Urological infections can significantly impact patient health, leading to complications and potential long-term consequences if not promptly diagnosed and managed. Screening plays a crucial role in identifying urological infections, allowing for early intervention and appropriate treatment.

This article summarises the best practices for screening patients, considering both symptomatic and non-symptomatic individuals, based on the European Association of Urology Guidelines on Urological Infections, 2023.

SCREENING FOR SYMPTOMATIC PATIENTS

Symptomatic patients with suspected urological infections should undergo a comprehensive clinical evaluation, including a detailed medical history, physical examination, and evaluation of specific symptoms. Symptoms such as dysuria, urinary frequency, urgency, suprapubic pain, and haematuria should be carefully assessed.

Urine analysis: A midstream urine sample should be obtained for urinalysis and microscopy to assess for the presence of bacteria, white blood cells, and red blood cells. Urine culture should be performed to identify the causative organism and determine antimicrobial susceptibility.

Imaging studies: Depending on the clinical presentation and suspected site of infection, imaging studies such as ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) may be necessary to evaluate the urinary tract for structural abnormalities or complications.

SCREENING FOR NON-SYMPTOMATIC PATIENTS

High-risk groups: Non-symptomatic patients belonging to high-risk groups, such as individuals with known risk factors (eg, previous urological procedures, renal transplantation, immunosuppression), should be considered for screening, even in the absence of symptoms.

Urine culture: Non-symptomatic patients with risk factors should undergo urine culture to identify asymptomatic bacteriuria. In specific situations, such as prior to urological procedures or renal transplantation, preoperative urine culture is recommended to detect and treat asymptomatic bacteriuria.

FOLLOW-UP AND MONITORING

Symptomatic patients: Following diagnosis and treatment, symptomatic patients should be monitored closely to ensure resolution of symptoms and eradication of the infection. Repeat urine analysis and culture may be necessary to confirm microbiological clearance.

Non-symptomatic patients: Non-symptomatic patients with asymptomatic bacteriuria should be periodically monitored without initiating treatment, except in specific situations (eg, pregnant women). Antibiotic treatment is generally not recommended due to the lack of evidence supporting its benefit.

ANTIBIOTIC STEWARDSHIP

Antibiotic stewardship is a critical component of responsible healthcare practice aimed at optimising antibiotic use to improve patient outcomes, reduce the emergence of antimicrobial resistance, and minimise the risks associated with unnecessary antibiotic exposure. Considering the ever-growing threat of antimicrobial resistance, the EAU updated guidelines on urological infections have emphasised the importance of antibiotic stewardship.

The important components of antimicrobial stewardship programmes are:

• Regular training of staff in best use of antimicrobial agents
• Adherence to local, national or international guidelines
• Regular ward visits and consultation with infectious diseases physicians and clinical microbiologists
• Audit of adherence and treatment outcomes
• Regular monitoring and feedback to prescribers of their performance and local pathogen resistance profiles.

Diagnosis and decision-making: Accurate diagnosis and appropriate decision-making are vital to effective antibiotic stewardship. Healthcare professionals should employ evidence-based diagnostic strategies to identify urological infections, considering patient symptoms, physical examination findings, and relevant laboratory tests. Clinicians should also be aware of local patterns of antimicrobial resistance to guide appropriate antibiotic selection.

Non-antibiotic measures: The EAU guidelines emphasise the importance of non-antibiotic measures whenever possible. Non-pharmacological interventions, such as fluid intake, pain relief, and removal of urinary tract obstructions, should be considered as adjunctive or primary treatments, particularly in uncomplicated cases or when antimicrobial resistance is a concern.

Empirical antibiotic therapy: Empirical antibiotic therapy is the initial treatment provided before the specific pathogen is identified. The guidelines recommend using narrow-spectrum antibiotics with good tissue penetration and minimal resistance rates as the first-line empirical therapy. Local antibiograms and clinical factors such as patient age, comorbidities, and recent antibiotic exposure should be considered when selecting empirical therapy.

