Guidelines on Urological Infections M. Grabe (chairman), T.E. Bjerklund-Johansen, H. Botto, B. Wullt, M. Çek, K.G. Naber, R.S. Pickard, P. Tenke, F. Wagenlehner © European Association of Urology 2012 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 9 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 Level of infection 12 2.3 Grade of severity 13 2.4 Pathogens 14 2.5 Classification of UTI 14 2.6 Reference 14 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 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 16 3.4.2.1 Mild and moderate cases of acute uncomplicated pyelonephritis (Table 3.2) 17 3.4.2.2 Severe cases of acute uncomplicated pyelonephritis (Table 3.2) 17 3.4.3 Follow-up 18 3.5 Recurrent (uncomplicated) UTIs in women 20 3.5.1 Diagnosis 20 3.5.2 Prevention 20 3.5.2.1 Antimicrobial prophylaxis 20 3.5.2.2 Immunoactive prophylaxis 21 3.5.2.3 Prophylaxis with probiotics 21 3.5.2.4 Prophylaxis with cranberry 21 3.6 UTIs in pregnancy 21 3.6.1 Definition of significant bacteriuria 21 3.6.2 Screening 21 3.6.3 Treatment of asymptomatic bacteriuria 21 3.6.4 Duration of therapy 22 3.6.5 Follow-up 22 3.6.6 Prophylaxis 22 3.6.7 Treatment of pyelonephritis 22 3.6.8 Complicated UTI 22 3.7 UTIs in postmenopausal women 22 3.7.1 Risk factors 22 3.7.2 Diagnosis 22 2 UPDATE MARCH 2011 3.7.3 Treatment 23 3.8 Acute uncomplicated UTIs in young men 23 3.8.1 Men with acute uncomplicated UTI 23 3.8.2 Men with UTI and concomitant prostate infection 23 3.9 Asymptomatic bacteriuria 23 3.9.1 Diagnosis 23 3.9.2 Screening 24 3.10 References 24 4. COMPLICATED UTIs DUE TO UROLOGICAL DISORDERS 28 4.1 Summary and recommendations 28 4.2 Definitions and classification 28 4.2.1 Clinical presentation 29 4.2.2 Urine cultures 29 4.3 Microbiology 29 4.3.1 Spectrum and antibiotic resistance 29 4.3.2 Complicated UTIs associated with urinary stones 29 4.3.3 Complicated UTIs associated with urinary catheters 29 4.4 Treatment 29 4.4.1 General principles 29 4.4.2 Choice of antibiotics 30 4.4.3 Duration of antibiotic therapy 30 4.4.4 Complicated UTIs associated with urinary stones 30 4.4.5 Complicated UTIs associated with indwelling catheters 31 4.4.6 Complicated UTIs in patients with spinal cord injury 31 4.4.7 Follow-up after treatment 31 4.5 References 32 5. SEPSIS SYNDROME IN UROLOGY (UROSEPSIS) 33 5.1 Summary and recommendations 33 5.2 Background 33 5.3 Definition and clinical manifestation of sepsis in urology 34 5.4 Physiology and biochemical markers 35 5.4.1 Cytokines as markers of the septic response 35 5.4.2 Procalcitonin is a potential marker of sepsis 35 5.5 Prevention 35 5.5.1 Preventive measures of proven or probable efficacy (9,10) 35 5.5.2 Appropriate perioperative antimicrobial prophylaxis 36 5.5.3 Preventive measures of debatable efficacy 36 5.5.4 Ineffective or counterproductive measures 36 5.6 Algorithm for the management of urosepsis 36 5.7 Treatment 37 5.7.1 Clinical algorithm for management of urosepsis 37 5.7.2 Relief of obstruction 37 5.7.3 Antimicrobial therapy 37 5.7.4 Adjunctive measures (12,13) 37 5.8 Conclusion 37 5.9 Acknowledgement 38 5.10 References 38 6. CATHETER-ASSOCIATED UTIs 39 6.1 Abstract 39 6.2 Summary of recommendations 40 6.3 Reference 41 7. UTIs IN CHILDREN 41 7.1 Summary and recommendations 41 7.2 Background 41 7.3 Aetiology 42 7.4 Pathogenesis and risk factors 42 UPDATE MARCH 2011 3 7.5 Signs and symptoms 42 7.6 Classification 42 7.6.1 Severe UTI 43 7.6.2 Simple UTI 43 7.7 Diagnosis 43 7.7.1 Physical examination 43 7.7.2 Laboratory tests 43 7.7.2.1 Collection of the urine 43 7.7.2.1.1 Suprapubic bladder aspiration 43 7.7.2.1.2 Bladder catheterisation 43 7.7.2.1.3 Plastic bag attached to the genitalia 