New paradigms in the management of recurrent urinary tract infections.

PURPOSE OF REVIEW: Recurrent urinary tract infections (rUTIs) represent a large burden on the healthcare system. Recent guidelines from the AUA/CUA/SUFU and advancements in the field reflect a paradigm shift for clinician and patients, steering away from empiric antibiotic therapy towards judicious antibiotic use. RECENT FINDINGS: Antibiotic stewardship, including increasing awareness of the collateral damage of antibiotics and the risks of bacterial resistance are a major focus of the new guidelines. Accurate diagnosis of rUTIs is imperative. Urine cultures are necessary to document rUTI and should be obtained prior to any treatment. First line treatment options (trimethoprim-sulfamethoxazole, nitrofurantoin, and fosfomycin) should be used whenever possible. Asymptomatic bacteriuria should not be treated in these patients with rUTI. Although antibiotic prophylaxis methods are effective, nonantibiotic regimens show promise. SUMMARY: The management of rUTIs has evolved significantly with the goal of antibiotic stewardship. It is increasingly important to ensure the accuracy of diagnosis with a positive urine culture in the setting of cystitis symptoms, and standardize treatment with first-line therapies to minimize antibiotic side effects.

[Bacterial urinary tract infection and subclinical bacteriuria in the dog: a current review]. / Bakterielle Harnwegsinfektion und subklinische Bakteriurie des Hundes: eine aktuelle Übersicht.

Bacterial urinary tract infection (UTI) is a common clinical presentation in dogs and a frequent reason for the prescription of antimicrobial drugs. UTI refers to adherence, multiplication and persistence of an infectious agent within the urogenital system. This causes an associated inflammatory response as well as the pertaining clinical signs. Depending on the site of infection, UTI's may be classified as bacterial cystitis, prostatitis or pyelonephritis. In contrast, subclinical bacteriuria (SB) is defined as the presence of a significant number of bacteria in the urine of an individual not showing clinical signs referrable to UTI. UTI's typically occur as a consequence of ascending pathogen migration from the host's own fecal or distal urogenital microbial flora. The most commonly isolated pathogen in cases of UTI and SB is Escherichia coli. The diagnosis is based on clinical signs and the results of urine examination and culture. The recently revised guidelines of the International Society for Companion Animal Infectious Diseases provide detailed recommendations for diagnosis and management of different forms of bacterial UTI's in dogs. Adherence to treatment guidelines will improve treatment success and is imperative in avoiding further deterioration of the antimicrobial resistance situation.

In vitro bactericidal effect of Ho:YAG laser and pneumatic lithotripsy on ureteral stones colonized with Escherichia coli and Enterococcus faecalis.

The endoscopic treatment of urolithiasis has a high success rate and the complications decreased after the development of lithotripsy techniques. The aim of this study is to investigate the in vitro bactericidal effect of laser and pneumatic lithotripsy on urinary stones colonized with Escherichia coli and Enterococcus faecalis. A total of 40 natural calcium oxalate stones, which were obtained from the patients' urinary systems with rigid ureteroscopy were used in the study. Surfaces of the stones were colonized with E. coli and E. faecalis strains. The fragmentation of the stones was performed using holmium:yttrium-aluminum-garnet laser (Ho:YAG laser) and pneumatic lithotripters in vitro in Eppendorf tubes filled with liquid. After fragmentation, samples taken from Eppendorf tubes were inoculated on blood and EMB agar. The number of colonies was evaluated after 18-24-hour incubation period. The laser lithotripsy technique reduced the number of colonies by 100% and had bactericidal effect on E. coli and E. faecalis. Pneumatic lithotripsy technique had no bactericidal effect on these strains (0%). In the fifth minute of laser irradiation, the average temperature in the Eppendorf tube was 51-55 °C, and the average temperature in the tenth minute was 54-60 °C. The temperatures did not change in the fifth and tenth minutes with the pneumatic lithotripsy procedure. The present study revealed the bactericidal effect of Ho:YAG laser on E. coli and E. faecalis in vitro. Increased ambient temperature during Ho:YAG laser lithotripsy is thought to play a role in the bactericidal effect. But the question of whether an ideal lithotripter efficiently inactivates or destroys bacteria has still not been answered in urology practice. This preliminary study showed the bactericidal effect of Ho:YAG laser lithotripsy, but further studies are needed to investigate the bactericidal effect of Ho:YAG laser in vivo.

Evaluation and Management of Urinary Tract Infection in the Emergency Department.