Culture-guided therapy: Obtaining urine cultures and conducting susceptibility testing play a crucial role in antibiotic stewardship. The EAU guidelines emphasise the importance of obtaining a urine culture before initiating antibiotic therapy, especially in complicated infections or when initial empirical treatment fails. Healthcare providers should follow the principles of ‘test before treat’ to ensure targeted antibiotic therapy based on the identified pathogen and its susceptibility pattern.

Duration of antibiotic therapy: The guidelines advocate for shorter durations of antibiotic therapy to minimise the risk of antimicrobial resistance and associated complications. Tailoring the duration of treatment based on infection site, pathogen, patient factors, and clinical response is essential. In uncomplicated lower urinary tract infections, a short course of three to seven days is recommended, while upper urinary tract infections or complicated cases may require longer treatment durations.

Asymptomatic bacteriuria: Asymptomatic bacteriuria (ABU), which refers to the presence of bacteria in the urine without any urinary tract symptoms, is a common condition. It is considered a harmless colonisation of bacteria in the urinary tract. Research has shown that ABU may protect against symptomatic UTIs. Therefore, treatment should only be considered if there is proven benefit to the patient, as unnecessary treatment can lead to antimicrobial resistance and the eradication of potentially protective bacteria.

The prevalence of ABU varies across different populations. It is estimated to occur in 1%-5% of healthy pre-menopausal females, 4%-19% of healthy elderly females and men, 0.7%-27% of patients with diabetes, 2%-10% of pregnant women, 15%-50% of institutionalised elderly populations, and 23%-89% of patients with spinal cord injuries. ABU is uncommon in younger men, but if detected, it could indicate chronic bacterial prostatitis.

Diagnosing ABU involves testing urine samples. In women, ABU is defined by bacterial growth of more than 105 colony-forming units per millilitre (cfu/mL) in two consecutive samples. In men, a single sample with bacterial growth above this threshold is sufficient. However, in catheterised samples, even lower bacterial growth of 102cfu/mL can be considered significant. Additional tests like cystoscopy or imaging are not necessary unless there are other indications in the medical history. In cases where urease-producing bacteria like Proteus mirabilis are consistently present, the possibility of urinary tract stone formation should be investigated. For men, a digital rectal examination (DRE) should be performed to assess the prostate for potential diseases.

Intravenous to oral switch: Whenever possible, clinicians should consider switching from intravenous to oral antibiotics once the patient's clinical condition improves. This approach minimises the risks associated with prolonged intravenous therapy, reduces healthcare costs, and enhances patient convenience. The choice of oral antibiotic should be guided by susceptibility data and the patient's individual factors.

Patient education and follow-up: Patient education is a critical component of antibiotic stewardship. Healthcare providers should educate patients about the appropriate use of antibiotics, emphasising adherence to prescribed regimens, completion of therapy, and the risks of unnecessary antibiotic use. Furthermore, close follow-up with patients should be ensured to monitor treatment response, address any adverse effects, and reinforce the importance of completing the
prescribed course.

CONCLUSION

Screening for urological infections involves a comprehensive approach to accurately diagnose and manage both symptomatic and non-symptomatic patients. Prompt identification of infections allows for timely treatment, reducing the risk of complications and improving patient outcomes.

The EAU guidelines on urological infections provide valuable recommendations for antibiotic stewardship in urology practice. By implementing these best practices, healthcare professionals can contribute to the optimisation of antibiotic use, preservation of antimicrobial efficacy, and improvement of patient outcomes. It is crucial for clinicians to remain updated on the latest guidelines and actively engage in antibiotic stewardship efforts to combat the growing challenge of antimicrobial resistance.

Reference

EAU Guidelines. Edn. presented at the EAU Annual Congress Milan, Italy 2023. ISBN 978-94-92671-19-6.