Stopping the effective non-fluoroquinolone antibiotics at day 7 vs continuing until day 14 in adults with acute pyelonephritis requiring hospitalization: A randomized non-inferiority trial

European Association of Urology Guidelines on Urological Infections: Summary of the 2024 Guidelines

BACKGROUND AND OBJECTIVE

Urological infections significantly impact the wellbeing and quality of life of individuals owing to their widespread occurrence and diverse clinical manifestations. The objective of the guidelines panel was to provide evidence-based guidance on the diagnosis, treatment, and prevention of urinary tract infections (UTIs) and male accessory-gland infections, while addressing crucial public health aspects related to infection control and antimicrobial stewardship.

METHODS

For the 2024 guidelines on urological infections, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences.

KEY FINDINGS AND LIMITATIONS

Key recommendations emphasise the importance of a thorough medical history and physical examination for patients with urological infections. The guidelines stress the role of antimicrobial stewardship to combat the rising threat of antimicrobial resistance, providing recommendations for antibiotic selection, dosing, and duration on the basis of the latest evidence.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This overview of the 2024 EAU guidelines offers valuable insights into managing urological infections and are designed for effective integration into clinical practice.

PATIENT SUMMARY

The European Association of Urology has issued an updated guideline on urological infections. The guidelines provide recommendations for diagnosis, treatment, and prevention, with a particular focus on minimising antibiotic use because of the increasing global threat of antimicrobial resistance.

The harmful effects of overlooking acute bacterial prostatitis

Prostatitis is a major urological disease affecting 25%-50% of men over their lifetime. However, prostatitis is often overlooked in nonurologic departments due to its sometimes indeterminate symptoms. In this review, we describe how to recognize and treat acute bacterial prostatitis, which manifests as a clinical problem in other departments as well as urology, to help prevent this disease from being overlooked. There are several possible negative effects of not recognizing acute bacterial prostatitis (ABP). First, initial treatment can fail. In the hyperacute phase, common antibiotics are often effective, but in rare cases, such antibiotics may not be effective. In addition, once ABP progresses to form a prostate abscess, potentially avoidable surgical interventions are often needed. A second issue is the transition to chronic prostatitis. If chronic bacterial prostatitis progresses, treatment requires long-term antibiotic administration and the response rate is not high. Some patients may have to deal with urinary tract infections for the rest of their lives. Finally, there is the problem of overlooking the underlying disease. ABP is rare in healthy adult men without underlying disease, including sexually transmitted diseases as well as benign prostatic hyperplasia, urinary stones, and malignant tumors, and may not be obvious. When examining patients with fever of unknown origin, it is necessary to exclude not only infectious diseases but also collagen diseases and malignant tumors. If there are any doubts, we recommend a rectal exam and consultation with a urologist.

Clinical features, outcomes and predictors of drug resistance and complications in patients admitted with pyelonephritis

Drug resistance and the presence of structural complications have significant implications for the treatment of acute pyelonephritis. We aimed to examine the predictors of drug resistance and complications in a retrospective cohort of patients admitted with pyelonephritis. 188 patients were included in this study. Patients who had had a urinary catheterization in the previous month and who lived outside the district in which the hospital was located were more likely to have ESBL infections. Carbapenem resistance was associated with recent urinary catheterization, a positive urine nitrate test, hypotension requiring vasopressors and the need for intensive care. A history of flank pain, urea level >13.3 mmol/L, a differential neutrophil count >75% and a urinalysis with >1000 leucocytes per high power field was associated with an increased risk of complications. A score derived from these variables to predict structural complications of infection had a sensitivity of 77.8% and a specificity of 67.1.

Usefulness of computed tomography in the diagnosis of acute pyelonephritis in older patients suspected of infection with unknown focus

BACKGROUND

In older adults, the diagnosis of acute pyelonephritis is challenging because of non-specific symptoms and false-positive urine test results. Few studies have investigated the diagnostic performance of computed tomography (CT) signs.

PURPOSE

To evaluate the diagnostic performance of CT signs for acute pyelonephritis in older patients suspected of infection with unknown focus.

MATERIAL AND METHODS

This cross-sectional study was conducted between 2015 and 2018. Patients aged ≥65 years who underwent blood cultures, urine culture, and non-contrast or contrast-enhanced CT on admission were included. Cases with clinically presumable infection focus before CT were excluded. Two radiologists blinded to clinical information independently reviewed five CT signs: perirenal fat stranding; pelvicalyceal wall thickening and enhancement; renal enlargement; thickening of Gerota's fascia; and area(s) of decreased attenuation. The final diagnoses were made by a clinical expert panel.

RESULTS

Among 473 eligible patients, 61 were diagnosed with acute pyelonephritis. When the laterality of findings between the left and right kidneys were considered, the positive and negative likelihood ratios of perirenal fat stranding were 4.0 (95% confidence interval [CI] = 2.3-7.0) and 0.8 (95% CI = 0.7-0.9) in non-contrast CT, respectively. The other signs in non-contrast CT showed similar diagnostic performance with positive and negative likelihood ratios of 3.5-11.3 and 0.8-0.9, respectively.

CONCLUSION

CT signs can help physicians diagnose acute pyelonephritis in older patients suspected of infection with unknown focus.

