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Abstract
The European Section for Infections in Urology (EAU) has introduced a new
concept of severity assessment of urinary tract infections (UTI). The assessment is based on clinical presentation, patient risk factors and availability
of effective antibiotics. Instead of the old classification of uncomplicated
and complicated UTI, ESIU suggests to describe risk factors by means of
phenotyping. In this paper we present the new classification and give practical recommendations on antibiotic treatment of the most common community acquired and hospital acquired urinary tract infections.
Antibiotics have been prescribed so extensively that resistant bacteria
have made prophylaxis and treatment of urinary tract infections a more
difficult task.
Prophylaxis during surgical procedures should be prescribed according
to the risk of infective complications. The most important criterion is the
contamination category of the procedure. Basically there are four categories: clean, clean-contaminated, contaminated and dirty, but in urology
the clean-contaminated category is subdivided depending on whether the
urinary tract or the gastrointestinal tract is opened.
International guidelines consider pharmacokinetic and pharmacodynamics features of antibiotics and global resistance data. These recommendations may therefore need local adaptations. Urologists,
microbiologists and infectious disease specialists should meet in every
hospital to adapt their own guidelines according to local resistance data.
Keywords Antibiotic treatment; clinical presentation; ORENUC; prophylaxis; risk factors; urinary tract infections
Clinical presentation
Introduction
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Clinical presentation of cystitis (CY), pyelonephritis (PN) and urosepsis (US) and grading of severity2
Acronym
Clinical diagnosis
Clinical symptoms
Grade of severity
CY-1
Cystitis
PN-2
PN-3
Severe pyelonephritis
US-4
Urosepsis (simple)a
US-5
Severe urosepsisa
US-6
Uroseptic shocka
3
4
Note: Hypotension due to urosepsis is defined as a systolic blood pressure of <90 mmHg or a reduction of >40 mmHg from baseline in the absence of other causes of
hypotension.
a
Urosepsis is defined as sepsis originating from the urogenital tract.
CVA, costovertebral angle; SIRS, systemic inflammatory response syndrome; WBC, white blood cell.
Table 1
needs initial parenteral therapy and hospitalization. For urosepsis the severity grading of sepsis in general use is: sepsis,
severe sepsis and septic shock. Recently the ESIU suggested
ascribing each of the clinical presentations a severity grade in
Arabic letters.1 The clinical presentation is always the most
important prognostic criterion.
Risk factors
Many categories of risk factors are described in literature on UTI,
such as risk factors for getting UTI, risk factors for recurrences,
risk factors for serious complications, risk factors for kidney
failure, etc. Long and often overlapping lists of risk factors have
been described within a concept of UTIs being either uncomplicated or complicated.7,8 The ESIU found this old concept
not sufficiently reflecting the clinical needs, and introduced a
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Host risk factors in urinary tract infections categorized according to the ORENUC system1,2
Phenotype
O
R
Table 2
Antibiotic stewardship
The overall aim of antibiotic treatment in UTI is to restore a normal
balance between pathogens and the host. This either means getting rid of the pathogens, or causing the pathogens to withdraw to
their habitats outside the urinary tract, or even inside urothelial
cells. Not all pathogens will receive a lethal dose of antibiotics and
some may survive. While resting in their trenches some pathogens
are even capable of developing resistance mechanisms to classes
of antibiotics such as betalactams and spread to other hosts. This is
what collateral damage is about. With a generation time of only 20
minutes new genes are multiplied at high speed thus making
pathogens appear as intelligent creatures. As long as the number of
available antibiotics is limited and resistance increases, our chance
of giving effective prophylaxis and treatment is steadily being
reduced. This is why antibiotic stewardship is important.13
Over the past ten years we have seen a rise in multiresistant
pathogens such as extended spectrum betalactamase producing
strains (ESBL), vancomycin resistant strains and methicillin
resistant staphylococci (MRSA). Recently the first omniresistant
bacteria NDM-1, was described in urine cultures in UK.14 Within
a short time the pathogen spread to most European countries.
Clean
Clean-contaminated
Contaminated
Dirty
Box 1
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Biopsy routes, contamination categories and risk of infection without prophylaxis in prostate biopsies3,11
Biopsy route
Contamination category
Transperineal
Clean
Clean-contaminated
Transperineal
Contaminated
Transrectal
Transrectal
Contaminated
Dirty
Key criteria
Sterile urine
No history UTI/UGI
Sterile urine
History of UTI/UGI
Sterile urine
Bacteriuria Urethral catheter
Risk of infection
<5%
5e10%
10e15%
10e15%
15e40%
Table 3
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Suspected UTI
Suspected UTI always means that treatment is started on an
empirical basis, and usually the situation has to be reassessed
once the identity and susceptibility of the pathogen is known.
According to both US and European guidelines it is acceptable to
diagnose UTI by patient history and clinical examination only
and to initiate treatment on this basis, which should be tailored
as soon as urine culture results are available.
In the majority of community acquired UTI the identity and
susceptibility of the pathogen is unknown at the time when
treatment is started. Primary care physicians must however,
acquaint themselves with local resistance figures because only
drugs with a general resistance in the population of <20% are
recommended as first-line therapy. In terms of hospital acquired
UTI we advocate waiting for evidence from urinalysis and culture
if clinically suitable, otherwise empirical treatment for suspected
UTI is considered. All general recommendations have to be
modified by patient related risk factors.
Community acquired cystitis without known risk factors: according to known susceptibility patterns, the following antibiotics
can be considered the drugs of first choice in many countries,
where available:
fosfomycin trometamol 3 g as a single dose
pivmecillinam 400 mg bid for 3 days and
nitrofurantoin macrocrystal 100 mg bid for 5 days.
Cotrimoxazole 160/800 mg bid for 3 days or trimethoprim
200 mg for 5 days should only be considered as the first choice in
areas with known resistance rates of Escherichia coli below 20%.
Alternative antibiotics are ciprofloxacin 250 mg bid, ciprofloxacin ER 500 mg qd, levofloxacin 250 mg qd, norfloxacin 400 mg
bid and ofloxacin 200 mg bid, each as a 3-day course. However,
collateral effects have to be considered.
Symptomatology may be sufficient for routine follow-up. In
treated patients where symptoms do not resolve and in patients
with early relapse (<2 weeks) urine culture and antimicrobial
susceptibility testing should be performed for guidance of
therapy.19
Community acquired acute pyelonephritis without known
risk factors: due to lack of suitable surveillance studies the
spectrum and susceptibility patterns of uropathogens causing
uncomplicated cystitis has to be used as guide for empiric therapy in a given country. However, Staphylococcus saprophyticus is
to be less considered in acute pyelonephritis as compared to
acute cystitis. In mild and moderate cases of acute uncomplicated
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Conclusions
Severity scoring in UTI is based on clinical presentation,
risk factors and availability of effective antibiotics. Risk
factors may be classified by the ORENUC system.
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Acknowledgements
The authors wish to acknowledge with thanks Drs Peter Tenke, Mete
Cek and Kurt Naber for their critical review of this article during its
preparation.
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