43 7.7.2.2 Quantification of bacteriuria 43 7.7.2.3 Other biochemical markers 44 7.7.2.3.1 Nitrite 44 7.7.2.3.2 Leukocyte esterase 44 7.7.2.3.3 C-reactive protein 44 7.7.2.3.4 Urinary N-acetyl-b-glucosaminidase 44 7.7.2.3.5 IL-6 44 7.7.3 Imaging of the urinary tract 45 7.7.3.1 Ultrasonography 45 7.7.3.2 Radionuclide studies 45 7.7.3.3 Cystourethrography 45 7.7.3.3.1 Conventional voiding cystourethrography 45 7.7.3.3.2 Radionuclide cystography (indirect) 45 7.7.3.3.3 Cystosonography 45 7.7.3.4 Additional imaging 45 7.7.3.5 Urodynamic evaluation 46 7.8 Schedule of investigation 46 7.9 Treatment 46 7.9.1 Severe UTIs 46 7.9.2 Simple UTIs 47 7.9.3 Prophylaxis 47 7.10 Acknowledgement 47 7.11 References 48 8. UTIs IN RENAL INSUFFICIENCY, TRANSPLANT RECIPIENTS, DIABETES MELLITUS AND IMMUNOSUPPRESSION 52 8.1 Summary and recommendations 52 8.1.1 Acute effects of UTI on the kidney 52 8.1.2 Chronic renal disease and UTI 52 8.1.2.1 APCKD 52 8.1.2.2 Calculi and UTI 53 8.1.2.3 Obstruction of the urinary tract and UTI 53 8.1.3 UTI in renal transplantation and immunosuppression 53 8.1.4 Antibiotic treatment for UTI in renal insufficiency and after renal transplantation 53 8.2 Background 53 8.3 Acute effects of UTI on the kidney 53 8.3.1 VUR and intrarenal reflux 53 8.3.2 Obstructive neuropathy 53 8.3.3 Renal effects of severe UTI 54 8.3.4 Acute effects of UTI on the normal kidney 54 8.3.5 Renal scarring 54 8.3.6 Specific conditions in which an acute UTI causes renal damage 55 8.3.6.1 Diabetes mellitus 55 8.3.6.2 Tuberculosis 56 8.4 Chronic renal disease and UTI 56 8.4.1 Adult dominant polycystic kidney disease (ADPKD) 56 8.4.2 Renal calculi 56 8.5 UTI in renal transplantation 56 8.5.1 Donor organ infection 57 4 UPDATE MARCH 2011 8.5.2 Graft failure 57 8.5.3 Kidney and whole-organ pancreas transplantation 57 8.6 Antibiotic therapy in renal failure and transplant recipients 57 8.6.1 Treatment of UTI in renal transplant recipients 58 8.6.2 Fungal infections 59 8.6.3 Schistosomiasis 59 8.7 Immunosuppression 59 8.7.1 Human immunodeficiency virus (HIV) infection 59 8.7.2 Viral and fungal infections 59 8.8 References 59 8.8.1 Further reading 63 9. URETHRITIS 63 9.1 Epidemiology 63 9.2 Pathogens 63 9.3 Route of infection and pathogenesis 63 9.4 Clinical course 63 9.5 Diagnosis 63 9.6 Therapy 63 9.6.1 Treatment of gonorrhoeal urethritis 63 9.6.2 Treatment of non-gonorrhoeal urethritis 64 9.7 Follow-up and prevention 64 9.8 References 64 10. PROSTATITIS AND CHRONIC PELVIC PAIN SYNDROME 65 10.1 Summary and recommendations 65 10.2 Introduction and definition 65 10.3 Diagnosis 66 10.3.1 History and symptoms 66 10.3.1.1 Symptom questionnaires 66 10.3.2 Clinical findings 66 10.3.3 Urine cultures and expressed prostatic secretion 66 10.3.4 Perineal biopsy 67 10.3.5 Other tests 67 10.3.6 Classification systems 68 10.3.7 Diagnostic evaluation 68 10.3.8 Additional investigations 68 10.4 Treatment 69 10.4.1 Antibiotics 69 10.4.2 Antibiotics and b-blockers in combination therapy 69 10.4.3 Other oral medication 70 10.4.4 Intraprostatic injection of antibiotics 70 10.4.5 Surgery 70 10.4.6 Other treatment forms 71 10.5 References 71 11. EPIDIDYMITIS AND ORCHITIS 73 11.1 Summary and recommendations 73 11.2 Definition and classification 74 11.3 Incidence and prevalence 74 11.4 Morbidity 74 11.5 Pathogenesis and pathology 74 11.6 Diagnosis 74 11.6.1 Differential diagnosis 75 11.7 Treatment 75 11.8 References 75 12. SEXUALLY TRANSMITTED INFECTIONS 76 12.1 Reference 76 UPDATE MARCH 2011 5 13. FOURNIER’S GANGRENE 76 13.1 Summary of recommendations 76 13.2 Background 76 13.3 Clinical presentation 76 13.4 Microbiology 76 13.5 Management 77 13.6 References 77 14.