›Class IIa recommendation
›Monitor for ischemic complications
›Stress-dose corticosteroids
›Hydrocortisone IV for vasopressor-refractory septic shock
›200 mg/day continuous infusion or 50 mg IV every 6 hours
›Duration 5-7 days with taper
›Class IIa recommendation when vasopressors not reducing
Empiric antibiotic therapy
›Risk stratification for antibiotic selection
›Step 1: Severity of illness assessment
›Septic shock requires broader initial coverage
›Sepsis without shock may allow narrower initial spectrum
›Step 2: MDR risk factor assessment
›Prior ESBL or carbapenem-resistant organism
›Prior antibiotic exposure within 90 days
›Healthcare contact or nursing home residence
›Step 3: Patient-specific factors
›Antibiotic allergies
›Renal function for dose adjustment
›Step 4: Local antibiogram data
›Institution-specific E. coli resistance patterns
›IDSA 2025 cUTI guideline 4-step approach
›Non-MDR-risk patients (community-onset)
›Ceftriaxone IV
›1-2 g IV every 24 hours
›First-line for non-severe urosepsis without MDR risk
›Renal dose adjustment if CrCl <30 mL/min
›Piperacillin-tazobactam IV
›4.5 g IV every 6 hours
›Extended infusion over 4 hours per local protocol
›Broader gram-negative coverage including Pseudomonas
›Fluoroquinolone IV (if culture susceptible)
›Ciprofloxacin 400 mg IV every 8-12 hours
›Avoid as empiric if local E. coli resistance >10-20%
›Reserve for confirmed susceptibility
›MDR-risk patients or septic shock
›Meropenem IV
›1 g IV every 8 hours (standard dosing)
›2 g IV every 8 hours extended infusion for severe sepsis
›Drug of choice for ESBL-producing organisms
›Ertapenem IV
›1 g IV every 24 hours
›No Pseudomonas coverage
›Alternative for ESBL without Pseudomonas risk
›If Enterococcus suspected (indwelling catheter, prior cultures)
›Add ampicillin 2 g IV every 4 hours if susceptible
›Vancomycin 15-20 mg/kg IV every 8-12 hours for VRE or ampicillin-resistant Enterococcus
›AUC-guided vancomycin monitoring
De-escalation and oral step-down
›Culture-directed de-escalation
›Narrow spectrum once susceptibilities available
›Typically 48-72 hours after cultures reported
›ACEP Level A recommendation for antibiotic stewardship
›Oral step-down when clinically improving
›Afebrile for >=24 hours
›Hemodynamically stable
›Able to tolerate oral medications
›Preferred oral step-down agents
›Trimethoprim-sulfamethoxazole 160/800 mg PO every 12 hours (if susceptible)
›Ciprofloxacin 500 mg PO every 12 hours (if susceptible)
›Amoxicillin-clavulanate 875 mg PO every 12 hours for susceptible organisms
›Total duration of therapy
›Uncomplicated pyelonephritis and urosepsis
›10-14 days total (IV plus oral)
›7 days acceptable if rapid clinical response and appropriate oral agent
›Complicated urosepsis with obstruction
›14-21 days depending on source control adequacy
›Longer if abscess or persistent structural issue
›Do not use nitrofurantoin or oral fosfomycin
›Inadequate serum and tissue levels for systemic infection
›Appropriate only for uncomplicated lower UTI
›Urgent urologic decompression
›Obstructive uropathy with urosepsis
›Emergent ureteral stent placement
›Percutaneous nephrostomy as alternative
›Should not be delayed for antibiotic response
›Timing of source control
›Ideally within 6-12 hours of urosepsis recognition with obstruction
›Class I recommendation
›Mortality increases with decompression delay
›Pyonephrosis
›Emergent percutaneous nephrostomy
›Pus drainage and culture
›Definitive stone treatment deferred until infection cleared
›Abscess drainage
›Renal abscess >3 cm
›Percutaneous drainage preferred
›Antibiotics alone for <3 cm in select stable patients
›Prostatic abscess
›Transrectal or transperineal ultrasound-guided drainage
›Surgical TURP or open drainage if large or loculated
›Catheter-associated urosepsis
›Remove or replace indwelling urinary catheter if present
›Culture new catheter specimen if replaced