Urinary Tract Infection

These guidelines provide essential summarized updated information for diagnosis, treatment and prevention of urinary tract Infections with emphasizing on judicious use of antimicrobials based on culture and sensitivity to reduce bacterial resistance which is a serious issue especially with malpractice and misuse of antibiotics in Egypt. Moreover, the recommendations included in these guidelines are not representing absolute mandates but provisional protocols respecting environmental and socioeconomic conditions of Egypt, considering our religious and traditional background

1.  Diagnosis of ABU is made by urine culture, either properly collected clean-catch specimen or a catheterized specimen is acceptable.         (Strong)                                                    

2.  Do not to treat ABU in the following condition.   (Strong)                                                  

·  Women without risk factors.

·   Patients with regulated diabetes mellitus.

·  Post-menopausal women.

·   Elderly institutionalized patients.

·   Patients with spinal cord injury, dysfunctional and/or reconstructed lower urinary tracts, and indwelling catheter

·  Patients with renal transplant. Patients with arthroplasty surgeries.

·   Patients with recurrent urinary tract infections.

3. Treat ABU prior urologic procedure breaching the mucosa and in pregnancy. (Strong)

4.  Diagnosis of uncomplicated cystitis in women who have no risk factors for complicated urinary tract infections by a focused history of lower urinary tract symptoms. (Strong)

5.  Uses of urine cultures in the following situations:                                         (Strong)

a.   suspected acute pyelonephritis.

b.  symptoms that do not resolve or recur within four weeks after the completion of treatment.

c.  women who present with atypical symptoms. Pregnant women.                 

6.  Women with uncomplicated cystitis should be treated by antimicrobial therapy with or without symptomatic treatment. (Strong)

Recommendations for Recurrent UTIs                                                                            

7.     Diagnosis of each UTI episode clinically and is supported by symptoms of dysuria, frequency, urgency, hematuria, back pain, costovertebral tenderness and the absence of vaginal discharge or irritation. (Strong) 

                                                                

8.     Complicated cases of UTI may also be ruled out on history and physical examination. Uroflowmetry and determining post void residual are suggested tests in postmenopausal women to exclude complicated cases of UTI. (Conditional)                

9.     Culture and sensitivity analysis when symptomatic and in 2 weeks from sensitivity-adjusted treatment to confirm UTI guide further treatment and exclude persistence. (Strong)

10. Further investigations e.g. (pelviabdominal US, PUT, CT abdomen and pelvis with or without contrast or cystoscopy) are not routinely recommended except in atypical cases. (Strong)

11. management and follow-up

Behavioral modifications are suggested e.g. reduced fluid intake, habitual and post-coital delayed urination, wiping from front to back after defecation, douching and wearing occlusive underwear. (good practice statement)

12. Non antimicrobial measures: Hormonal replacement: Use vaginal estrogen cream in post- menopausal women to prevent recurrent UTIs.   (good practice statement)

13. Immunoactive prophylaxis: Use OM-89(Uro-vaxom) as an immunoprophylaxis in females with recurrent UTIs. (Strong)                                                                                      

14. Prophylaxis with cranberry: Do not use cranberry as a prophylaxis against recurrent UTIs.     (Conditional)

 

Recommendations for uncomplicated pyelonephritis

15. Detailed history taking and urinalysis including the assessment of white and red blood cells and nitrite, for routine diagnosis. (Strong)

16. perform urine culture and antimicrobial susceptibility testing in patients with pyelonephritis. (Strong)

17. Imaging of the urinary tract (US) to exclude urgent urological disorders.Strong

18. treat patients who will be managed as outpatients by single-drug oral therapy with a fluoroquinolone or cephalosporines. (Strong)

19. Patients requiring hospitalization should be treated initially with an intravenous antimicrobial regimen e.g. a fluoroquinolone, an aminoglycoside (with or without ampicillin), or an extended- spectrum cephalosporin.       (Strong)

20. Carbapenem is used only in patients with early culture results indicating the presence of multi-drug resistance organisms. (Strong)

 

     Recommendations for complicated UTI

21. Urinalysis is recommended including the assessment of white and red blood cells and nitrite, for routine diagnosis.     (Strong)

22. Performing urine culture and antimicrobial susceptibility testing is also recommended in patients with complicated UTI. (Strong)

23. Imaging of the urinary tract with US to exclude urgent urological disorders is recommended. Additional investigations, such as an unenhanced helical computed tomography (CT) is recommended if the patient remains febrile after 72 hours of treatment. (Strong)

24. For diagnosis of complicating factors in pregnant women, US, or magnetic resonance imaging (MRI) is recommended to avoid radiation risk to the foetus. (Strong)

25. It is recommended to properly manage the urological abnormality or the underlying complicating factor.        (Strong)

