Guidelines on Urological Infections M. Grabe (chair), R. Bartoletti, T.E. Bjerklund-Johansen, H.M. Çek, R.S. Pickard, P. Tenke, F. Wagenlehner, B. Wullt © European Association of Urology 2014 TABLE OF CONTENTS PAGE 1. INTRODUCTION 8 1.1 Background 8 1.2 Bacterial resistance development 8 1.3 The aim of the guidelines 8 1.4 Pathogenesis of UTIs 8 1.5 Microbiological and other laboratory findings 9 1.6 Methodology 10 1.6.1 Level of evidence and grade of guideline recommendations 10 1.6.2 Publication history 10 1.7 References 11 2. CLASSIFICATION OF UTIs 12 2.1 Introduction 12 2.2 Anatomical level of infection 12 2.3 Grade of severity 13 2.4 Pathogens 14 2.5 Classification of UTI 14 2.6 Reference 15 3. UNCOMPLICATED UTIS IN ADULTS 15 3.1 Summary and recommendations 15 3.2 Definition 15 3.2.1 Aetiological spectrum 15 3.3 Acute uncomplicated sporadic cystitis in premenopausal, non-pregnant women 15 3.3.1 Diagnosis 15 3.3.1.1 Clinical diagnosis 15 3.3.1.2 Laboratory diagnosis 15 3.3.2 Therapy 15 3.3.3 Follow-up 16 3.4 Acute uncomplicated pyelonephritis in premenopausal, non-pregnant women 16 3.4.1 Diagnosis 16 3.4.1.1 Clinical diagnosis 16 3.4.1.2 Laboratory diagnosis 16 3.4.1.3 Imaging diagnosis 16 3.4.2 Therapy 17 3.4.2.1 Mild and moderate cases of acute uncomplicated pyelonephritis 17 3.4.2.2 Severe cases of acute uncomplicated pyelonephritis 17 3.4.3 Follow-up 19 3.5 Recurrent uncomplicated UTIs in premenopausal women 20 3.5.1 Diagnosis 20 3.5.2 Antimicrobial treatment and prevention 20 3.5.2.1 Antimicrobial prophylaxis 20 3.5.3 Non-antimicrobial prophylaxis 21 3.5.3.1 Immunoactive prophylaxis 21 3.5.3.2 Prophylaxis with probiotics (Lactobacillus sp) 21 3.5.3.3 Prophylaxis with cranberry 21 3.6 UTIs in pregnancy 22 3.6.1 Diagnosis of UTIs in pregnant women 22 3.6.2 Definition of bacteriuria 22 3.6.3 Screening 22 3.6.4 Treatment of asymptomatic bacteriuria and acute cystitis 22 3.6.5 Duration of therapy 22 3.6.6 Follow-up 22 3.6.7 Prophylaxis 22 3.6.8 Treatment of pyelonephritis 22 3.6.9 Complicated UTI 23 3.7 UTIs in postmenopausal women 23 2 UROLOGICAL INFECTIONS - LIMITED UPDATE MARCH 2013 3.7.1 Risk factors 23 3.7.2 Diagnosis 23 3.7.3 Treatment 23 3.8 Acute uncomplicated UTIs in young men 24 3.8.1 Men with acute uncomplicated UTI 24 3.9 Asymptomatic bacteriuria 24 3.9.1 Diagnosis 24 3.9.2 Screening 24 3.10 References 25 4. COMPLICATED UTIs DUE TO UROLOGICAL DISORDERS 28 4.1 Summary and recommendations 28 4.2 Definitions and classification 29 4.2.1 Clinical presentation 29 4.2.2 Urine cultures 30 4.3 Microbiology 30 4.3.1 Spectrum and antibiotic resistance 30 4.3.2 Complicated UTIs associated with urinary stones 30 4.3.3 Complicated UTIs associated with urinary catheters 30 4.4 Treatment 30 4.4.1 General principles 30 4.4.2 Choice of antibiotics 30 4.4.3 Duration of antibiotic therapy 31 4.4.4 Complicated UTIs associated with urinary stones 31 4.4.5 Complicated UTIs associated with indwelling catheters 31 4.4.6 Complicated UTIs in patients with spinal cord injury 32 4.4.7 Follow-up after treatment 32 4.5 References 32 5. SEPSIS SYNDROME IN UROLOGY (UROSEPSIS) 34 5.1 Summary and recommendations 34 5.2 Background 34 5.3 Definition and clinical manifestation of sepsis in urology 35 5.4 Physiology and biochemical markers 35 5.4.1 Cytokines as markers of the septic response 36 5.4.2 Procalcitonin is a potential marker of sepsis 36 5.5 Prevention 36 5.5.1 Preventive measures of proven or probable efficacy 36 5.5.2 Appropriate perioperative antimicrobial prophylaxis 36 5.5.3 Preventive measures of debatable efficacy 36 5.5.4 Ineffective or counterproductive measures 37 5.6 Algorithm for the management of urosepsis 37 5.7 Treatment 37 5.7.1 Clinical algorithm for management of urosepsis 37 5.7.2 Relief of obstruction 38 5.7.3 Antimicrobial therapy 38 5.7.4 Adjunctive measures 38 5.8 Conclusion 38 5.9 Acknowledgement 38 5.10 References 38 6. CATHETER-ASSOCIATED UTIs 40 6.1 Abstract 40 6.2 Summary of recommendations 41 6.3 Reference 42 7. UTIs IN CHILDREN 42 7.1 Summary and recommendations 