Community-onset urosepsis: incidence and risk factors for 30-day mortality – a retrospective cohort study

Figures & data

Figure 1. Flow chart with the number of bloodstream infection episodes and the number of eligible urosepsis patients (n = 282), divided into non-survivors (n = 38) and survivors (n = 244).

Table 1. Demographics, comorbidity, and comparison of patients according to 30-day all-cause mortality in a cohort of 282 urosepsis patients.

	Total (n = 282)	Non-survivors (n = 38)	Survivors (n = 244)
Demographics
Male (%)	164 (58)	26 (68)	138 (57)
Mean age (SD)	72 y (±14)	76 y (±10)	71 y (±14)
Surgery within 30 days (%)	25 (9)	6 (16)	19 (8)
Comorbidity (%)
Myocardial infarction	37 (13)	5 (13)	32 (13)
Congestive heart failure	65 (23)	8 (21)	57 (23)
Peripheral vascular disease	14 (5)	1 (3)	13 (5)
Cerebrovascular disease	32 (11)	4 (11)	28 (11)
Dementia	11 (4)	1 (3)	10 (4)
Chronic pulmonary disease	41 (15)	5 (13)	36 (15)
Connective tissue or rheumatic disease	25 (9)	4 (11)	21 (9)
Peptic ulcer disease	6 (2)	1 (3)	5 (2)
Mild liver disease	8 (3)	2 (5)	6 (2)
Diabetes without chronic complications	51 (18)	9 (24)	42 (17)
Diabetes with chronic complications	47 (17)	8 (21)	39 (16)
Paraplegia and hemiplegia	10 (4)	1 (3)	9 (4)
Renal disease	50 (18)	8 (21)	42 (17)
Cancer	50 (18)	9 (24)	41 (17)
Moderate or severe liver disease	14 (5)	2 (5)	12 (5)
Metastatic carcinoma	24 (9)	6 (16)	18 (7)
HIV/AIDS	–	–	–
Charlson Comorbidity Score (SD)
Charlson (weighted)	2.8 (2.5)	3.5 (2.5)	2.7 (2.4)
Charlson (weighting updated)	2.2 (1.9)	2.9 (2.3)	2.2 (2.2)
Sepsis (%)
Sepsis on admission	259 (92)	36 (95)	223 (91)
Sepsis at 24 h	272 (96)	38 (100)	232 (95)

Data presented as n (%) or mean (SD).

Table 2. Comparison of clinical characteristics of non-survivors and survivors in community-onset urosepsis.

	Non-survivors	Survivors	p-value
	(n = 38)	(n = 244)
Presence of urinary catheter before admission (%)	5 (13)	36 (15)	0.80
Nephrostomy	2 (5)	8 (3)	0.54
Indwelling catheter	2 (5)	18 (7)	0.64
Intermittent catheter	1 (3)	10 (4)	0.66
Vital signs (SD)^a
Body temp, °C (BT)	37.4 (1.2)	38.3 (1.3)	<0.01*
Systolic blood pressure, mmHg (SBP)	105 (26)	133 (27)	<0.01*
Diastolic blood pressure, mmHg (DBP)	64 (16)	71 (18)	0.02*
Pulse rate, BPM (HR)	102 (25)	98 (21)	0.29
Respiration rate, BPM (RR)	26 (9)	22 (7)	<0.01*
O2 saturation (SPO2)^b	95 (5)	95 (4)	> 0.99
Reaction level scale (RLS)	1.3 (0.8)	1.2 (0.5)	0.30
Severity of illness (SD)
Habitual SOFA	0.7 (1.1)	0.4 (0.9)	0.07
SOFA score on admission	3.4 (1.0)	2.5 (0.8)	<0.01*
SOFA score at 24 h	4.3 (2.7)	3.0 (1.3)	<0.01*
Laboratory (SD)^a
C-reactive protein (mg/L)	181 (98)	152 (95)	0.08
White blood cell count (×10^9/L)	12 (9.5)	13 (10.9)	0.59
Platelet count (µmol/L)	185 (134)	205 (123)	0.36
Creatinine (µmol/L)	158 (112)	102 (85)	<0.01*
eGFR MDRD (mL/min/1.73m^b)	34 (17)	53 (22)	<0.01*
Albumin (g/L)	25 (7)	28 (7)	0.01*
Procalcitonin (µg/L)	5 (5.3)	5.4 (5.5)	0.68
CT-scan or ultrasound during hospital stay (%)	32 (84)	142 (58)	<0.01*
Time to CT-scan or ultrasound from admission^c (SD)	885 (511)	622 (460)	<0.01*
Urinary tract disorder (%)	22 (58)	41 (17)	<0.01*
Hydronephrosis/pyelonephritis	19 (50)	24 (10)	<0.01*
Obstructive stone in ureter	12 (32)	14 (6)	<0.01*
Non-obstructive stone in ureter	0	1 (0.5)	–
Urological malignancy	2 (5)	0	–
Emphysematous pyelonephritis	0	1 (0.5)	–
Renal abscess	3 (8)	1 (0.5)	<0.01*
Displaced nephrostomy	2 (5)	2 (1)	0.03
Ureteric stricture	1 (3)	1 (0.5)	0.13
Renal stone	1 (3)	1 (0.5)	0.13
Ureteropelvic junction obstruction	1 (3)	1 (0.5)	0.13
Time to decompression from CT-scan or ultrasound^c (SD)	455 (180) (n19)	305 (146) (n19)	<0.01*
Time to decompression from admission^c (SD)	1212 (494) (n19)	837 (294) (n19)	<0.01*
Time to antibiotics from admission, minutes (SD)	87 (78)	103 (95)	0.32
Correct empirical choice of antibiotics based on local recommendations^d	37 (97)	243 (99)	0.13
Correct empirical choice of antibiotics based on bacterial culture^e	29 (76)	224 (92)	<0.01*
Intravenous fluids in the ED (%)	34 (89)	232 (95)	0.16
ICU admission	11 (29)	44 (18)	0.11
Time to ICU^c (SD)	249 (180)	280 (191)	0.35

