EUROPEAN UROLOGY 86 (2024) 27–41

available at www.sciencedirect.com
journal homepage: www.europeanurology.com

Review – Infections – Editor’s choice

European Association of Urology Guidelines on Urological Infections:

Summary of the 2024 Guidelines

Jennifer Kranz a,b,*, Riccardo Bartoletti c, Franck Bruyère d,e, Tommaso Cai f, Suzanne Geerlings g,h,
Bela Köves i, Sören Schubert j, Adrian Pilatz k, Rajan Veeratterapillay l, Florian M E Wagenlehner k,
Kathrin Bausch m, Wout Devlies n, József Horváth o, Lorenz Leitner p, Guglielmo Mantica q,
Tunde Mezei r, Emma J. Smith s, Gernot Bonkat t
a
Department of Urology and Pediatric Urology, RWTH Aachen University, Aachen, Germany; b Department of Urology and Kidney Transplantation, Martin-
Luther-University, Halle, Germany; c Department of Translational Research and New Technologies, University of Pisa, Pisa, Italy; d Department of Urology,
CHRU Bretonneau, Tours, France; e Université Francois Rabelais, PRES Centre Val de Loire, Tours, France; f Department of Urology, Santa Chiara, Regional
Hospital, Trento, Italy; g Department of Internal Medicine, Amsterdam Institute for Infection and Immunity, Amsterdam Public Health Research Institute,
Amsterdam, The Netherlands; h Amsterdam University Medical Center, Amsterdam, The Netherlands; i Department of Urology, University of Szeged, Szeged,
Hungary; j Max von Pettenkofer Institute, Faculty of Medicine, LMU Munich, Munich, Germany; k Department of Urology, Pediatric Urology and Andrology,
Justus-Liebig-University Giessen, Giessen, Germany; l Freeman Hospital, Newcastle Upon Tyne, UK; m Department of Urology, University Hospital Basel,
University of Basel, Basel, Switzerland; n Department of Urology, UZ Leuven, Leuven, Belgium; o BKMK SZTE ÁOK Okt. Kh. Urológiai Osztálya, Kecskemét,
Hungary; p Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland; q IRCCS Ospedale Policlinico San Martino,
Genova, Italy; r Department of Urology, Telemark Hospital, Skien, Norway; s European Association of Urology Guidelines Office, Arnhem, The Netherlands; t alta
Uro AG, Merian Iselin Klinik, Center of Biomechanics & Calorimetry, University of Basel, Basel, Switzerland

Article info Abstract

Article history: Background and objective: Urological infections significantly impact the wellbeing and
Accepted March 28, 2024 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
Associate Editor: guidance on the diagnosis, treatment, and prevention of urinary tract infections (UTIs)
Alberto Briganti and male accessory-gland infections, while addressing crucial public health aspects
related to infection control and antimicrobial stewardship.
Keywords: Methods: For the 2024 guidelines on urological infections, new and relevant evidence
Urological infections was identified, collated, and appraised via a structured assessment of the literature.
Antimicrobial stewardship Databases searched included Medline, EMBASE, and the Cochrane Libraries.
Cystitis Recommendations within the guidelines were developed by the panel to prioritise clin-
Pyelonephritis ically important care decisions. The strength of each recommendation was determined
Complicated urinary tract according to a balance between desirable and undesirable consequences of alternative
infections management strategies, the quality of the evidence (including the certainty of esti-
Periprocedural antibiotic mates), and the nature and variability of patient values and preferences.
prophylaxis Key findings and limitations: Key recommendations emphasise the importance of a thor-
Antibiotics ough medical history and physical examination for patients with urological infections.
Male accessory gland infections The guidelines stress the role of antimicrobial stewardship to combat the rising threat
Urinary tract infections of antimicrobial resistance, providing recommendations for antibiotic selection, dosing,
and duration on the basis of the latest evidence.

* Corresponding author. Department of Urology and Pediatric Urology, RWTH Aachen University,
Pauwelsstrasse 30, 52074 Aachen, Germany. Tel. +49 241 8089374.
E-mail address: [email protected] (J. Kranz).

https://doi.org/10.1016/j.eururo.2024.03.035
0302-2838/Ó 2024 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
28 EUROPEAN UROLOGY 86 (2024) 27–41

Conclusions and clinical implications: This overview of the 2024 EAU guidelines offers
valuable insights into managing urological infections and are designed for effective inte-
gration into clinical practice.
Please visit www.eu-acme.org/europeanurology
Patient summary: The European Association of Urology has issued an updated guideline
to answer questions on-line. The EU-ACME cred-
its will then be attributed automatically. on urological infections. The guidelines provide recommendations for diagnosis, treat-
ment, and prevention, with a particular focus on minimising antibiotic use because of
the increasing global threat of antimicrobial resistance.
Ó 2024 The Author(s). Published by Elsevier B.V. on behalf of European Association of
Urology. This is an open access article under the CC BY-NC-ND license (http://creative-
commons.org/licenses/by-nc-nd/4.0/).

