in China. The authors studied patients who developed postoperative urosepsis and looked for any predictive factors that would herald impending sepsis.

In this latest report, the authors analysed 802 patients with complex kidney stones undergoing PCNL in a single centre. ‘Complex’ was defined as complete staghorn, partial staghorn or pelvic stone with at least two calyceal stones. Midstream urines (MSU) were collected and analysed for white blood cells (WBC) and nitrites (NIT). Antibiotics were given preoperatively if the urine culture (UC) was positive for WBC (WBC+) or NIT (NIT+). Standard single‐dose antibiotic was given on induction of anaesthesia and only continued for 48 h if the culture was positive. Stone cultures (SCs) were routinely collected. Of the 802 patients, UCs were positive (UC+) in 171 (21%) and SCs subsequently positive (SC+) in 30%. Postoperatively, 98 (12%) developed a fever, 62 (7.7%) developed systemic inflammatory response syndrome (SIRS), and 19 (2.4%) developed sepsis as defined by the quick Sequential (sepsis‐related) Organ Failure Assessment (qSOFA).

Multiple factors were significantly associated with sepsis: female sex (79% vs 40%), infection stone (47% vs 21%), long operating time ≥100 min (74% vs 45%), multiple accesses (32% vs 10%), UC+ (63% vs 20%), SC+ (89% vs 29%), fever (74% vs 11%), as well as being both WBC+ and NIT+ (63% vs 13%). Conversely, if WBC and NIT were negative (WBC–NIT–) the risk of sepsis was only 5.3%. On multivariate analysis SC+ (odds ratio [OR] 8.0), operating time ≥100 min (OR 4.4), WBC+ and NIT+ (OR 3.9), UC+ (OR 3.2), were independent risk factors for sepsis. Not surprisingly having UC+, SC+ or both showed a statistically higher incidence of fever, SIRS, and sepsis. Being WBC+ and NIT+ was the best predictor of having both UC+ and SC+ with an impressive 92% sensitivity and 98% specificity.* Similarly, WBC+ and NIT+ was the best predictor of sepsis with 92% sensitivity and 82% specificity. The absolute risk of sepsis was only 0.2% if WBC–NIT–, 2.8% if only one was positive, and 10% if WBC+NIT+.

The authors also report on the bacterial findings of the UCs and SCs. In the SCs, Escherichia coli (44%), Proteus mirabilis (14%) and Staphylococcus (7.4%) were the most common; whilst in the UCs, E. coli (54%), Enterococcus (9.4%) and P. mirabilis (7.6%) were predominant. It is important to remember the potential differences when interpreting UCs preoperatively and to ensure broad‐spectrum cover is given and this justifies the sending of SCs, particularly in high‐risk patients [1].

The recognition of early sepsis is paramount and has been recognised in previous studies leading to the ‘golden hour’, when early aggressive treatment of the infection has been shown to lead to better outcomes [2]. In a large study by Kumar et al. [2], early antimicrobial administration (within the first hour of hypotension from septic shock) led to a higher overall survival; but worryingly, only 50% of patients received appropriate antibiotics within 6 h. Thus, if high‐risk patients could be predicted then closer monitoring, aggressive fluid management, and early broad‐spectrum antibiotics with intensive care support could be targeted at those specific patients.

There are multiple definitions for infection, e.g., sepsis, severe sepsis, septic shock, and SIRS. The 2016 International Consensus attempted to clarify these and defined sepsis as ‘A life‐threatening organ dysfunction due to dysregulated host response to infection’ [3]. They found the term ‘severe sepsis’ to be obsolete. Septic shock is defined as ‘a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone’ [3]. The Consensus recommended organ dysfunction is assessed by a SOFA score increase of ≥2, as this is associated with a mortality of 10%. This then led to the bedside assessment clinical score called qSOFA. Poorer outcomes were associated with two or more of the qSOFA criteria: respiratory rate ≥22 breaths/min, altered mentation (as judged by the Glasgow Coma Scale), and systolic blood pressure ≤100 mmHg.

