Systematic Review and Meta-Analysis Provide no Guidance on Management of Asymptomatic Bacteriuria within the First Year after Kidney Transplantation.

(1) Background: Urinary tract infections (UTIs) are among the most frequent complications in kidney transplant (KT) recipients. Asymptomatic bacteriuria (ASB) may be a risk factor for UTIs and graft rejection. We aimed to evaluate available evidence regarding the benefit of screening and treatment of ASB within the first year after KT. (2) Evidence acquisition: A systematic literature search was conducted in MEDLINE, the Cochrane Library CENTRAL and Embase. Inclusion criteria were manuscripts in English addressing the management of ASB after KT. The PICO questions concerned Patients (adults receiving a KT), Intervention (screening, diagnosis and treatment of ASB), Control (screening and no antibiotic treatment) and Outcome (UTIs, sepsis, kidney failure and death). (3) Evidence synthesis: The systematic review identified 151 studies, and 16 full-text articles were evaluated. Seven were excluded because they did not evaluate the effect of treatment of ASB. There was no evidence for a higher incidence of lower UTIs, acute pyelonephritis, graft loss, or mortality in patients not treated with antibiotics for ASB. Analysis of comparative non-randomized and observational studies did not provide supplementary evidence to guide clinical recommendations. We believe this lack of evidence is due to confounding risk factors that are not being considered in the stratification of study patients.

Management of patients who opt for radical prostatectomy during the coronavirus disease 2019 (COVID-19) pandemic: an international accelerated consensus statement.

OBJECTIVE: Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. The objective of this work is to develop guidance on criteria for prioritisation of surgery and reconfiguring management pathways for patients with non-metastatic prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve a low likelihood of coronavirus disease 2019 (COVID-19) hazard if radical prostatectomy (RP) was to be carried out during the outbreak and whilst the disease is endemic. METHODS: We conducted an accelerated consensus process and systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n = 34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. The Consensus opinion was defined as ≥80% agreement and this was used to reconfigure the prostate cancer pathways. RESULTS: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and measures developed to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritisation criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as 'COVID-19 cold' sites. CONCLUSION: Reconfiguring management pathways for patients with prostate cancer is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing RP within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery.

Metagenomics in diagnosis and improved targeted treatment of UTI.

INTRODUCTION: The genomic revolution has transformed our understanding of urinary tract infection. There has been a paradigm shift from the dogmatic statement that urine is sterile in healthy people, as we are becoming forever more familiar with the knowledge that bacterial communities exist within the urinary tracts of healthy people. Metagenomics can investigate the broad populations of microbial communities, analysing all the DNA present within a sample, providing comprehensive data regarding the state of the microenvironment of a patient's urinary tract. This permits medical practitioners to more accurately target organisms that may be responsible for disease-a form of 'precision medicine'. METHODS AND RESULTS: This paper is derived from an extensive review and analysis of the available literature on the topic of metagenomic sequencing in urological science, using the PubMed search engine. The search yielded a total of 406 results, and manual selection of appropriate papers was subsequently performed. Only one randomised clinical trial comparing metagenomic sequencing to standard culture and sensitivity in the arena of urinary tract infection was found. CONCLUSION: Out of this process, this paper explores the limitations of traditional methods of culture and sensitivity and delves into the recent studies involving new high-throughput genomic technologies in urological basic and clinical research, demonstrating the advances made in the urinary microbiome in its entire spectrum of pathogens and the first attempts of clinical implementation in several areas of urology. Finally, this paper discusses the challenges that must be overcome for such technology to become widely used in clinical practice.

Appropriate empiric antibiotic choices in health care associated urinary tract infections in urology departments in Europe from 2006 to 2015: A Bayesian analytical approach applied in a surveillance study.

