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1. CASE PRESENTATION ON UROSEPSIS PRESENTED BY: RASHEDA FATIMA 170721882014 Pharm-D 3rd Year PRESENTED TO : DR.ZEENATH UNNISA ASST.PROFESSOR,DSOP.

2. UROSEPSIS :- DEFINITION : What Is Urosepsis? Urosepsis is when an untreated UTI spreads through your urinary tract to your kidney (pyelonephritis) and causes sepsis. It can also be caused by a  bladder infection  (cystitis), although cystitis rarely causes sepsis by itself. ‌ A UTI is when your urinary tract is infected. This can be caused by bacterial or fungal infections and is typically easy to treat. You can get a UTI through sexual activity, unsanitary conditions, or wiping after going to the washroom. Sepsis is an often dangerous condition that happens when your body damages its own tissues while responding to infection. In some cases, sepsis may develop into septic shock , which is a dramatic drop in  blood pressure  that can lead to organ dysfunction and death. ‌ Even though most people recover from mild sepsis, the mortality rate for septic shock is around 40%. Having severe sepsis will also make you more likely to develop infections in the future. Sepsis in the body’s extreme reaction to infection. The body attacks its own organs and tissues, which can lead to tissue damage, organ failure, and death. However, with early diagnosis sepsis can be treated with antibiotics and fluids. Severe sepsis occurs when one or more of your body’s organs is damaged from this inflammatory response. Any organ can be affected, your heart, brain, kidneys, lungs, and/or liver. The symptoms you can experience are based on which organ or organs that are affected. For example, if your lungs are damaged, your breathing is affected, if your kidneys are damaged, your ability to urinate is affected, and so on. People with severe sepsis can also develop a condition called  acute respiratory distress syndrome  (ARDS).

3. EPIDEMIOLOGY : I n the United States, the number of sepsis cases appears to be increasing over the last 30 to 40 years, but the overall mortality of patients from sepsis has declined. It is estimated that the mortality rate from urosepsis is 30% to 40%. The severity of the disease also appears to be increasing and is typically associated with acute respiratory distress syndrome (ARDS), acute kidney injury, and disseminated intravascular coagulopathy (DIC). ETIOLOGY : Urosepsis is caused by a bacterial infection of the urinary tract or prostate that spreads into the bloodstream. Even if you are in general good health, many of the bacteria that cause urosepsis can normally occur in your intestines. Post surgical infection Skin infection (cellulites ) Flu (influenza) Lining of GI system (peritonitis) COMMUNITY ACQUIRED UTI Escherichia coli derived from GIT ( 75% OF Infection ) proteus staphylococcus epidermidis HOSPITAL ACCQUIRED UTI E.coli Streptococci

4. A number of factors increase the risk of developing urosepsis. Not all people with risk factors will get urosepsis. Risk factors for urosepsis include: Advanced age Compromised immune system due to such conditions as  HIV  and  AIDS , taking corticosteroids, organ transplant, or cancer and  cancer  treatment Diabetes Fecal incontinence (inability to control stools) Female gender Immobility Incomplete bladder emptying or urinary retention Polycystic kidney disease Pregnancy Surgeries or procedures involving the urinary tract Urinary tract obstruction by stones, an enlarged prostate, urethral scarring, or other causes Use of catheters to drain urine RISK FACTORS

5. CLINICAL PRESENTATION : What are the potential complications of urosepsis? Disseminated intravascular coagulation (DIC; a clotting disorder leading to the formation of multiple  blood clots  in the bloodstream) Kidney damage Kidney or other organ failure Perirenal abscesses (collections of pus near the kidneys) Prostatic abscesses (collections of pus in the prostate) Renal abscesses (collections of  pus  in the kidneys) Scarring of the urinary tract Shock

