Guidelines on Urological Infections M. Grabe (Chairman), T.E. Bjerklund-Johansen, H. Botto, M. Çek, K.G. Naber, P. Tenke, F. Wagenlehner © European Association of Urology 2010 TABLE OF CONTENTS PAGE 1. INTRODUCTION 7 1.1 Pathogenesis of urinary tract infections 7 1.2 Microbiological and other laboratory findings 7 1.3 Classification of urological infections 8 1.4 Aim of guidelines 8 1.5 Methods 9 1.6 Level of evidence and grade of guideline recommendations 9 1.7 References 9 2. UNCOMPLICATED URINARY TRACT INFECTIONS IN ADULTS 11 2.1 Definition 11 2.1.1 Aetiological spectrum 11 2.2 Acute uncomplicated cystitis in premenopausal, non-pregnant women 11 2.2.1 Diagnosis 11 2.2.1.1 Clinical diagnosis 11 2.2.1.2 Laboratory diagnosis 11 2.2.2 Therapy 11 2.2.3 Follow up 12 2.3 Acute uncomplicated pyelonephritis in premenopausal, non-pregnant women 12 2.3.1 Diagnosis 12 2.3.1.1 Clinical diagnosis 12 2.3.1.2 Laboratory diagnosis 12 2.3.1.3 Imaging diagnosis 13 2.3.2 Therapy 13 2.3.2.1 Mild and moderate cases of acute uncomplicated pyelonephritis 13 2.3.2.2 Severe cases of acute uncomplicated pyelonephritis 13 2.3.3 Follow-up 14 2.4 Recurrent (uncomplicated) UTIs in women 16 2.4.1 Diagnosis 16 2.4.2 Prevention 16 2.4.2.1 Antimicrobial prophylaxis 16 2.4.2.2 Immunoactive prophylaxis 16 2.4.2.3 Prophylaxis with probiotics 17 2.4.2.4 Prophylaxis with cranberry 17 2.5 Urinary tract infections in pregnancy 17 2.5.1 Definition of significant bacteriuria 17 2.5.2 Screening 17 2.5.3 Treatment of asymptomatic bacteriuria 17 2.5.4 Duration of therapy 18 2.5.5 Follow-up 18 2.5.6 Prophylaxis 18 2.5.7 Treatment of pyelonephritis 18 2.5.8 Complicated UTI 18 2.6 UTIs in postmenopausal women 18 2.6.1 Risk factors 18 2.6.2 Diagnosis 18 2.6.3 Treatment 18 2.7 Acute uncomplicated UTIs in young men 19 2.7.1 Men with acute uncomplicated UTI 19 2.7.2 Men with UTI and concomitant prostate infection 19 2.8 Asymptomatic bacteriuria 19 2.8.1 Diagnosis 19 2.8.2 Screening 19 2.9 References 26 3. URINARY TRACT INFECTIONS IN CHILDREN 34 3.1 Summary and recommendations 34 3.2 Background 34 2 UPDATE APRIL 2010 3.3 Aetiology 34 3.4 Pathogenesis and risk factors 35 3.5 Signs and symptoms 35 3.6 Classification 35 3.6.1 Severe UTI 36 3.6.2 Simple UTI 36 3.7 Diagnosis 36 3.7.1 Physical examination 36 3.7.2 Laboratory tests 36 3.7.2.1 Collection of urine 36 3.7.2.1.1 Suprapubic bladder aspiration 36 3.7.2.1.2 Bladder catheterization 36 3.7.2.1.3 Plastic bag attached to the genitalia 36 3.7.2.2 Quantification of bacteriuria 36 3.7.2.3 Other biochemical markers 36 3.7.2.3.1 Nitrite 37 3.7.2.3.2 Leucocyte esterase 37 3.7.2.3.3 C-reactive protein 37 3.7.2.3.4 Urinary N-acetyl-ß-glucosaminidase 37 3.7.2.3.5 Interleukin-6 37 3.7.3 Imaging of the urinary tract 38 3.7.3.1 Ultrasonography 38 3.7.3.2 Radionuclide studies 38 3.7.3.3 Cystourethrography 38 3.7.3.3.1 Conventional voiding cystourethrography 38 3.7.3.3.2 Radionuclide cystography (indirect) 38 3.7.3.3.3 Cystosonography 38 3.7.3.4 Additional imaging 38 3.7.3.5 Urodynamic evaluation 39 3.8 Schedule of investigation 39 3.9 Treatment 39 3.9.1 Severe UTIs 39 3.9.2 Simple UTIs 40 3.9.3 Prophylaxis 40 3.10 Acknowledgement 40 3.11 References 41 4. UTIs IN RENAL INSUFFICIENCY, TRANSPLANT RECIPIENTS, DIABETES MELLITUS 45 AND IMMUNOSUPRESSION 45 4.1 Summary 45 4.1.1 Acute effects of UTI on the kidney 45 4.1.2 Chronic renal disease and UTI 45 4.1.2.1 Adult polycystic kidney disease (APCKD) 45 4.1.2.2 Calculi and UTI 46 4.1.2.3 Obstruction and UTI 46 4.1.3 UTI in renal transplantation and immunosuppression 46 4.1.4 Antibiotic treatment for UTI in renal insufficiency and after renal transplantation 46 4.2 Background 46 4.3 Acute effects of a UTI on the kidney 46 4.3.1 Vesicoureteric and intrarenal reflux 46 4.3.2 Obstructive neuropathy 46 4.3.3 Renal effects of severe UTI 47 4.3.4 Acute effects of UTI on the normal kidney 47 4.3.5 Renal scarring 47 4.3.6 Specific conditions in which an acute UTI causes renal damage 48 4.3.6.1 Diabetes mellitus 48 4.3.6.2 Tuberculosis 49 4.4 Chronic renal disease and UTI 49 4.4.1 Adult dominant polycystic kidney disease (ADPK) 49 4.4.2 Renal calculi 49 UPDATE APRIL 2010 3 4.5 UTI in renal