Data are presented as n (%) or mean (SD). Pearson Chi^b, Fisher’s exact test or T-test, as appropriate. *p < 0.05 is considered statistically significant.

^aFirst registered on admission. ^bMeasured by pulse oximeter (non-invasive device). ^cDecompression nephrostomy, stent (JJ-catheter), drainage of abscess or nephrectomy. Times in minutes. ^dBased on suspected source of infection, severity of illness, dosage, and correction for renal function. ^eAccording to cultured pathogen and its susceptibility pattern.

LLST, Limited life-sustaining treatment; EoLC, End-of-life care; 0-ICU: Withholding of intensive care; 0-CPR: Withholding of cardiopulmonary resuscitation; ED: Emergency department; BPM: Beats per minute or breaths per minute; SOFA: Sequential Organ Failure Assessment.

Table 3. Distribution of microorganisms in patients with community-onset urosepsis.

	Non-survivors (n = 38)	Survivors (n = 244)		p-value
Monomicrobial BSI	36 (95)	236 (97)		0.80
Polymicrobial BSI	2 (5)	8 (3)		0.80
Gram-negative bacteria	23 (61)	215 (88)		<0.01*
Enterobacterales
Escherichia coli^a	6 (16)	171 (70)		<0.01*
ESBL Escherichia coli.	4 (11)	8 (3)		0.13
Klebsiella pneumoniae^b	0 (0)	14 (6)		0.25
Klebsiella oxytoca^b	2 (5)	2 (1)		0.18
Klebsiella variicola^b	2 (5)	1 (0)		0.10
Enterobacter cloacae^b	3 (8)	5 (2)		0.16
Proteus Mirabilis^b	2 (5)	6 (2)		0.59
Citrobacter spp^b	1 (3)	5 (2)		>0.99
Other than Enterobacterales
Pseudomonas aeruginosa	3 (8)	3 (1)		0.07
Gram-positive bacteria	14 (37)	29 (12)		<0.01*
Enterococci^c
Enterococcus faecalis	8 (21)	10 (4)		<0.01*
Enterococcus faecium	1 (3)	3 (1)		0.88
Staphylococci
Staphylococcus aureus^d	2 (5)	7 (3)		0.70
Staphylococcus spp	0 (0)	3 (1)		>0.99
Streptococcus
Streptococcus agalactiae (GBS)	1 (3)	3 (1)		0.88
Others	2 (5)	3 (1)		0.27

Data are presented as n (%). Pearson Chi² or Fisher’s exact test as appropriate. *p < 0.05 is considered statistically significant. Microorganism from monomicrobial community-onset bloodstream infections (CO-BSIs) and primary microorganism from polymicrobial CO-BSIs are listed.

^aWithout Extended Spectrum Beta-Lactamase (ESBL). ^bNon-ESBL-producing strains were identified. ^cNon-Vancomycin-resistant Enterococci (non-VRE) were identified. ^dNon-Methicillin-Resistant Staphylococcus Aureus (non-MRSA) were identified.

Table 4. Risk factors for 30-day mortality in patients with urosepsis.

	Crude analysis		Multivariable analysis
Risk factor	OR	95% CI	OR	95% CI
Male	2.87	1.38–5.95	0.62	0.16–2.36
Mean age, years,	1.03	1.00–1.07	1.04	1.00–1.08
Charlson score	1.10	0.95–1.24	0.77	0.59–1.02
In-SOFA^a	2.49	1.60–3.88	1.82	1.05–3.16
SOFA score at 24 h^a	1.63	1.32–2.02	1.98	1.29–3.05
CT-scan or ultrasound during the hospital episode	3.83	1.55–9.50	2.65	0.67–10.53
Urinary tract disorder	6.81	3.29–14.07	4.63	1.47–14.56
Inadequate empirical choice of antibiotics^b	3.48	1.45–8.35	4.19	1.41–12.48

^aSeverity of illness as expressed by SOFA score, ^bAccording to cultured pathogen and its susceptibility pattern.

OR, Odds ratio; CI, Confidence interval; SOFA, Sequential Organ Failure Assessment; Charlson score, weighted Charlson Index, comorbidity (see Supplementary Appendix: Table A1).

Data availability statement

All relevant data are within the manuscript and its supplementary files.