BACKGROUND: Health care associated urinary tract infections (HAUTI) is a common complicating factor of urological practice. It is unclear what the appropriate empirical antibiotic choices are and how infection control policies (ICP) influence this. The aim of this study is to use probabilistic approaches towards the problem. That is to determine the chances of coverage of empirical antibiotic choices in HAUTIs and their annual trends in Europe. In addition, the impact of departmental self-reported compliance with catheter management and regulated usage of prophylactic antibiotics policies was tested. The estimated chances of coverage of antibiotics and further probabilistic calculations are carried out using the Global Prevalence of Infections in Urology (GPIU) annual surveillance study European data. METHODS: GPIU is a multi-state annual prevalence study conducted in urology departments to detect patients with HAUTIs, using the Center for Disease Control (CDC) definitions and antimicrobial resistance (AMR). In this analysis; the European cohort from 2005 to 2015 was used. The estimated chance of coverage for each antibiotic choice in HAUTIs was calculated using the Bayesian Weighted Incidence Syndromic Antibiogram (WISCA) approach. Annual trend of the overall cohort and number of appropriate antibiotic choices were estimated. Departments were compared according to their self-reported compliance to ICPs to determine if there was an impact on chances of coverage and appropriate antibiotic choices. RESULTS: We estimated that in most study years less than half of the single agent antibiotics and all combination options were appropriate for empirical treatment of HAUTIs. Departments with compliance to both ICPs were estimated to have 66%(2006) to 44% (2015) more antibiotic choices compared to departments with complete lack of compliance to the ICPs. In our estimates departments with adherence to a single policy was not superior to departments with complete lack of adherence to ICPs. CONCLUSIONS: Most single agent choices had limited coverage for HAUTIs and combination choices had improved chance of coverage. Optimal antibiotic selection decision should be part of decision experiments and tested in local surveillance studies. Departments with self-reported compliance to ICPs have more antibiotic choices and details of the compliance should be evaluated in future studies. The analysis herein showed that over the 10-year course there was no clear time trend in the chances of coverage of antibiotics (Bayesian WISCA) in European urology departments.

Management of Urethritis: Is It Still the Time for Empirical Antibiotic Treatments?

CONTEXT: Urethritis prevalence in Europe changed in the last years due to both the increase of migratory streams from North Africa and the more frequent exposition of males to relevant risk factors. Owing to these reasons, urethritis treatment should be optimized by accurate microbiological investigations to avoid the risk of persistence, recurrence, or reinfection. OBJECTIVE: The aim of this systematic review is to optimize the treatments for urethritis and investigate the applicability of nucleic acid amplification test (NAAT) as the primary microbiological investigation. EVIDENCE ACQUISITION: A literature search in Medline, Cochrane, and Google Scholar databases was conducted up to June 2018. Subject headings were selected as follows: Urethritis OR gonococcal urethritis OR non-gonococcal urethritis AND Antibiotics OR Recurrence. A total of 528 abstracts were identified and selected. Finally, 12 full-text articles were selected for a qualitative synthesis. The Preferred Reported Items for Systematic Reviews and Meta-Analyses statement was used to perform an accurate research checklist and report. EVIDENCE SYNTHESIS: Empirical treatments are no more recommended, although a broad spectrum of antibiotic therapy may be initiated while awaiting the results from pathogens' microbiological characterization. First-line treatment for gonococcal urethritis consists of a single dose of ceftriaxone/azithromycin combined therapy. Specific therapies should be initiated for nongonococcal urethritis according to each single pathogen involved in the infection process. Owing to this reason, NAAT is mandatory in the clinical approach to the disease, although the Gram stain of urethral discharge or smear remains applicable for some less frequent nongonococcal urethritis. Moreover, the urethritis "modern view" also includes noninfectious etiologies that occurred after traumas or injection of irritating compounds. Sexual abstinence of at least 7 d should be observed from the start of treatment to avoid reinfection, while sexual partners should evenly be treated. CONCLUSIONS: The treatment of urethritis implies accurate determination of pathogens involved in the infection process by NAAT with subsequent appropriate antibiotic therapy, thus avoiding the risk of antibiotic resistance and overuse of antibiotics indicated for empirical treatments. The population exposed to relevant risk factors should be adequately informed about the increased risk of developing infections and motivated toward the intensive use of condoms during sexual intercourses. PATIENT SUMMARY: Urethritis is a sexually transmitted disease generally characterized by urethral discharge or other symptoms such as itching, tingling, and apparent difficulties in having a regular urinary flow. Microbiological investigations are mandatory to obtain satisfactory results from the treatment. Multiple antibiotic treatments are often necessary due to the high risk of multiple pathogens responsible for the disease. Similarly, sexual partners should be investigated and treated in the same way. Several risk factors such as immunodeficiency, multiple sexual partners, homo- and bisexuality, and alcohol abuse may be related to the disease. In these cases, the use of condom is strongly recommended.