transplantation 49 4.5.1 Donor organ infection 50 4.5.2 Graft failure 50 4.5.3 Kidney and whole-organ pancreas transplantation 50 4.6 Antibiotic therapy in renal failure/transplantation 50 4.6.1 Treatment of UTI in renal transplant recipients 51 4.6.2 Fungal infections 52 4.6.3 Schistosomiasis 52 4.7 Immunosuppression 52 4.7.1 HIV infection 52 4.7.2 Viral and fungal infections 52 4.8 References 52 4.8.1 Further reading 56 5. COMPLICATED UTIs DUE TO UROLOGICAL DISORDERS 56 5.1 Summary and recommendations 56 5.2 Definitions and classification 56 5.2.1 Clinical presentation 57 5.2.2 Urine cultures 57 5.3 Microbiology 57 5.3.1 Spectrum and antibiotic resistance 57 5.3.2 Complicated UTIs associated with urinary stones 57 5.3.3 Complicated UTIs associated with urinary catheters 58 5.4 Treatment 58 5.4.1 General principles 58 5.4.2 Choice of antibiotics 58 5.4.3 Duration of antibiotic therapy 59 5.4.4 Complicated UTIs associated with urinary stones 59 5.4.5 Complicated UTIs associated with indwelling catheters 59 5.4.6 Complicated UTIs in spinal-cord injured patients 59 5.4.7 Follow-up after treatment 59 5.5 Conclusions 60 5.6 References 60 6. CATHETER-ASSOCIATED UTIs 61 6.1 Abstract 61 6.2 Summary of recommendations 62 6.3 Reference 63 7. SEPSIS IN UROLOGY (UROSEPSIS) 63 7.1 Summary and recommendations 63 7.2 Background 64 7.3 Definition and clinical manifestation of sepsis in urology 64 7.4 Physiology and biochemical markers 65 7.4.1 Cytokines as markers of the septic response 65 7.4.2 Procalcitonin is a potential marker of sepsis 65 7.5 Prevention 65 7.5.1 Preventive measures of proven or probable efficacy 65 7.5.2 Appropriate peri-operative antimicrobial prophylaxis 66 7.5.3 Preventive measures of debatable efficacy 66 7.5.4 Ineffective or counterproductive measures 66 7.6 Treatment 66 7.6.1 Relief of obstruction 66 7.6.2 Antimicrobial therapy 66 7.6.3 Adjunctive measures 66 7.7 Conclusion 67 7.8 Acknowledgement 67 7.9 References 67 4 UPDATE APRIL 2010 8. URETHRITIS 68 8.1 Definition 68 8.2 Epidemiology 68 8.3 Pathogens 68 8.4 Route of infection and pathogenesis 68 8.5 Clinical course 68 8.6 Diagnosis 69 8.7 Therapy 69 8.7.1 Treatment of gonorrhoeal urethritis 69 8.7.2 Treatment of non-gonorrhoeal urethritis 69 8.8 Follow-up and prevention 69 8.9 References 70 9. PROSTATITIS AND CHRONIC PELVIC PAIN SYNDROME 71 9.1 Summary and recommendations 71 9.2 Introduction and definition 71 9.3 Diagnosis 71 9.3.1 History and symptoms 71 9.3.1.1 Symptom questionnaires 72 9.3.2 Clinical findings 72 9.3.3 Urine cultures and expressed prostatic secretion 72 9.3.4 Perineal biopsy 73 9.3.5 Other tests 73 9.3.6 Classification systems 73 9.3.7 Diagnostic evaluation 74 9.3.8 Additional investigations 74 9.4 Treatment 75 9.4.1 Antibiotics 75 9.4.2 Antibiotics and α-blockers in combination therapy 75 9.4.3 Other oral medication 76 9.4.4 Intraprostatic injection of antibiotics 76 9.4.5 Surgery 76 9.4.6 Other treatment forms 76 9.5 References 76 10. EPIDIDYMITIS AND ORCHITIS 79 10.1 Definition and classification 79 10.2 Incidence and prevalence 80 10.3 Morbidity 80 10.4 Pathogenesis and pathology 80 10.5 Diagnosis 80 10.5.1 Differential diagnosis 80 10.6 Treatment 80 10.7 References 81 11. PERI-OPERATIVE ANTIBACTERIAL PROPHYLAXIS IN UROLOGY 81 11.1 Summary 81 11.2 Introduction 83 11.3 Goals of peri-operative antibacterial prophylaxis 83 11.4 Risk factors 84 11.5 Principles of antibiotic prophylaxis 84 11.5.1 Timing 85 11.5.2 Route of administration 85 11.5.3 Duration of the regimen 85 11.5.4 Choice of antibiotics 85 11.6 Prophylactic regimens in defined procedures 85 11.6.1 Diagnostic procedures 86 11.6.2 Endo-urological treatment procedures 86 11.6.3 Laparoscopic surgery 87 UPDATE APRIL 2010 5 11.6.4 Open or laparoscopic urological operations without opening of the urinary tract (clean procedures) 87 11.6.5 Open or laparoscopic urological operations with open urinary tract (clean- contaminated procedures) 87 11.6.6 Open urological operations with bowel segment (clean-contaminated or contaminated procedures) 87 11.6.7 Post-operative drainage of the urinary tract 87 11.6.8 Implantation of prosthetic devices 87 11.7 References 89 12.