In this current study [1], many of the factors associated with postoperative sepsis are logical and have been demonstrated before, e.g., female sex, infection stone, prolonged operating times, and multiple accesses. This paper has shown that careful attention to the preoperative urine dipstick can provide important prediction of potential severe infective complications postoperatively. In an era of antibiotic stewardship this could help guide targeted preoperative and prolonged postoperative antibiotics for a small group of patients, whilst managing WBC–NIT– patients with standard prophylaxis only. The high‐risk group should also be observed very closely postoperatively and moved to a high‐dependence setting rapidly if clinical signs of sepsis develop. It would also suggest that in this high‐risk group, operating times and intra‐renal pressure should be minimised. It may be that in these patients it is better to use larger tract PCNL sizes to allow rapid fragmentation and evacuation of the stone and that consideration should be given to staged procedures in complicated stones where multiple access is being considered to minimise operating time and allow analysis of intraoperative SCs.

It should of course be remembered that antibiotic decisions should be based on local policies and sensitivities, which may be very different from this population. Rapid treatment of sepsis is paramount and the most recent ‘Hour‐1’ bundle provides the most up‐to‐date guidance for immediate resuscitation and management with lactate management, blood cultures, broad‐spectrum antibiotics, i.v. fluids, and early use of vasopressors if the blood pressure does not respond to fluid replacement [4].

by Matt Bultitude and Kay Thomas

References

  1. Chen, D, Jiang, C, Liang, X et al. Early and rapid prediction for postoperative infections following percutaneous nephrolithotomy in patients with complex kidney stones. BJU Int 2019; 123: 1041– 7
  2. 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. Crit Care Med 2006; 34: 1589– 96
  3. Singer, M, Deutschman, CS, Seymour, CW et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis‐3). JAMA 2016; 315: 801– 10
  4. Levy, MM, Evans, LE, Rhodes, A. The surviving sepsis campaign bundle: 2018 update. Crit Care Med 2018; 46: 997– 1000

*FileS1; FileS2

 

Article of the Week: NICE Guidance. Sepsis – recognition, diagnosis and early management

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Every Week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this month, it should be this one.

Sepsis: recognition, diagnosis and early management

 

Overview
This guideline covers the recognition, diagnosis and early management of sepsis for all populations. The guideline
committee identified that the key issues to be included were: recognition and early assessment, diagnostic and prognostic value of blood markers for sepsis, initial treatment, escalating care, iden tifying the source of infection, early monitoring, information and support for patients and carers, and training and education.
Who is it For?
•People with sepsis, their families and carers.
•Healthcare professionals working in primary, secondary and tertiary care. Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in
your care [https://www.nice.org.uk/about/nice-communities/public-involvement/your-care].Making decisions  using NICE guidelines [https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/using-NICE-guidelines-to-make-decisions] explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

 

More Information
You can also see this guideline in the NICE pathway on sepsis [https://pathways.nice.org.uk/pathways/sepsis].
To find out what NICE has said on topics related to this guideline, see our web page on infections [https://www.nice.org.uk/guidance/conditions-and-diseases/infections]. See also the guideline committee’s discussion and the evidence reviews (in the full guideline [https://www.nice.org.uk/Guidance/NG51/evidence]), and information about how the guideline was developed [https://www.nice.org.uk/Guidance/NG51/documents], including details of the committee. Recommendations for Research The guideline committee has made the following recommendations for research.

 

Read the full article

© NICE (2017) Sepsis: recognition, diagnosis and early management

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Article of the Week: Ureteric stent dwelling time: a risk factor for post-ureteroscopy sepsis

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Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Ureteric stent dwelling time: a risk factor for post-ureteroscopy sepsis

Amihay Nevo*†, Roy Mano*†, Jack Baniel*† and David A. Lifshitz*†

 

*Department of Urology, Rabin Medical Centre, Petach Tikva, Israel, and †Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

 

 
Read the full article

Abstract

Objectives

To evaluate the association between stent dwelling time and sepsis after ureteroscopy, and identify risk factors for sepsis in this setting.