1. Introduction tant care decisions. The strength of each recommendation

was determined according to a balance between desirable
Urinary tract infections (UTIs) are among the most frequent and undesirable consequences of alternative management
bacterial infections, with various medical specialties strategies, the quality of the evidence [5] (including cer-
involved in their diagnosis, treatment, and prevention [1]. tainty of estimates), and the nature and variability of
Clinical presentations of UTIs vary widely, from rather patient values and preferences. Recommendations are rated
benign, uncomplicated infections to severe conditions such as strong when the evidence quality is high and/or there is a
as complicated UTIs, pyelonephritis, and even urosepsis favourable balance of benefits to harms and patient prefer-
[2,3]. While the overall incidence of sepsis is decreasing, ences. Recommendations are rated as weak when the evi-
there has been a notable rise in severe UTIs. Antimicrobial dence is of lower quality and/or benefits and patient
resistance has emerged as a significant global health con- preferences are less clear.
cern, particularly for complicated UTIs including
pyelonephritis, with antibiotic resistance increasingly 3. Guidelines
encountered in daily clinical practice, which poses chal-
lenges for effective treatment [4]. 3.1. UTI classification
The European Association of Urology (EAU) urological
infections guidelines panel has compiled these clinical The clinical spectrum of UTIs is heterogeneous and ranges
guidelines to equip health care professionals with from benign to life-threatening infections [2,6–9], with
evidence-based insights and recommendations for the diag- important variations in both diagnosis and treatment.
nosis, treatment, and prevention of UTIs and male Hence, patient stratification is crucial. There are several
accessory-gland infections. The guidelines also address cru- classification systems for describing and classifying UTIs,
cial public health aspects such as infection control and with the common rationale that the risks of recurrence, pro-
antimicrobial stewardship. gression, chronic status, and severe outcomes are worse for
It must be emphasised that clinical guidelines present complicated than for uncomplicated UTIs [2] (Fig. 1).
the best evidence available to experts. However, following
guideline recommendations will not necessarily result in 3.2. Asymptomatic bacteriuria in adults
the best outcome. Guidelines are not a substitute for clinical Asymptomatic bacteriuria (ABU) is common and corre-
expertise in tailoring treatment decisions for individual sponds to commensal colonisation [10]. In an individual
patients; instead, they serve as a framework for decisions, without urinary tract symptoms, ABU is defined as a mid-
which should also take into consideration patients’ personal stream sample of urine showing bacterial growth >105
values, preferences, and unique circumstances. The EAU cfu/ml in two consecutive samples in women [11] and in
urological infections guidelines panel is a multidisciplinary a single sample in men [12]. The spectrum of bacteria in
group of urologists with expertise in this area, an infectious ABU is similar to species found in uncomplicated or compli-
disease specialist, and a clinical microbiologist. All contrib- cated UTIs, depending on the presence of risk factors . Cys-
utors to this document have disclosed potential conflicts of toscopy and/or imaging of the upper urinary tract is not
interest, accessible for review on the EAU website (http:// mandatory if the medical history is otherwise unremark-
uroweb.org/guideline/urological-infections/). able. If persistent growth of urease-producing bacteria (Pro-
teus mirabilis) is detected, stone formation in the urinary
2. Methods tract must be excluded [13]. For men, digital rectal exami-
nation should be performed to investigate the possibility
For the 2024 urological infections guidelines, new evidence of prostate diseases. Clinical studies have shown that ABU
was identified, collated, and appraised via a structured may protect against superinfecting symptomatic UTI, and
assessment of the literature. Databases searched included thus ABU should only be treated in cases of proven benefit
Medline, EMBASE, and the Cochrane Libraries. Detailed for the patient to avoid the risk of selecting antimicrobial
search strategies are available on the EAU website resistance and eradicating a potentially protective ABU
(https://uroweb.org/guidelines/urological-infections/publi- strain [14,15] (Table 1). A meta-analysis of the available evi-
cations-appendices). Recommendations in the guidelines dence revealed that treatment of ABU in pregnant women
were developed by the panel to prioritise clinically impor- was beneficial; however, most studies have low method-
 EUROPEAN UROLOGY 86 (2024) 27–41 29

Cystitis

Uncomplicated UTI Pyelonephritis Complicated UTI

Recurrent UTI

Catheter-associated UTI

Low risk High risk

UTI in men

Urosepsis

Fig. 1 – Concept of uncomplicated and complicated urinary tract infection (UTI).