Aspects of urinary tract infections and antimicrobial resistance in hospitalized urology patients in Asia: 10-Year results of the Global Prevalence Study of Infections in Urology (GPIU).

OBJECTIVES: To assess Asian data from Global Prevalence Study on Infections in Urology (GPIU study) which has been performed more than 10 years. METHODS: Seventeen Asian countries participated in the GPIU study between 2004 and 2013. Data for these countries were collected from the web-based GPIU database. The point prevalence of urinary tract infections (UTI) and antimicrobial susceptibility of representative pathogens were analysed for Asian geographic regions. RESULTS: A total of 6706 patients (5271 male, 1435 female) were assessed during the study period, and 659 patients were diagnosed with a UTI (9.8%). Of these UTI patients, 436 were male and 223 were female. Mean patient age was 54.9 ± 19.3 years. Pyelonephritis and cystitis were the most common clinical diagnoses, representing 30.7% and 29.9% of patients, respectively. Escherichia coli was the most frequently identified uropathogen (38.7%). For the patients with urinary tract infection, cephalosporins were the most frequently used antibiotics (34.4%), followed by fluoroquinolones (24.1%), aminoglycosides (16.8%). Fluoroquinolone resistance was relatively high (ciprofloxacin 54.9%, levofloxacin 39.0%), and cephalosporin resistance 42% (42.5-49.4%). Of the antibiotics evaluated, uropathogens had maintained the highest level of susceptibility to amikacin and imipenem (24.9% and 11.3% resistance rates, respectively). CONCLUSION: Uropathogens in many Asian countries had high resistance to broad-spectrum antibiotics. Knowledge of regional and local resistance data and prudent use of antibiotics are important for proper management of UTI in Asian countries.

Comparison of White Light, Photodynamic Diagnosis, and Narrow-band Imaging in Detection of Carcinoma In Situ or Flat Dysplasia at Transurethral Resection of the Bladder: the DaBlaCa-8 Study.

OBJECTIVE: To compare findings in NBI to findings in WL and PDD in a high-risk patient population. MATERIALS AND METHODS: A total of 171 patients were included in the study from 4 different urology departments in Denmark and Norway. Patients were scheduled for a PDD-guided transurethral tumor resection or cystoscopy-guided biopsy in accordance with Danish guidelines, on the suspicion of primary or concomitant CIS. All patients were examined with WL cystoscopy followed by both NBI and PDD before biopsy. RESULTS: A total of 136 patients were biopsied due to findings with suspicion of CIS in at least 1 modality (482 biopsies with a mean of 3.5 biopsies per patient). Analysis at patient level showed that NBI and PDD had a significantly higher sensitivity regarding identification of CIS and dysplasia compared with WL (NBI: 95.7%, PDD: 95.7% vs WL: 65.2%, P < .05). Specificity was not significantly different between the 3 methods (NBI: 52.0%, PDD: 48.0%, and WL: 56.8%). When analyzed per biopsy, NBI and PDD had a significantly higher sensitivity than WL (NBI: 72.7% and PDD: 78.2% vs WL: 52.7%, P < .05), whereas the positive predictive values were not significantly different (NBI: 23.7%, PDD: 22.2%, and WL: 19.0%). CONCLUSION: NBI was found to be a valid alternative to PDD regarding diagnosis of CIS and flat dysplasia.

Renal Abscess Caused by Extended-Spectrum Beta-Lactamase-Producing Bacteria and Complicated by the Perforation to a Cyst and to the Renal Pelvis.