6. Diagnosis. Sepsis is diagnosed by a medical professional following a physical examination, evaluation of medical history, and blood tests. D emonstration of an infection, or clinical suspicion of infection in the presence of “some” of the following criteria: General signs Fever >38.3°C Hypothermia <36°C Tachycardia >90/min or >2 SD above age-specific normal value Tachypnea >30/min Impaired neurologic status Edema or positive fluid balance (>20 mL/kg/d) Hyperglycemia (blood sugar >120 mg/dL or 7.7 mmoL /L) in the absence of previously diagnosed diabetes mellitus Signs of inflammation Leukocytosis >12/ nL Leukopenia <4/ nL Normal leukocyte count with >10% immature forms C- reaktive protein >2 SD above normal Procalcitonin >2 SD above normal Hemodynamic signs Hypotension (SBP <90 mm Hg, MAP <70 mm Hg or SBP drop by >40 mm Hg or to <2 SD below the age-specific normal value) Cardiac index (CI) >3–5 L/min/m 2 Organ dysfunction Arterial hypoxemia (p a O 2 /F i O 2 <300) Acute oliguria <0.5 mL/kg/h or 45 mmoL /L for (≥ 2h Creatinine rise by (≥ 0.5 mg/dL Coagulopathy (INR >1.5 or aPTT > 60 s) Thrombocytopenia <100/ nL Hyperbilirubinemia (total bilirubin >4 mg/dL or >70 mmoL /L) Ileus

7. PATIENT DEMOGRAPHICS: PATIENTS NAME: Mrs.XYZ AGE: 60 years GENDER: Female UNIT: NEPHROLOGY IP NUMBER: R12 3 01- 0021224 DATE OF ADMISSION: 06/ 12/ 2 3 DATE OF DISCHARGE: NOT YET DISCHARGE

8. SOAP FORMAT SUBJECTIVE:- A 60year old female patient was admitted in NEPHROLOGY department with chief complaints of FEVER and chills followed by Nausea and vomiting's . CHIEF COMPLAINTS : Fever nausea chills and vomiting . HISTORY OF PRESNT ILLNESS : Hypertension since 1 year PAST HISTORY : Non smoker No consumption of alcohol PERSONAL HISTORY : Non smoker ,no consumption of alcohol , Diet: mixed( non veg ) allergies : not known

9. PROVISIONAL DIAGNOSIS: RECURRENT UTI ( UROSEPSIS )

10. LABORATORY INVESTIGATIONS: HAEMATOLOGY Haemoglobin – 7.8gm/dl RBC Count : 4,620.000/L Total WBC : 8,900/L Neutrophils : 74% Eosinophils: 0.1% Basophils :0.8% Monocytes: 5.8% Platelet count : 2, 940,000/L SERUM ELECTROLYTES : Sodium Na -140mEq/L Potassium K-4.5 mEq/L Chloride Cl – 100 mEq/L URINE ANALYSIS Color : yellow SERUM CREATININE : 4.3 NORMAL VALUE (0.6-1.5) Urea :8.3 normal value (10-45) Uric acid :6.1 normal value (3.5- 7.0) Other investigations : CTKUB SCAN

11. FINAL DIAGNOSIS: UROSEPSIS PYELONEPHRITIS

12. VITALS:- VITALS DAY-1 DAY-2 DAY-3 TEMP. 102 100 AFEBRILE BP (mm/Hg) 140/90 110/70 110/80 PULSE (b/min) 90 86 82 RR ( /min) 22 21 22

13. DAY NOTES:- DAY NOTES DAY-2 DAY-3 DAY-4 C/O FEVER CHILLS nausea vomiting JOINT PAIN NAUSEA Tenderness decreased no No fever O/E Pt. Conscious, B.P:130/80mmHg LUMBAR TENDERNESS NO PEDAL EDEMA NO VOMITING NO NAUSEA ADV CTKUB ,RFT CBP RFT Rx TAB STAMLO TAB THYRONORM TAB CINIZOL CST ADDED INJ HUMAN MIXTARD INJ OPTINEURON CST