White paper on antimicrobial stewardship in solid organ transplant recipients

Antimicrobial stewardship programs (ASPs) have made immense strides in optimizing antibiotic, antifungal, and antiviral use in clinical settings. However, although ASPs are required institutionally by regulatory agencies in the United States and Canada, they are not mandated for transplant centers or programs specifically. Despite the fact that solid organ transplant recipients in particular are at increased risk of infections from multidrug-resistant organisms, due to host and donor factors and immunosuppressive therapy, there currently are little rigorous data regarding stewardship practices in solid organ transplant populations, and thus, no transplant-specific requirements currently exist. Further complicating matters, transplant patients have a wide range of variability regarding their susceptibility to infection, as factors such as surgery of transplant, intensity of immunosuppression, and presence of drains or catheters in situ may modify the risk of infection. As such, it is not feasible to have a "one-size-fits-all" style of stewardship for this patient population. The objective of this white paper is to identify opportunities, risk factors, and ASP strategies that should be assessed with solid organ transplant recipients to optimize antimicrobial use, while producing an overall improvement in patient outcomes. We hope it may serve as a springboard for development of future guidance and identification of research opportunities.

Antibiotic treatment of common infections: more evidence to support shorter durations

PURPOSE OF REVIEW

Although there is increasing recognition of the link between antibiotic overuse and antimicrobial resistance, clinician prescribing is often unnecessarily long and motivated by fear of clinical relapse. High-quality evidence supporting shorter treatment durations is needed to give clinicians confidence to change prescribing habits. Here we summarize recent randomized controlled trials investigating antibiotic short courses for common infections in adult patients.

RECENT FINDINGS

Randomized trials in the last five years have demonstrated noninferiority of short-course therapy for a range of conditions including community acquired pneumonia, intraabdominal sepsis, gram-negative bacteraemia and vertebral osteomyelitis.

SUMMARY

Treatment durations for many common infections have been based on expert opinion rather than randomized trials. There is now evidence to support shorter courses of antibiotic therapy for many conditions.

Antibiotics for complicated urinary tract infection and acute pyelonephritis: A systematic review

BACKGROUND

The increasing rates of antibiotic-resistance in recent years have supported emergence of multiple drug-resistant bacteria. Therefore, antibiotics that are recommended by the current clinical guidelines may not be effective for the treatment of complicated urinary tract infection (UTI) and acute pyelonephritis.

AIM

To determine the clinical efficacy and safety of antibiotics for the treatment of complicated UTI and acute pyelonephritis.

METHOD

A search of PubMed, EMBASE, and Google Scholar was conducted for eligible articles describing the use of antibiotics in managing complicated UTI and acute pyelonephritis. The following keywords were used to perform the literature search: “urinary tract infection”, “complicated UTI”, “pyelonephritis”, “treatment”, and “antibiotics”. Additional articles of interest were retrieved from the reference lists of selected papers. Eligibility criteria for this systematic review were diagnosis of either complicated UTI or acute pyelonephritis and use of antibiotics in management. Clinical trials and observational studies were included, while case reports and reviews were excluded. The methodological quality of clinical trials and observational studies was assessed. A descriptive approach was adopted to analyze the data, due to the variation of methodology and interventions.

RESULT

A total of 183 studies were screened, and 8 matched all the eligibility criteria and were included in this review. The antibiotics used included ceftazidime-avibactam, doripenem, levofloxacin, meropenem-vaborbactam, piperacillin-tazobactam, plazomicin, tazobactam-ceftolozane, and gentamicin. Two clinical trials reported that shorter-duration levofloxacin or non-fluoroquinolone antibiotic treatment was as effective as the duration of antibiotic therapy recommended by the current guidelines in treating complicated UTI and pyelonephritis. Besides that, ceftazidime-avibactam, piperacillin-tazobactam and tazobactam-ceftolozane can be used as alternatives to carbapenem in treating extended-spectrum -lactamase-producing Escherichia coli. The cure rates of complicated UTI and pyelonephritis by meropenem-vaborbactam, piperacillin-tazobactam and tazobactam-ceftolozane was comparable (95.6%-98.4%). Furthermore, levofloxacin had a relatively high rate of adverse events (33.1% and 47.7% in two clinical trials respectively), while tazobactam-ceftolozane had a relatively low rate of adverse events (17.5%). All studies have limitations and a potential for bias.

CONCLUSION

N

Frequency and clinical significance of prostatic involvement in men with febrile urinary tract infection: a prospective observational study

Background: Frequent asymptomatic involvement of the prostate has been demonstrated in men with febrile urinary tract infection (fUTI). In view of this, men with fUTI are often given a longer duration of antibiotic treatment; however, evidence to support this is limited. Methods: We prospectively studied adult men with fUTI admitted under the Department of Medicine in a tertiary care hospital in southern India.  fUTI was defined as fever of ≥38°C with at least one symptom/sign of UTI and pyuria, requiring hospitalization. We estimated serum total prostate-specific antigen (PSA) levels at enrollment, one month and three months after treatment completion. We assessed prostatic volume by transrectal ultrasonography (TRUS) and estimated the serum high sensitivity C-reactive protein (hs-CRP) levels at baseline and after three months. Results: We enrolled 64 men (median [IQR] age 53 [45-60] years); 50 patients completed follow-up. At baseline, 24 (38%) of 64 patients had elevated serum PSA values compared to age-specific upper limit. The median (IQR) serum PSA level was 2.15 (1.18-3.02) ng/mL and median (IQR) serum hs-CRP level was 2.23 (1.85-2.74) mg/dL (N=64). At three months, serum PSA levels decreased by ≥25% in 47 (94%) of 50 patients. The median (IQR) of prostatic volume was 25.4 (18.9-34) mL at baseline (N=64), and ≥10% decrease in prostatic volume was observed in 24 (48%) of 50 patients at three months. The change in the serum PSA levels did not correlate with clinical findings like prostatic tenderness or with prostatic volume changes. Further, serum PSA levels did not correlate with hs-CRP levels. On follow-up, seven patients had lower urinary tract symptoms; only one of them had recurrent fUTI.   Conclusions: Asymptomatic prostatic involvement, although common in men with fUTI, does not seem to influence the treatment outcomes.