26. Renal abscess: IT can rupture into the urinary tract or penetrate through the renal capsule to become a perinephric abscess. Use of IV combined antibiotics and careful observation of a small abscess less than 3 cm or even 5 cm in a clinically stable patient. Percutaneous drainage if greater than 5 cm in diameter or open surgical drainage if percutaneous drainage failed. (Strong)

27. Perinephric abscess: Broad spectrum antimicrobial agents are to be started immediately upon diagnosis of perinephric abscess. For larger collections or those not responsive to initial antibiotic therapy, intervention by percutaneous drainage techniques, by US or CT is recommended. Surgical drainage, or nephrectomy if the kidney is nonfunctioning or severely infected. (Strong)

28. Emphysematous pyelonephritis: Most patients are septic, and fluid resuscitation and broad-spectrum antimicrobial therapy is nedded . If the kidney is functioning, medical therapy can be considered. If a kidney is obstructed, catheter drainage is considered. If the affected kidney is nonfunctioning and not obstructed, nephrectomy should be performed because medical treatment alone is usually lethal. Nephrectomy is recommended for patients who do not improve after a few days of therapy. (Strong)

29. Xanthogranulomatous pyelonephritis (XGP): This is characterized by a chronic purulent, fatty inflammation of the renal parenchyma, the pelvis, and the hilar tissue. The primary obstacle to the correct treatment ofXGP is incorrect diagnosis. broad-spectrum antimicrobial therapy is recommended to stabilize the patient preoperatively, and, occasionally, long-term antimicrobial therapy will eradicate the infection and restore renal function. Because the renal abnormality may be diagnosed preoperatively as a renal tumor and/ or is diffuse, nephrectomy is  usually  performed.  If  localized  XGP  is  diagnosed preoperatively or at exploration, it is amenable to partial nephrectomy. (Strong)

Recommendations for catheter-associated UTI

30. Routine urinary culture only in symptomatic patients, take the sample from the catheter using an aseptic technique, if the catheter has been removed obtain a midstream urine sample.  (Strong)

31. Don’t use pyuria as indicator for catheter associated UTI, the longer the catheter in place, the most likely bacteria will be found. After one month nearly all patients have bacteriuria. (Strong)

32. Don’t use the presence or absence of odorous or cloudy urine  alone to differentiate CA-UTI from CA- asymptomatic bacteriuria. (Strong)

33. Give oral antibiotics as a first line if the person can take oral medications, and the severity of their condition does not require intravenous antibiotics. (Strong)

34. Choice of intravenous antibiotics (if vomiting, unable to take oral antibiotics or severely unwell). Antibiotics may be combined if susceptibility of sepsis is a concern. (Strong)

35. Don’t treat CA-UTI asymptomatic bacteriuria in general except prior to traumatic urinary tract intervention and pregnant woman as of increased risk of pyelonephritis and preterm labor.     (Strong)

 Recommendations for urosepsis

36. Perform the quick SOFA score to identify patients with potential sepsis. (Strong)

37. Take a urine culture and two sets of blood cultures before starting antimicrobial treatment. (Strong)

38. We suggest Using biomarkers for diagnosis; however, urosepsis cannot be diagnosed from biomarkers alone. Procalcitonin monitoring may be useful in patients likely to develop sepsis and to differentiate from a severe inflammatory status not due to bacterial infection, Serum lactate is a marker of organ dysfunction and is associated with mortality in sepsis. (Conditional)

39. urosepsis treatment requires a combination of appropriate antimicrobial therapy, source control (obstruction of the urinary tract) and adequate life-support care. (Strong)

40. urologists collaborate with intensive care and infectious disease specialists for the best management of the patient is suggested.  (good practice statement)

 

 Recommendations for urethritis

41. Detailed history taking and urine analysis (first voided urine) and leukocyte esterase testing is diagnostic of urethritis.  (Strong)

42.  We suggest Gram or methylene-blue stain of urethral secretions, to diagnose gonococcal urethritis. (Conditional)

43. It is strongly recommended to instruct Patients to abstain from sexual intercourse for seven days after therapy. (Strong)

44. Gonococcal urethritis : Nucleic acid amplification tests are suggested (NAAT) especially in cases of urethritis with negative Gram stain test as it is more sensitive and specific in diagnosis of chlamydial and gonococcal infections.Urethral swab culture is suggested before initiation of treatment, in patients with a positive NAAT for gonorrhea to assess the antimicrobial resistance profile of the infective strain. (Conditional)

45. Urethral swab culture for N. gonorrhoeae and C. trachomatis is suggested in treatment failure or persistence of symptoms more than 4 weeks of treatment. (Conditional)

46. It is recommended to assess all sexual partners at risk. Empirical treatment is strongly recommended following diagnosis especially in severe cases.Combination treatment using two antimicrobials with different mechanisms of action is strongly recommended.It is strongly recommended to start with Ceftriaxone 1 g intramuscularly or intravenously with azithromycin 1 g single oral dose as first line treatment.   (Strong)