42 7.2 Background 42 7.3 Aetiology 43 UROLOGICAL INFECTIONS - LIMITED UPDATE MARCH 2013 3 7.4 Pathogenesis and risk factors 43 7.5 Signs and symptoms 43 7.6 Classification 43 7.6.1 Severe UTI 44 7.6.2 Simple UTI 44 7.7 Diagnosis 44 7.7.1 Physical examination 44 7.7.2 Laboratory tests 44 7.7.2.1 Collection of the urine 44 7.7.2.1.1 Suprapubic bladder aspiration 44 7.7.2.1.2 Bladder catheterisation 44 7.7.2.1.3 Plastic bag attached to the genitalia 44 7.7.2.2 Quantification of bacteriuria 44 7.7.2.3 Other biochemical markers 45 7.7.2.3.1 Nitrite 45 7.7.2.3.2 Leukocyte esterase 45 7.7.2.3.3 C-reactive protein 45 7.7.2.3.4 Urinary N-acetyl-b-glucosaminidase 45 7.7.2.3.5 IL-6 45 7.7.3 Imaging of the urinary tract 46 7.7.3.1 Ultrasound 46 7.7.3.2 Radionuclide studies 46 7.7.3.3 Cystourethrography 46 7.7.3.3.1 Conventional voiding cystourethrography 46 7.7.3.3.2 Radionuclide cystography (indirect) 46 7.7.3.3.3 Cystosonography 46 7.7.3.4 Additional imaging 46 7.7.3.5 Urodynamic evaluation 47 7.8 Schedule of investigation 47 7.9 Treatment 47 7.9.1 Severe UTIs 47 7.9.2 Simple UTIs 48 7.9.3 Prophylaxis 48 7.10 Acknowledgement 48 7.11 References 49 8. UTIs IN RENAL INSUFFICIENCY, TRANSPLANT RECIPIENTS, DIABETES MELLITUS AND IMMUNOSUPPRESSION 53 8.1 Summary and recommendations 53 8.1.1 Acute effects of UTI on the kidney 53 8.1.2 Chronic renal disease and UTI 53 8.1.2.1 Adult polycystic kidney disease 53 8.1.2.2 Calculi and UTI 54 8.1.2.3 Obstruction of the urinary tract and UTI 54 8.1.3 UTI in renal transplantation and immunosuppression 54 8.1.4 Antibiotic treatment for UTI in renal insufficiency and after renal transplantation 54 8.2 Background 54 8.3 Acute effects of UTI on the kidney 54 8.3.1 VUR and intrarenal reflux 54 8.3.2 Obstructive neuropathy 55 8.3.3 Renal effects of severe UTI 55 8.3.4 Acute effects of UTI on the normal kidney 55 8.3.5 Renal scarring 55 8.3.6 Specific conditions in which an acute UTI causes renal damage 56 8.3.6.1 Diabetes mellitus 56 8.3.6.2 Tuberculosis 57 8.4 Chronic renal disease and UTI 57 8.4.1 Adult dominant polycystic kidney disease (ADPKD) 57 8.4.2 Renal calculi 57 8.5 UTI in renal transplantation 58 4 UROLOGICAL INFECTIONS - LIMITED UPDATE MARCH 2013 8.5.1 Donor organ infection 58 8.5.2 Graft failure 58 8.5.3 Kidney and whole-organ pancreas transplantation 58 8.6 Antibiotic therapy in renal failure and transplant recipients 58 8.6.1 Treatment of UTI in renal transplant recipients 60 8.6.2 Fungal infections 60 8.6.3 Schistosomiasis 60 8.7 Immunosuppression 60 8.7.1 Human immunodeficiencey virus (HIV) infection 60 8.7.2 Viral and fungal infections 60 8.8 References 61 8.8.1 Further reading 64 9. URETHRITIS 64 9.1 Epidemiology 64 9.2 Pathogens 64 9.3 Route of infection and pathogenesis 64 9.4 Clinical course 64 9.5 Diagnosis 64 9.6 Therapy 65 9.6.1 Treatment of gonorrhoeal urethritis 65 9.6.2 Treatment of non-gonorrhoeal urethritis 65 9.7 Follow-up and prevention 65 9.8 References 65 10. BACTERIAL PROSTATITIS 66 10.1 Summary and recommendations 66 10.2 Introduction and definition 66 10.3 Diagnosis 67 10.3.1 History and symptoms 67 10.3.1.1 Symptom questionnaires 67 10.3.2 Clinical findings 67 10.3.3 Urine cultures and expressed prostatic secretion 68 10.3.4 Prostate biopsy 68 10.3.5 Other tests 68 10.3.6 Additional investigations 68 10.3.6.1 Ejaculate analysis 68 10.3.6.2 Prostate Specific Antigen (PSA) 68 10.4 Treatment 69 10.4.1 Antibiotics 69 10.4.2 Intraprostatic injection of antibiotics 70 10.4.3 Drainage and surgery 70 10.5 References 70 11. EPIDIDYMITIS AND ORCHITIS 71 11.1 Summary and recommendations 71 11.2 Definition and classification 72 11.3 Incidence and prevalence 72 11.4 Morbidity 72 11.5 Pathogenesis and pathology 72 11.6 Diagnosis 72 11.6.1 Differential diagnosis 73 11.7 Treatment 73 11.8 References 73 12. FOURNIER’S GANGRENE 74 12.1 Summary of recommendations 74 12.2 Background 74 12.3 Clinical presentation 74 12.4 Microbiology 74 UROLOGICAL INFECTIONS - LIMITED UPDATE MARCH 2013 5 12.5 Management 74 12.6 Further reading 75 13.