Guidelines-on-urological-infections2010

182UrologicalInfectionsGuidelinesonuroloGicalinfections(TextupdateApril2010)M.Grabe(chairman),T.E.Bjerklund-Johansen,H.Botto,M.Çek,K.G.Naber,R.S.Pickard,P.Tenke,F.Wagenlehner,B.WulltintroductionInfectionsoftheurinarytractposeaserioushealthproblem,partlybecauseoftheirfrequentoccurrence.Clinicalandexperimentalevidencesupporttheascentofmicro-organismswithintheurethraasthemostcommonpathwayleadingtourinarytractinfections,especiallyfororganismsofentericori-gin(i.e.E.coliandotherEnterobacteriaceae).Thisalsopro-videsalogicalexplanationforthegreaterfrequencyofUTIsinwomenthaninmenandfortheincreasedriskofinfectionfollowingbladdercatheterisationorinstrumentation.classificationanddefinitionsForpracticalclinicalreasons,urinarytractinfections(UTIs)andmalegenitaltractinfectionsareclassifiedintoentitiesdefinedbythepredominantclinicalsymptoms(Table1).table1:classificationofurinaryandmalegenitaltractinfections•UncomplicatedlowerUTI(cystitis)•Uncomplicatedpyelonephritis•ComplicatedUTIwithorwithoutpyelonephritis183UrologicalInfections•Urosepsis.•Urethritis•Prostatitis,epididymitis,orchitisThedefinitionsofbacteriuriaandpyuriaarelistedinTable2.table2:significantbacteriuriainadults1.103uropathogens/mLofmidstreamurineinacuteuncomplicatedcystitisinfemale.2.104uropathogens/mLofmidstreamurineinacuteuncomplicatedpyelonephritisinfemale.3.105uropathogens/mLinmidstreamurineofwomenor104uropathogens/mLofmidstreamurineinmen(orinstraightcatheterurineinwomen)withcomplicatedUTI.4.Inasuprapubicbladderpuncturespecimen,anycountofbacteriaisrelevant.AsymptomaticbacteriuriaAsymptomaticbacteriuriaisdefinedastwopositiveurineculturestakenmorethan24hoursapartcontaining105uropathogens/mLofthesamebacterialstrain(usuallyonlythespeciescanbedetected).PyuriaThediagnosticrequirementforpyuriais10whitebloodcellsperhigh-powerfield(HPF)(x400)intheresuspendedsedi-mentofacentrifugedaliquotofurineorpermm3inunspunurine.Forroutineinvestigation,adipstickmethodcanalsobeused,includingaleukocyteesterasetestandtheassess-mentofhaemoglobinandofnitrites.184UrologicalInfectionsUrethritisSymptomaticurethritisischaracterisedbyalguriaandpuru-lentdischarge.Classificationofprostatitis/chronicpelvicpainsyndrome(CPPS)ItisrecommendedthattheclassificationaccordingtoNIDDK/NIHisused(Table3).table3:classificationofprostatitisaccordingtoniddK/niHIAcutebacterialprostatitis(ABP)IIChronicbacterialprostatitis(CBP)IIIChronicpelvicpainsyndrome(CPPS)A.InflammatoryCPPS:WBCinEPS/voidedbladderurine-3(VB3)/semenB.Non-inflammatoryCPPS:noWBC/EPS/VB3/semenIVAsymptomaticinflammatoryprostatitis(histologicalprostatitis)Epididymitis,orchitisMostcasesofepididymitis,withorwithoutorchitis,arecausedbycommonurinarypathogens.Bladderoutletobstructionandurogenitalmalformationsareriskfactorsforthistypeofinfection.ConsiderChlamydiatrachomatisinfec-tionintheyoungermalepopulation.diagnosisUTI(general)Adiseasehistory,physicalexaminationanddipstickurinaly-sis,includingwhiteandredbloodcellsandnitritereaction,185UrologicalInfectionsisrecommendedforroutinediagnosis.ExceptinisolatedepisodesofuncomplicatedlowerUTI(cystitis)inpremeno-pausal,healthywomen,aurinecultureisrecommendedinallothertypesofUTIbeforetreatment,soallowingantimi-crobialtherapytobeadjustedifnecessary.PyelonephritisIncasesofsuspectedpyelonephritis,itmaybenecessarytoevaluatetheupperurinarytracttoruleoutupperurinarytractobstructionorstonedisease.UrethritisPyogenicurethritisisindicatedbyaGramstainofsecretionorurethralsmearthatshowsmorethanfiveleukocytesperHPF(x1,000)andincaseofgonorrhoeagonococciarelocat-edintracellularlyasGram-negativediplococci.Apositiveleukocyteesterasetestormorethan10leukocytesperHPF(x400)inthefirstvoidingurinespecimenisdiagnostic.Prostatitis/CPPSInpatientswithprostatitis-likesymptoms,anattemptshouldbemadetodifferentiatebetweenbacterialprostatitisandCPPS.ThisisbestdonebythefourglasstestaccordingtoMearse&Stamey,ifacuteUTIandSTDcanberuledout.treatmentandProphylaxisTreatmentofUTIdependsonavarietyoffactors.Table4providesanoverviewofthemostcommonpathogens,antimicrobialagentsanddurationoftreatmentfordifferentconditions.ProphylactictreatmentmayberecommendedforpatientswithrecurrentUTI.TheregimensshowninTable186UrologicalInfectionstable4:recommendationsforantimicrobialtherapyinurologyDiagnosisMostfrequentpathogen/speciesInitial,empiricalantimicrobialtherapyTherapydurationCystitis•E.coli•TMP-SMX°3daysacute,•Klebsiella•Nitrofurantoin(5-)7daysuncomplicated•Proteus•Fosfomycintrometamol1day•Staphylococci•Pivmecillinam(3-)7days•Fluoroquinolone(altern.)1,2(1-)3daysPyelonephritis•E.coli•Fluoroquinolone17-10daysacute,•Proteus•Cephalosporin(group3a)uncomplicated•KlebsiellaAlternatives:•Otherenterobacteria•Aminopenicillin/BLI•Staphylococci•AminoglycosideUTIwith•E.coli•Fluoroquinolone13-5daysaftercomplicating•Enterococci•Aminopenicillin/BLIdefeverescenceorfactors•Pseudomonas•Cephalosporin(group2)control/elimination•Staphylococci•Cephalosporin(group3a)ofcomplicatingNosocomialUTI•Klebsiella•Aminoglycosidefactor•ProteusIncaseoffailureofinitialtherapyPyelonephritis•