We report a 50-year-old female patient with a left-sided renal abscess caused by extended-spectrum ß-lactamase-producing bacteria. According to the ORENUC classification she had phenotype N. The course was complicated by a perforation to an adjacent cyst and later to the renal pelvis. A primarily conservative approach of intravenous antibiotics had to be changed to an ultrasonography-guided percutaneous drainage of the lesion and insertion of a ureteral stent to stem a high volume of urine leakage. Drainage of a renal abscess is indicated if the size is larger than 3 cm according to EAU guidelines (relative size) or when the resolution does not occur after antibiotics. One-year follow-up showed the patient made a full recovery with no recurrence of a urinary tract infection or of any abscess.

The Global Prevalence of Infections in Urology (GPUI) Study: A Worldwide Surveillance Study in Urology Patients.

The GPIU study is currently the only study registering health care-associated urogenital tract infections, especially in urology patients, in an ongoing surveillance protocol that can help to deliver data on adequate empirical antibiotic therapy in hospitalised urology patients according to guideline recommendations. The annual GPIU study will continue to be performed in November of each year under the URL http://gpiu.esiu.org/.

Urinary Tract Infections in Immunocompromised Patients with Diabetes, Chronic Kidney Disease, and Kidney Transplant.

CONTEXT: This paper provides a brief overview of urinary tract infections (UTIs) in immunocompromised patients from the perspective of a practicing urologist. OBJECTIVE: The primary objective was to provide an update on UTIs in immunocompromised patients. Diabetes mellitus (DM), chronic kidney disease, and kidney transplant (KT) are the most common clinical cases encountered by urologists. Diagnosis, management, and future research needs are summarised. EVIDENCE ACQUISITION: We conducted a nonsystematic review of the literature. A comprehensive search of the PubMed database between 1996 and 2016 was performed. EVIDENCE SYNTHESIS: Clinical diagnosis of UTIs in immunocompromised patients is challenging. Causative pathogens in DM are slightly different to those in the general population, but without any difference in resistance profiles. Keeping serum glucose under control is the most important preventive measure. The prevalence of UTIs in patients with autosomal dominant polycystic kidney disease (ADPKD) is 21-75%. Lipophilic antibiotics are effective in the treatment of infected cysts, albeit with a trend for lower effectiveness due to increasing resistance rates. UTIs are the most common infections in KT recipients, with a reported rate of 45-72%. Diagnostic challenges exist for both ADPKD and KT patients who develop UTIs. Treatment of UTIs should be tailored according to individual patient characteristics and the severity classification framework suggested by the European Society of Infections in Urology. CONCLUSIONS: The underlying pathophysiology of UTIs in immunocompromised patients is not well known, which limits UTI management, including early diagnosis, treatment, and prevention. Future research to identify patients at higher risk of UTIs is necessary. PATIENT SUMMARY: In this report we looked at patients with a weakened immune system who are more likely to develop a urine infection. We focused on the patient groups most commonly encountered in a urology setting. We found that these patients have a higher risk of urinary infection, but the signs of infection may be different to those in the general population. Early diagnosis is imperative in this group. Further research on early diagnosis and better individualised management strategies are necessary.

Healthcare-associated urinary tract infections in hospitalized urological patients--a global perspective: results from the GPIU studies 2003-2010.