14. Treatment. Sepsis is a medical emergency. Early diagnosis and treatment of sepsis significantly increases one’s chances of survival. Sepsis is treated with antibiotics and IV fluids. In most cases broad-spectrum antibiotics will be administered. Once blood tests have been performed, antibiotics that target the particular strain of bacterium responsible for the infection may be used. Common treatments for urosepsis Common treatments for urosepsis include: Blood transfusions if necessary Drainage of abscesses if present Initial treatment with broad-spectrum antibiotics to fight the most likely infectious organisms Intravenous fluids to maintain blood volume and blood pressure support Lithotripsy  to break up kidney or bladder stones if present Mechanical ventilation if needed Medications (vasopressors) to increase blood pressure Monitoring and maintenance of blood sugar Oxygen therapy to maintain blood oxygenation Removal of any catheters or other devices that may be infected Targeted antibiotic therapy to treat specific bacteria once culture results are available

15. TREATMENT CHART DOSAGE FORMF DRUG GENERIC NAME DOSE ROUTE FREQ. DAY 1 DAY 2 DAY 3 INJ INJ PIPTAZ PIPERACILLIN 2.2gm IV TID ✓ ✓ ✓ INJ INJ PAN PANTOPRAZOLE 40mg IV TID ✓ ✓ ✓ INJ INJ ZOFER ONDANSETRON 4mg IV TID ✓ ✓ ✓ TAB STAMLO AMLODIPINE 5mg oral OD(0-0-1) ✓ ✓ ✓ INJ PERINORM METOCLOPRAMIDE 23mg IV TID ✓ ✓ ✓ INJ MIXTARD INSULIN 300mg IV BD - ✓ ✓ TAB THYRONORM LEVOTHROXINE 50mg ORAL OD ✓ ✓ ✓ TAB LINEZOLID OXAZOLIDINONE 400mg ORAL BD - ✓ ✓ INJ METROZYLE METRONIDAZOLE 500mg/100ml IV BD - ✓ ✓

16. ASSESSMENT:- Problem: to treat bacterial infections Medication : INJ PIPTAZ Problem acidity, heartburn, acid reflux and pain in swallowing . Medication : INJ PAN Problem nausea and vomiting Medication : INJ ZOFER Problem   to control blood sugar in people who have type 1 diabetes Medication: INJ MIXTARD Problem : (hypertension) Medication: TAB STAMLO Problem Depression ,Diarrhea ,Decreased level of consciousness Medication : INJ PERINORM Problem Hypothyroidism Medication :TAB THYRONORM

17. PLAN INJ DOSAGE FORMF DRUG GENERIC NAME DOSE ROUTE FREQ. INJ INJ PIPTAZ PIPERACILLIN 2.2gm IV TID INJ INJ PAN PANTOPRAZOLE 40mg IV TID INJ INJ ZOFER ONDANSETRON 4mg IV TID TAB STAMLO AMLODIPINE 5mg oral OD(0-0-1) INJ PERINORM METOCLOPRAMIDE 23mg IV TID INJ MIXTARD INSULIN 300mg IV BD

18. PATIENT COUNSELLING: REGARDING DIASEASE: . Urosepsis is more common in women than in men, and is more likely to occur in the elderly or people who have weakened immune systems or conditions such as  diabetes . urosepsis is sepsis that complicates a urinary tract infection. Urosepsis requires treatment with antibiotics and may require supportive therapies such as intravenous fluids and oxygen. If undiagnosed or untreated, urosepsis can progress to  septic shock , a serious and life-threatening condition complicated by dropping blood pressure, rapid heart and breathing rates, decreasing urine output, and alterations in mental status. . ABOUT THE MEDICATIONS: Take medicines prescribed properly don’t refill prescription unless advised . Inform the physician for ant side effects . Don’t double the dose if missed .

19. REGARDING LIFE STYLE MODIFICATIONS: Lifestyle changes that can help with healing include: Passing urine when the urge is felt instead of holding it back, which may cause bacteria to grow Passing urine and drinking water after sex Washing genitals daily Wiping from front to back after a bowel movement (women) Not using douches and feminine sprays (women)

20. Prevention. The risk of developing sepsis can be reduced by practicing good hygiene, including washing hands regularly, caring for even minor cuts and scrapes using basic first aid techniques (especially keeping wounds clean), and by staying up to date on vaccinations.

21. THANK YOU!