Urinary tract infection (UTI) affects patients of all ages and is a diagnosis that emergency physicians might make multiple times per shift. This article reviews the evaluation and management of patients with infections of the urinary tract. Definitions of asymptomatic bacteriuria, uncomplicated UTI, and complicated UTI are presented, as well as techniques for distinguishing them. The pathophysiology and clinical and laboratory diagnoses of UTI are described. Treatment of UTI is reviewed, with attention to bacteriuria and special populations, including pregnant, elderly/geriatric, and spinal cord injury patients.

Serious Bacterial Infections in Neonates Presenting Afebrile With History of Fever.

BACKGROUND: Infants ≤28 days of age with fever are frequently hospitalized while undergoing infectious evaluation. We assessed differences in rates of serious bacterial infection (SBI; bacteremia, bacterial meningitis, urinary tract infection) and invasive bacterial infection (IBI; bacteremia, bacterial meningitis) among the following neonates: (1) febrile at presentation (FP), (2) afebrile with history of fever without subsequent fever during hospitalization, and (3) afebrile with history of fever with subsequent fever during hospitalization. METHODS: We performed a single-center retrospective study of neonates evaluated for SBI during emergency department evaluation between January 1, 2006, and December 31, 2017. Patients were categorized into FP, afebrile with no subsequent fever (ANF), and afebrile with subsequent fever (ASF) groups. We compared rates of SBI and IBI between groups using logistic regression and assessed time to fever development using time-to-event analysis. RESULTS: Of 931 neonates, 278 (29.9%) were in the ANF group, 93 (10.0%) were in the ASF group, and 560 (60.2%) were in the FP group. Odds of SBI in neonates ANF were 0.42 (95% confidence interval [CI] 0.23-0.79) compared with infants FP, although differences in IBI were not statistically significant (0.52, 95% CI 0.19-1.51). In infants ASF, median time to fever was 5.6 hours (interquartile range, 3.1-11.4). Infants ASF had higher odds of SBI compared to infants FP (odds ratio 1.93, 95% CI 1.07-3.50). CONCLUSIONS: Neonates with history of fever who remain afebrile during hospitalization may have lower odds for SBI and be candidates for early discharge after an observation period.

Perioperative infectious risk in urology: Management of preoperative polymicrobial urine culture. A systematic review. By the infectious disease Committee of the French Association of urology.

INTRODUCTION: The aim was to assess the risk of postoperative infections in patients with preoperative polymicrobial urine culture and to provide the urologist with practices to minimise the risk of infection in these clinical situations. METHODS: A systematic literature review was carried. All national and international recommendations have been reviewed. Data collection has been performed from the Cochrane, LILACS and the Medline database. 31 publications were selected for inclusion. RESULTS: Risk of infection in patients without ureteral stents or urinary catheters with previous polymicrobial urine culture is low. In the absence of leukocyturia, the urine sample can be considered as sterile. With ureteral stents or urinary catheters, the colonisation by biofilm ranges from 4 to 100% depending on the duration and ureteral stents or urinary catheters type. Urine culture is positive 24 to 45% of the time when ureteral stents or urinary catheters are known to be colonised. The post-operative risk of infection in endo-urological surgery in a patient with ureteral stents or urinary catheters is estimated around 8 to 11% depending on the type of surgery. A retrospective study reports a postoperative infections rate of 18.5% in photo selective vaporization of the prostate with preoperative polymicrobial urine culture. CONCLUSIONS: Scientific data are limited but for patients without ureteral stents or urinary catheters, in the absence of leukocyturia, the polymicrobial urine culture can be considered as negative. Considering a preoperative polymicrobial urine culture as sterile in patients with colonised ureteral stents or urinary catheters is at risk of neglecting a high risk of postoperative infections or sepsis even in case of perioperative antibiotic prophylaxis. It should not always be considered sterile and therefore, a perioperative antibiotic therapy could be an acceptable option.

Purple urine bag syndrome. / Lilla urinpose-syndrom.

