Urinary Tract Infection

Recommendations

GRADE

Level             of certainty

Strength Rating

Diagnosis of ABU is made by urine culture, either properly collected

clean-catch specimen or a catheterized specimen is acceptable.

High

(3,4)

Strong

Do not to treat ABU in the following condition. 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.

High (5,6)

Strong

Treat ABU prior urologic procedure breaching the mucosa and in pregnancy.

High (5,6)

Strong

Recommendations

GRADE

Level             of certainty

Strength Rating

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

High (7)

Strong

Uses of urine cultures in the following situations: suspected acute pyelonephritis.

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

women who present with atypical symptoms. Pregnant women.

High (7,8)

Strong

Women with uncomplicated cystitis should be treated by antimicrobial therapy with or without symptomatic treatment

High (9)

Strong

Recommendations

GRADE

Level    of certainty

Strength Rating

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.

High (8,9)

Strong

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

Low (8,9)

Conditional

Culture and sensitivity analysis when symptomatic and in 2 weeks from sensitivity-adjusted treatment to confirm UTI guide further

treatment and exclude persistence.

High (8,9)

Strong

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

High (8,9)

Strong

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.

Low (8,9)

good practice statement

Non antimicrobial measures:

Hormonal replacement: Use vaginal estrogen cream in post- menopausal women to prevent recurrent UTIs

Low (8,9)

good practice statement

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

High (8,9)

Strong

Prophylaxis with cranberry: Do not use cranberry as a prophylaxis against recurrent UTIs.

Moderate (8,9)

Conditional

Recommendations

GRADE

Level of certainty

Strength Rating

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

High (10-12)

Strong

perform urine culture and antimicrobial susceptibility testing in patients with pyelonephritis.

High (10-12)

Strong

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

High (10-12)

Strong

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

High (10-12)

Strong

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.

High (10-12)

Strong

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

High (10-12)

Strong

Recommendations

GRADE

Level of certainty

Strength Rating

Urinalysis is recommended including the assessment of white and red blood cells and nitrite, for routine diagnosis

High (10)

Strong

Performing urine culture and antimicrobial susceptibility testing is also recommended in patients with complicated UTI

High (10,11)

Strong

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.

High (10-12)

Strong

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

High (10)

Strong

It is      recommended     to properly manage             the urological abnormality or the underlying complicating factor.

High (10)

Strong

Recommendations

GRADE

Level of certainty

Strength Rating

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.

High (13,14)

Strong

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.

High (15)

Strong

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.

High (16)

Strong

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

High (17)

Strong

Recommendations

GRADE

Level of certainty

Strength Rating

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.

High (18,19)

Strong

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.

High (18,19)

Strong

Don’t use the presence or absence of odorous or cloudy urine

alone to differentiate CA-UTI from CA- asymptomatic bacteriuria.

High (18,19)

Strong

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.

High (18,19)

Strong

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.

High (18,19)

Strong

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

High (18,19)

Strong

Recommendations

GRADE

Level of certainty

Strength Rating

Perform the quick SOFA score to identify patients with potential sepsis.

High (21)

Strong

Take a urine culture and two sets of blood cultures before starting antimicrobial treatment.

High (20,21)

Strong

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.

Moderate (20,21)

Conditional

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

High (22)

Strong

urologists collaborate with intensive care and infectious disease specialists for the best management of the patient is suggested.

Low (22)

good practice statement

Recommendations

GRADE

Level of certainty

Strength Rating

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

High (24)

Strong

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

Moderate (24)

Conditional

It is strongly recommended to instruct Patients to abstain from sexual intercourse for seven days after therapy

High (24)

Strong

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.

Low (24)

Conditional

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

Moderate (24)

Conditional

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

High (24)

Strong

Non-gonococcal urethritis:

Oral doxycycline 100 mg twice daily for seven days as first-line treatment is strongly recommended.

High (24)

Strong

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.

Moderate (24)

Conditional

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

High (24)

Strong

Recommendations

GRADE

Level of certainty

Strength Rating

Detailed history taking and mid stream urine analysis, testing for nitrite and leukocytes is strongly recommended.

High (25)

Strong

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

Moderate (26)

Conditional

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

High (26,27)

Strong

Recommendations

GRADE

Level of certainty

Strength Rating

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

High

Strong

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

High (27,28)

Strong

Prostatic biopsy is not recommended to avoid sepsis.

Moderate (27,28)

Strong

Transrectal ultrasound is suggested in selected cases to rule out chronic prostatic abscess and prostatic calcification.

Low (27,28)

good practice statement

Semen culture is suggested as a part of evaluation of chronic bacterial prostatitis.

Low (28)

good practice statement

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

Moderate (28)

Strong

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

High (28)

Strong

Metronidazole is recommended in patients with Trichomonas vaginalis for 14 days

High (28)

conditional

Recommendations

GRADE

Level of certainty

Strength Rating

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.

High (29)

Strong

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.

High (29)

Strong

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

High (29)

Strong

Recommendations

GRADE

Level of certainty

Strength Rating

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

High (30)

Strong

Commence repeated surgical debridement for Fournier’s gangrene within 24 hours of presentation.

High (30)

Strong

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.

Low (30)

good practice statement

Recommendations

GRADE

Level of certainty

Strength Rating

We consider it before urodynamic study and cystography.

Low (35)

Conditional

We consider it before urethral catheterization and removal.

Low(36)

good practice statement

We consider it before Shock-Wave Lithotripsy.

Moderate (37)

Conditional

We consider it before Simple Cystoscopy.

Moderate (10)

Conditional

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.

High (39-44)

Strong