Patients and Methods

The prospectively collected database of a single institution was queried for all patients who underwent ureteroscopy for stone extraction between 2010 and 2016. Demographic, clinical, preoperative and operative data were collected. The primary study endpoint was sepsis within 48 h of ureteroscopy. Logistic regressions were performed to identify predictors of post-ureteroscopy sepsis in the ureteroscopy cohort and specifically in patients with prior stent insertion.

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Results

Between October 2010 and April 2016, 1 256 patients underwent ureteroscopy for stone extraction. Risk factors for sepsis included prior stent placement, female gender and Charlson comorbidity index. A total of 601 patients had a ureteric stent inserted before the operation and were included in the study cohort, in which the median age was 56 years, 90 patients were women (30%), and 97 patients were treated for positive preoperative urine cultures (16.1%). Postoperative sepsis, <48 h after surgery, occurred in eight (1.2%) non-stented patients and in 28 patients (4.7%) with prior stent insertion. Sepsis rates after stent dwelling times of 1, 2, 3 and >3 months were 1, 4.9, 5.5 and 9.2%, respectively. On multivariate analysis, stent dwelling time, stent insertion because of sepsis, and female gender were significantly associated with post-ureteroscopy sepsis in patients with prior stent placement.

Conclusions

Patients who undergo ureteroscopy after ureteric stent insertion have a higher risk of postoperative sepsis. Prolonged stent dwelling time, sepsis as an indication for stent insertion, and female gender are independent risk factors. Stent placement should be considered cautiously, and if inserted, ureteroscopy should be performed within 1 month.

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Editorial: Pre-stenting and the risk of postoperative sepsis: a shorter dwell time is better

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In this edition of the BJUI, Nevo et al. [1] report their retrospective review of 1256 patients who underwent ureteroscopy (URS)/flexible ureterorenoscopy (FURS) for stone disease and identified an overall sepsis rate of 2.8% within 48 h of surgery. About half of the cohort had a previously placed JJ stent, and the key finding of the study was the association between this and postoperative sepsis. In particular, the risk of sepsis in unstented patients was 1.2%, compared with 4.7% in those with a stent, such that overall, 80% of the patients who developed sepsis had a prior JJ stent in situ. Furthermore, this risk increased cumulatively with longer stent dwell-time before definitive surgery, increasing the risk of sepsis to 9.2% in patients who had a stent in situ for >3 months before the treatment of their stone.

Pre-stenting before ureteroscopic stone treatment can be for ‘absolute’ reasons (e.g. achieving ureteric drainage following presentation with an obstructed/infected kidney, or for an inaccessible ureter during the initial attempt at ureteroscopic stone treatment) or ‘relative’ reasons (e.g. emergency pain relief from ureteric colic if stone clearance cannot be offered immediately, or strategically inserted to allow passive ureteric dilatation to facilitate a subsequent definitive procedure). Data from the Clinical Research Office of the Endourological Society (CROES) URS Global Study showed that pre-stenting occurred in 36.4% of patients with rena l stones, and was associated with an increased stone-free rate (SFR), with a small but significant decrease in intraoperative complications. Pre-stenting was less common in ureteric stone management (11.9% of 8189 patients) and showed no difference in the SFR or complications, but was associated with a shorter length of stay [2]. Similarly, Jessen et al. [3] have reported that pre-stenting conferred a significant improvement in SFR for renal stones (83% vs 60%) but not for ureteric stones (94% vs 90%), although complications were reduced for pre-stented vs unstented patients in both renal stones (8.7% vs 19.4%) and ureteric stones (3.1% vs 10.7%) in that study. The advantage of pre-stenting appears to be greatest for larger stones: as a consequence of ureteric dilatation, and therefore improved renal access, in patients with stones >1 cm in whom a multi-phased approach was anticipated, Chu et al. [4] found that pre-stenting significantly reduced the operative time of the first URS, as well as the total operative time to stone clearance, including the need to re-operate at all in some patients.