BACKGROUND: Purple urine bag syndrome (PUBS) can occur in cases of bacteriuria with species expressing enzymes capable of converting tryptophan metabolites to red and blue pigments which are excreted in urine, leaving a characteristic purple colour. Risk factors include urinary catheterisation, constipation and chronic kidney disease. Treatment includes catheter replacement, and antibiotics in case of urinary tract infection. CASE PRESENTATION: A man in his 70s with myelodysplastic syndrome, stage 5 chronic kidney disease and chronic indwelling urinary catheterisation due to benign prostatic hyperplasia was admitted for transfusion for symptomatic anaemia. On the second day of hospitalisation, his urine turned purple. There was no sign of transfusion reaction, haemoglobinuria, myoglobinuria or bilirubinuria. Urine cultures were positive for Proteus vulgaris and Enterococcus faecalis, two species associated with PUBS. INTERPRETATION: The constellation was consistent with PUBS. His bacteriuria was considered colonisation not requiring antibiotic treatment. The catheter was replaced and the urine colour returned to normal.

The impact of the Hospital Elder Life Program on the treatment of asymptomatic bacteriuria: An unexpected benefit.

Delirium in older adults is often inappropriately attributed to presumed urinary tract infections (UTIs) leading to unnecessary prescribing of antibiotics for asymptomatic bacteriuria. We sought to examine whether implementation of the Hospital Elder Life Program (HELP), a delirium prevention program, reduced the inappropriate treatment of asymptomatic bacteriuria. We conducted a secondary data analysis of administrative data and electronic health records on a descriptive study in which HELP was implemented at an academic community hospital. Patients aged 70 and older admitted before HELP was implemented (n = 687) were compared to the intervention group after HELP implementation (n = 637). HELP intervention participants, compared to pre-intervention patients, were less likely to receive inappropriate treatment for asymptomatic bacteriuria (3.0% versus 6.7%, adjusted odds ratio=0.46, 95% confidence interval=0.26-0.79, P = 0.005). HELP was associated with a reduction in the treatment of asymptomatic bacteriuria. Therefore, HELP may decrease adverse events and costs related to unnecessary exposure to antibiotics.

Management of acute pyelonephritis.

INTRODUCTION: Acute pyelonephritis (APN) results from bacterial invasion of the renal parenchyma. The aim of this study was to investigate the epidemiological, clinico-biological, therapeutic and evolutionary APN and to identify the risk factors of this renal disease. METHODS: We conducted a retrospective and descriptive study, over a period of 37 years (1977-2014), including 43 patients with APN, hospitalized in our Department. RESULTS: There were 43 patients with mean age of 36.98 years. The sex ratio M/W was 0.39. The history of our patients was diabetes (16.28%), recurrent urinary tract infection (25.58%), chronic kidney failure (CKF) (46.51%), Renal lithiasis (9.3%), malformative uropathy (9.3%) and immunosuppressive therapy (23.3%). Typical clinical triad (fever, back pain and urinary functional signs) was present in 25 patients (58.14%). The Gram-negative bacilli represented 97.67% of bacteria isolated in urine culture, dominated by Escherchia coli in 83.72% of cases. APN was simple in 19 cases (44.18%) and at risk of complications in 24 cases (55.81%). Thirty-nine patients (90.69%) had non-severe APN. Four patients (9.3%) had severe APN. Complications were found in 30.23% of cases: acute renal failure (ARF) (30.23%), renal abscess (2.33%), septic shock (4.65%). Risk factors for developing ARF were the higher age group to 60 years (p = 0.02) and CKF (p = 0.001). A significant correlation was found between vesicoureteral reflux and recurrent infections (p = 0.01). Five years renal survival was 69%. CONCLUSION: APN induced ARF is a serious risk for progression to CKF.

The Use of Clinical Decision Support in Reducing Diagnosis of and Treatment of Asymptomatic Bacteriuria.

Clinical decision support (CDS) embedded within the electronic health record (EHR) is a potential antibiotic stewardship strategy for hospitalized patients. Reduction in urine testing and treating asymptomatic bacteriuria (ASB) is an important strategy to promote antibiotic stewardship. We created an intervention focused on reducing urine testing for asymptomatic patients at a large tertiary care center. The objective of this study was to design an intervention to reduce unnecessary urinalysis and urine culture (UC) orders as well as the treatment of ASB. We performed a quasiexperimental study among adult inpatients at a single academic institution. We implemented a bundled intervention, including information broadcast in newsletters, hospitalwide screensavers, and passive CDS messages in the EHR. We investigated the impact of this strategy on urinalysis, UC orders, and on the treatment of ASB by using an interrupted time series analysis. Our intervention led to reduced UC order as well as reduced antibiotic orders in response to urinalysis orders and UC results. This easily implementable bundle may play an important role as an antibiotic stewardship strategy.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients. Part II: Therapy and Prevention.