47. Non-gonococcal urethritis: Oral doxycycline 100 mg twice daily for seven days as first-line treatment is strongly recommended. (Strong)

48. It is also suggested, single dose oral azithromycin 500 mg day one and 250 mg days two to four. Fluoroquinolones, such as ofloxacin or levofloxacin is considered as second-line treatment only in selected cases. (Conditional)

49. Oral metronidazole or tinidazole 2 g single dose as first-line treatment for urethritis caused by T. vaginalis.  (Strong)

 

Recommendations for Acute Bacterial Prostatitis

50. Detailed history taking and mid-stream urine analysis, testing for nitrite and leukocytes is strongly recommended. (Strong)

51. Mid-stream urine culture and sensitivity for proper antimicrobial treatment is suggested  and Transrectal ultrasound is considered  if prostatic abscess is highly suggested. (Conditional)

52. Empirical high doses bactericidal antimicrobials, such as broad- spectrum penicillin, a third-generation cephalosporin or fluoroquinolones are recommended.It is recommended to continue oral treatment after improvement of general condition for two to four weeks.In case of prostatic abscess, both surgical drainage or conservative treatment according to abscess size and general condition is recommended. (Strong)

 

Recommendations for Chronic Bacterial Prostatitis CBP

53. Detailed history taking including (sexual activities, marital status and age of marriage) is recommended. (Strong)

54. The Meares and Stamey 2- or 4-glass test is strongly recommended in patients with CBP. (Strong)

55. Prostatic biopsy is not recommended to avoid sepsis. (Strong)

56. Transrectal ultrasound is suggested in selected cases to rule out chronic prostatic abscess and prostatic calcification. (good practice statement)

57. Semen culture is suggested as a part of evaluation of chronic bacterial prostatitis. (good practice statement)

58. PSA testing is not recommended for patients with CBP as it has no clinical or practical significance. (Strong)

59. Fluoroquinolone is strongly recommended as a first-line treatment for 4-6 weeks Doxycycline is recommended for Mycoplasma infection 100 mg BID for 10 days. (Strong)

60. Metronidazole is suggested in patients with Trichomonas vaginalis for 14 days. (conditional)

 

Recommendations for acute infective epididymitis

61. Obtain detailed history, symptoms analysis and also obtain first voided urine and a mid-stream urine for pathogen identification by culture and nucleic acid amplification test. (Strong)

62. Prescribe a single antibiotic or a combination of two antibiotics active against Chlamydia trachomatis and Enterobacteriaceae in young sexually active men. in older men without sexual risk factors only Enterobacteriaceae should be considered.      (Strong)

63. Give single dose ceftriaxone 500 mg intramuscularly in addition to a course of an antibiotic active against Chlamydia trachomatis if gonorrheal infection is suspected. (Strong)

 

Recommendations for Fournier’s gangrene

64. Start treatment for Fournier’s gangrene with broad-spectrum antibiotics on presentation, with subsequent refinements according to culture and clinical response. (Strong)

65. Commence repeated surgical debridement for Fournier’s gangrene within 24 hours of presentation. (Strong)

66. We consider performing primary or secondary wound closure for scrotal defects ≤ 50%, with the use of flaps or skin grafts for defects involving > 50% of the scrotum or with extension outside the scrotum.  (good practice statement)

 

 Recommendations for antimicrobial prophylaxis in different urologic procedures

67. We consider it before urodynamic study and cystography. (Conditional)

68. We consider it before urethral catheterization and removal. (good practice statement)

69. We consider it before Shock-Wave Lithotripsy. (Conditional)

70. We consider it before Simple Cystoscopy. (Conditional)

71. We recommend it before TRUS guided prostatic biopsy, Transurethral Resection of the Prostate and bladder tumors, ureteroscopy, percutaneous renal Surgery and open or laparoscopic surgery. (Strong)

 

Recommendations for urinary Schistosomiasis

72. Urine analysis for diagnosis should be collected between 9 AM and 3 PM. to assess the egg count. (Strong)

73. Serologic tests: (Strong)

o   It is strongly recommended when the diagnosis of urinary schistosomiasis is suspected, and urine is negative for eggs

o   FAST-ELISA followed by Western blot analysis.

o   Patients become antibody positive after 4-6 months from infection PCR for antigen detection:Detection of circulating anodic antigen in serum and urine are specific for active infection and quantitative measurements useful for determining infection severity   

74. Praziquantel is the recommended oral treatment now,It is currently recommended by the WHO Dose: Two 20-mg/kg oral doses of PZQ are given on the same day, 6 to 8 hours apart (or alternatively, one 40-mg/kg dose) The drug has lower effect against schistosomula than adult worms, so another course should be repeated after several weeks to ensure eradication of infection. (Strong)

75. Cystoscopy is highly recommended if LUTS is persisting after adequate medical treatment or radiological findings of bladder lesions. (Strong)