The study in this edition of the BJUI [1] has shown that these advantages must be balanced against the increased risk of postoperative sepsis in patients with a pre-placed JJ stent, particularly in cases where the stent has been in situ for >1 month. The ability to identify patients who are at greater risk of post-URS/FURS infections is clearly useful: female gender, diabetes mellitus, ischaemic heart disease, an American Society of Anesthesiologists (ASA) score of ≥II, a large-volume stone burden, and same-session bilateral URS, have already been established as significant risk factors for postoperative infection [5, 6]. In addition, preoperative infections, either as a positive midstream specimen of urine (MSU) or previous sepsis also increase the risk of postoperative infectious complications. Specifically, Blackmur et al. [6]reported that patients with a positive preoperative MSU were about five-times more likely to have postoperative urosepsis, even if they had been treated with an appropriate course of antibiotics before their stone surgery. Consistent with this, Youssef et al. [7] reported that the complication rate in patients undergoing URS after previous sepsis increased to 20% compared to 7% in matched non-septic controls, with an associated increased length of stay and duration of postoperative antibiotics.

In the present article [1], the overall sepsis rate was low at 2.8%, (and was comparable to recent CROES data that reported an overall prevalence of postoperative fever/UTI after URS or FURS of ≤2.2% [5]), but patients who had stents inserted for sepsis in the presence of an obstructing stone had a four-times higher postoperative infection rate when their stones were eventually treated than pre-stented patients without prior sepsis [1].

Taken together, these studies suggest that pre-stenting may have value in improving SFR, total operation time and reducing complication rates for large renal stones (i.e. >1 cm), but offers less advantage to stone clearance rates or complications in ureteric stones. Given the findings of increased risk of sepsis with stent-dwell time (increasing from 2.2% at 30 days, to 4.9% at 60 days, 5.5% at 90 days and 9.2% for >90 days) the authors recommendation ‘to keep stent dwelling time as short as possible’, is both practically beneficial to the patient and evidence-based. Furthermore, in addition to an awareness of the recognised risk factors for postoperative sepsis mentioned above, patients who have had stents inserted for prior sepsis, patients with positive preoperative MSU (even if treated), and patients with prolonged stent duration before definitive treatment should be counselled of the greater risk of postoperative sepsis, and watched cautiously in the early postoperative period.

In this study [1], patients with a stent in situ for <1 month had a similar risk of UTI to unstented patients. It would therefore seem reasonable to conclude that patients who have a stent inserted, especially for more ‘relative’ reasons to facilitate future surgery, should be scheduled for their definitive procedure within a month to achieve the benefits of pre-stenting, whilst minimising the potential for postoperative septic complications that Nevo et al. [1] have highlighted.

Daron Smith

 

Institute of Urology, University College Hospital, London, UK

 

 
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References

 

1 Nevo A, Mano R, Baniel J, Lifshitz D. Ureteric stent dwelling time: a risk factor for post-ureteroscopy sepsis. BJU Int 2017; 120: 117–22

 

2 Assimos D, Crisci A, Culkin D et al. Preoperative JJ stent placement in ureteric and renal stone treatment: results from the Clinical Research Office of Endourological Society (CROES) ureteroscopy (URS) Global Study. BJU Int 2016;117:648–54.

 

3 Jessen JP, Breda A, Brehmer M et al. International collaboration in endourology: multicenter evaluation of prestenting for ureterorenoscopy. J Endourol 2016; 30: 268–73

 

4 Chu L, Sternberg KM, Averch TD. Preoperative stenting decreases operative time and reoperative rates of ureteroscopy. J Endourol 2011; 25: 751–4

 

5 Martov A, Gravas S, Etemadian M et al. Postoperative infection rates in patients with a negative baseline urine culture undergoing ureteroscopic stone removal: a matched case-control analysis on antibiotic prophylaxis from the CROES URS global study. J Endourol 2015; 29: 171–80

 

6 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 Endourol 2016; 30: 963–9

 

7 Youssef RF, Neisius A, Goldsmith ZG et al. Clinical outcomes after ureteroscopic lithotripsy in patients who initially presented with urosepsis: matched pair comparison with elective ureteroscopy. J Endourol 2014; 28:

 

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