BACKGROUND: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Results are published in 2 parts. Part 1 covers methods, the definition of patient groups, and diagnostics. This second publication focuses on treatment of acute episodes of cystitis and pyelonephritis as well as on prophylaxis of recurrent UTIs. MATERIALS AND METHODS: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, EMBASE, and the Cochrane Library to identify literature published in 2010-2015. RESULTS: For the treatment of acute uncomplicated cystitis (AUC), fosfomycin-trometamol, nitrofurantoin, nitroxoline, pivmecillinam, and trimethoprim (depending on the local rate of resistance) are all equally recommended. Cotrimoxazole, fluoroquinolones, and cephalosporins are not recommended as antibiotics of first choice, for concern of an unfavorable impact on the microbiome. Mild to moderate uncomplicated pyelonephritis should be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For AUC with mild to moderate symptoms, instead of antibiotics symptomatic treatment alone may be considered depending on patient preference after discussing adverse events and outcomes. Primarily non-antibiotic options are recommended for prophylaxis of recurrent urinary tract infection. CONCLUSION: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients: Part 1.

OBJECTIVES: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. MATERIALS AND METHODS: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, -EMBASE, and the Cochrane Library to identify literature published in 2010-2015. RESULTS: We provide 75 recommendations and 68 statements in the updated evidence- and consensus-based national clinical guideline. The diagnostics part covers practical recommendations on cystitis and pyelonephritis for each defined patient group. Clinical examinations, as well as laboratory testing and microbiological pathogen assessment, are addressed. CONCLUSION: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

Misconceptions of Spanish general practitioners' attitudes toward the management of urinary tract infections and asymptomatic bacteriuria: an internet-based questionnaire study.

OBJECTIVE: The diagnosis and management of urinary tract infections (UTI) vary widely across countries and practices. The objective of this study was to gain insight into general practitioners' (GP) perceptions on the current management of UTIs and asymptomatic bacteriuria in Spain. METHODS: Cross-sectional, internet-based questionnaire study answered from July to September 2013. GPs affiliated with the largest Spanish scientific society in primary care (Sociedad Española de Medicina Familiar y Comunitaria) were invited to participate in the study. They were asked about the tests ordered in both uncomplicated and complicated UTIs and about the management in three clinical scenarios, depicting a 50-year woman with: 1. An uncomplicated UTI, 2. A complicated UTI, and 3. An asymptomatic bacteriuria. RESULTS: The questionnaire was completed by 1,239 GPs (6.7%). Urine cultures were reportedly requested by 26.3% of the GPs in uncomplicated UTIs and by 71.8% of the cases corresponding to the complicated UTIs whereas it was declared that dipsticks were the preferred tests in only uncomplicated UTIs (38.2%). A total of 22% and 13.2% of the GPs stated that they would withhold antibiotic therapy in patients with low-count and high-count asymptomatic bacteriuria, respectively. CONCLUSIONS: GPs have important misconceptions as to the indications for ordering urine cultures and in interpreting the definitions of common UTIs and treating UTIs and asymptomatic bacteriuria. The unnecessary use of antibiotics in patients with asymptomatic bacteriuria is considerable in Spain.

Asymptomatic bacteriuria, to screen or not to screen - and when to treat?

PURPOSE OF REVIEW: Asymptomatic bacteriuria (ABU) is a common clinical condition that often leads to unnecessary treatment. The purpose of this review is to outline and evaluate the most recent literature on the management of ABU. RECENT FINDINGS: The role of ABU management has been evaluated in several patient subgroups: healthy patients without identified risk factors, pregnant women, postmenopausal women, women with recurrent UTI, patients with diabetes, elderly institutionalized patients, patients with renal transplants, patients with indwelling catheters and prior to surgery. Available evidence only supports the need for screening and treatment of ABU in pregnant women and prior to urological procedures breaching the mucosa. In all the other conditions the treatment of ABU is not only useless but also harmful. A short course treatment in pregnant women is recommended; in patients with ABU prior to urological procedures breaching the mucosa the treatment should be given in line with antibiogram and in line with the recommendations of European Association of Urology guidelines. SUMMARY: The approach to patients with ABU has changed completely during recent years. Today, screening and treatment of ABU is recommended only in pregnant women and in all patients who are candidates for urological procedures breaching the mucosa.

Is Preoperative Assessment and Treatment of Asymptomatic Bacteriuria Necessary for Reducing the Risk of Postoperative Symptomatic Urinary Tract Infections After Urologic Surgical Procedures?