INTRODUCTION: European Section for Infections in Urology has been conducting an annual prevalence survey investigating various aspects of healthcare-associated urinary tract infections (HAUTI) since 2003. MATERIAL AND METHODS: The data on various clinical categories of HAUTI, the contamination status of HAUTI patients who underwent any urological intervention with regard to microorganisms isolated, resistance status and antibiotics used to treat HAUTI will be presented. RESULTS: Of a total of 19,756 patients screened, 1,866 patients had HAUTI (9.4 %); 1,313 males (70.4 %) and 553 (29.6 %) females. Mean age was 59.9 ± 18.2. Asymptomatic bacteriuria (ASB) and cystitis were the most frequent clinical diagnoses representing 27.0 and 26 % of all HAUTI, respectively. Echerichia coli was found to be the most frequent uropathogen (544 of 1,371 isolates) (39.7 %). Fluoroquinolones were preferred in 26.6 % of cases followed by cephalosporins (23.3 %), aminoglycosides (14.1 %) and penicillins (13.8 %). High global resistance rates to ciprofloxacin (>50 %), cephalosporins (35-50 %) and penicillins (50 %) were found in the GPIU studies 2003-2010. DISCUSSION: We showed that around 10 % of hospitalized urological patients are at risk to develop HAUTI often caused by multiresistant uropathogens. Increased antibiotic use often with broad-spectrum antimicrobials will inevitably be followed by increasing bacterial resistance. To interrupt such a vicious cycle, our results suggest (1) there is still room for improvement in surgical prophylaxis in terms of limiting exposure to antibiotics and (2) far too many patients with ASB are being treated which shows that the new proposal of classification should be adopted where ABS is regarded as colonization and not as an infection to be treated.

Antibiotic prophylaxis in urology departments, 2005-2010.

BACKGROUND: Antibiotic prophylaxis (AP) is an important measure in preventing health care-associated urinary tract infections (HAUTIs). Despite regional variations in the bacterial spectrum and antibiotic susceptibility patterns, guideline recommendations are usually given on an international level. OBJECTIVE: To describe the use of AP in urology departments and relate this to relevant parameters such as country, type of hospital, and European Association of Urology guideline recommendations. DESIGN, SETTING, AND PARTICIPANTS: Data from the Global Prevalence Study on Infections in Urology for the period 2005-2010 were analysed to evaluate the use of antibiotics in general and AP for urologic procedures. Of the 13 723 patients enrolled, 8178 received antibiotics on the study days. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Study data were imported from the Web-based survey into Microsoft Access and exported into SPSS v.17.0. The data were then coded and analysed. The Pearson chi-Square test was used to compare categorical data and a probability level of 5% was considered significant. Multiple logistic regression analysis was used to define significantly different variables in multiple set categories. RESULTS AND LIMITATIONS: Questions on AP were answered on 8370 forms and 6306 (75.3%) investigators reported their routine application of AP. Routine AP was highest in Latin America (n=337; 84%), followed by Asia (n=1338; 86%), Africa (n=234; 85%), and Europe (n=4116; 67%). The antibiotics most frequently used for AP were second-generation cephalosporins, ciprofloxacin, cefotaxime, and amoxicillin plus beta-lactamase inhibitor. CONCLUSIONS: There were significant differences between countries/regions and types of hospitals, both in using AP for clean procedures and in the types of antibiotics used. AP was not always consistent with recommended guidelines.

The immediate and 6-mo reproducibility of pressure-flow studies in men with benign prostatic enlargement.

OBJECTIVES: Urodynamics is an objective method of diagnosing bladder outlet obstruction (BOO) in men. This study examined the immediate and 6-mo reproducibility of this investigation. METHODS: Urodynamics was performed in men as part of a multinational, multicentre, double-blind, placebo-controlled drug trial. Each patient had two fill/void cycles both at baseline and 6 mo. The BOO index (BOOI) and bladder contractility index (BCI) were calculated for each cycle and data analysed to look for changes in immediate and 6-mo reproducibility between the two fill/void cycles. RESULTS: A total of 114 patients had urodynamics at baseline. In the immediate term, although there was a small but statistical fall in both the BOOI and BCI, with cycle one figures greater than those in cycle two, 81% and 79% of patients remained in the same BOOI and BCI category, respectively. At 6 mo, the differences were not statistically different with 70% of patients remaining unchanged in their BOOI category in cycle one and 71% in cycle two; 65% remained unchanged in their BCI category in cycle one and 74% in cycle two. No patient with a BOOI > 65 changed category in the second investigation, and only 5 of 103 first cycles with a BOOI > or = 50 changed category to equivocal obstruction. CONCLUSIONS: Urodynamics has good reproducibility when looking at the BOOI and BCI, indicating that a second study is not necessary in most patients and one investigation is sufficient for an accurate diagnosis on which treatment options can be based.