OBJECTIVE: To evaluate whether it is always necessary to test for the presence of asymptomatic bacteriuria (AB) in patients undergoing urologic surgical procedures, and if present, whether to treat AB with antimicrobial prophylaxis. MATERIALS AND METHODS: All patients who underwent urologic surgical procedures from December 2008 to October 2013 in a tertiary referral urologic center were considered for this study. All patients received antimicrobial prophylaxis in line with European Association of Urology guidelines on urologic infections. AB was diagnosed if ≥105 colony-forming units/mL were cultured. The population was subdivided into 2 groups: group A, patients with preoperative AB, and group B, patients without AB. Data on postoperative symptomatic urinary tract infections (UTIs) were compared for the 2 groups. RESULTS: A total of 2201 patients were considered eligible for this study and were analyzed; 668 (30.4%) patients were found to harbor AB (group A), and 1533 (69.6%) patients did not have AB (group B). Microbiologically verified symptomatic postoperative UTIs occurred in 198 patients (8.9%). No difference in terms of overall rate of postoperative symptomatic UTI was found between the 2 groups (group A: 70 [10.4%] and group B: 128 [8.3%]; OR: 1.28 95%CI 0.94-1.74; P = .12), as well as in terms of urosepsis (group A: 2 [0.30%] and group B: 4 [0.26%]; P = 1.0). CONCLUSION: In patients undergoing urologic surgical procedures who are receiving antimicrobial prophylaxis in accordance with European Association of Urology guidelines, the preoperative presence of AB in this study was not associated with a higher incidence of postoperative symptomatic UTI.

[Bacteriuria after Radical Prostatectomy: Importance of Bacterial Count]. / Bakteriurie nach radikaler Prostatektomie - Stellenwert der Keimzahl.

MATERIAL AND METHODS: 100 consecutive cases after radical prostatectomy with a bacterial count of 10(4) CFU/ml in midstream urine were followed during urological inpatient rehabilitation without antibiotic treatment. Before discharge, a follow-up examination with a urine dipstick and a second urine culture were performed. RESULTS: No symptomatic urinary tract infections (UTI) occurred during the average follow-up period of 15.2 days. Patients with unremarkable urine dipstick findings at follow-up (no leukocyturia and no haematuria and no nitrituria) had no relevant bacteriuria (≥10(5) CFU/ml).54 of urine culture controls before discharge were negative, 31 showed insignificant bacterial growth (≤10(4) CFU/ml) and 15 had a bacterial count≥10(5) CFU/ml. 4 patients (27%) with > 10(5) CFU/ml were successfully treated with antibiotics for clear signs of infection (fever, chills, leukocytosis); the other 11 patients were just followed further. CONCLUSIONS: Even though almost all patients after radical prostatectomy continue to suffer from some discomfort that might be due to UTI, patients with 10(4) CFU/ml in midstream urine samples should not receive antibiotic treatment unless they have clear systemic symptoms of an infection, e. g. fever, chills or leukocytosis. Unremarkable urine dipstick findings during the follow-up period (no leukocyturia and no erythrocyturia and no nitrituria) rule out a relevant bacteriuria (≥10(5) CFU/ml). Clear systemic signs of infection during follow-up only occurred in 4 patients, who were successfully treated with test-adapted antibiotics.

[Characteristic Features of Urinary Incontinence--Diagnostic Investigation in Geriatric Patients]. / Besonderheiten der Harninkontinenz--Diagnostik beim geriatrischen Patienten.

Urinary incontinence is a common medical and social problem in elderly people. It leads to a massive reduction in the quality of life of affected persons and their dependants and causes an enormous socio-economic burden, which will increase significantly within the next years and decades as the age structure of the German population changes. Successful treatment of urinary incontinence in the elderly requires a good pathophysiological understanding of the underlying problem as well as individually tailored diagnostic procedures, which must be oriented at the patient's wishes, the social environment and the resulting therapeutic consequences. This especially applies to persons with symptoms of dementia. Comorbidities such as diabetes mellitus, reduced mobility and a medication-induced decrease in cognitive function play a major role in the severity of urgency and urinary incontinence in the elderly. Also the frequently described concomitant diagnosis of urinary tract infection must be exactly evaluated. Before antibiotic treatment is given, it should be clarified if the patient suffers from "harmless" bacteriuria or a urinary tract infection requiring treatment. Patients with an age-associated decrease in brain power must be diagnosed quite carefully, because these patients may potentially be harmed by pharmacological treatment for overactive bladder syndrome.