Table 1 – Recommendations for the management of asymptomatic senting with typical symptoms of uncomplicated cystitis,
bacteriuria urine analysis (urine culture, dipstick testing) leads to only
Recommendation Strength a minimal increase in diagnostic accuracy [21]. However, if
rating the diagnosis is unclear, dipstick analysis can increase the
Do not screen or treat asymptomatic bacteriuria in the Strong likelihood of a diagnosis of uncomplicated cystitis [22,23].
following conditions:
 Women without risk factors A urine culture is recommended in the following situations:
 Patients with well-regulated diabetes mellitus suspected acute pyelonephritis; symptoms that do not
 Postmenopausal women resolve or recur within 4 wk after completion of treatment;
 Elderly institutionalised patients
 Patients with a dysfunctional and/or reconstructed women who present with atypical symptoms; and/or preg-
lower urinary tract nant women.
 Patients with a renal transplant For females with mild to moderate symptoms, symp-
 Patients before arthroplasty surgery
 Patients with recurrent urinary tract infections tomatic therapy (eg, ibuprofen) may be considered as an
Do not screen or treat asymptomatic bacteriuria in Weak alternative to antimicrobial treatment in consultation with
patients before cardiovascular surgeries. individual patients [24–27]. The choice of antimicrobial
Screen for and treat asymptomatic bacteriuria before Strong
urological procedures breaching the mucosa. therapy should be guided by the spectrum and susceptibil-
Screen for and treat asymptomatic bacteriuria in pregnant Weak ity patterns of the aetiological pathogens; efficacy for the
women with standard short-course treatment or particular indication in clinical studies; tolerability and
single-dose fosfomycin trometamol.
adverse reactions; adverse ecological effects; and costs
and/or availability [17]. Suggested regimens for antimicro-
bial therapy for uncomplicated cystitis are listed in Table 2.
ological quality and are from the 1960s to 1980s. Diagnostic Routine post-treatment urinalysis or urine cultures are
and treatment protocols and access to medical services have not indicated for asymptomatic patients [6]. For women
dramatically changed since then; therefore, the quality of whose symptoms do not resolve by the end of treatment,
evidence for this recommendation is low. In a newer study and for those whose symptoms resolve but recur within 2
of higher methodological quality, the beneficial effects of wk, a urine culture and antimicrobial susceptibility testing
antibiotic treatment are not as evident [16]. should be performed [28]. For therapy in this situation, it
should be assumed that the infecting organism is not sus-
3.3. Uncomplicated cystitis ceptible to the agent originally used. Retreatment with a
7-d regimen using another agent should be considered [28].
Uncomplicated cystitis is defined as acute, sporadic, or
recurrent cystitis limited to nonpregnant women with no
3.4. Recurrent UTIs
known relevant anatomic or functional abnormalities in
the urinary tract and no comorbidities. Risk factors include Recurrent UTIs (rUTIs) are recurrences of uncomplicated
sexual intercourse, use of spermicide, a new sexual partner, and/or complicated UTIs, with a frequency of at least three
a mother with a history of UTI, and a history of UTI during UTIs/yr or two UTIs in the last 6 mo. Although rUTIs include
childhood. Most cases of uncomplicated cystitis are caused both lower tract infection (cystitis) and upper tract infec-
by Escherichia coli. Diagnosis of uncomplicated cystitis can tion (pyelonephritis), repeated pyelonephritis should
be made with a high probability on the basis of a focused prompt consideration of a complicated aetiology. rUTIs neg-
history of lower urinary tract symptoms (dysuria, fre- atively impact a patient’s quality of life, with reductions in
quency, and urgency) and the absence of vaginal discharge the quality of social and sexual relationships, self-esteem,
[17,18]. In elderly women, genitourinary symptoms are and capacity for work [29]. Risk factors for rUTI are outlined
not necessarily related to cystitis [19,20]. In patients pre- in Table 3.
30 EUROPEAN UROLOGY 86 (2024) 27–41

Table 2 – Suggested antimicrobial therapy regimens for uncomplicated cystitis

Antimicrobial Daily dose Therapyduration Comments

First-line treatment in women
Fosfomycin trometamol 3 g SD 1d Recommended only in women with uncomplicated cystitis.
Nitrofurantoin macrocrystals 50–100 mg q. 5d
i.d.
Nitrofurantoin monohydrate or 100 mg b.i.d. 5d
macrocrystals
Nitrofurantoin macrocrystals 100 mg b.i.d. 5d
prolonged release
Pivmecillinam 400 mg t.i.d. 3–5 d
Alternatives
Cephalosporins (eg, cefadroxil) 500 mg b.i.d. 3d Or comparable
If the local resistance pattern for Escherichia coli is <20%
Trimethoprim 200 mg b.i.d. 5d Not in the first trimester of pregnancy
Trimethoprim-sulfamethoxazole 160/800 mg 3d Not in the last trimester of pregnancy
b.i.d.
Treatment in men
Trimethoprim-sulfamethoxazole 160/800 mg 7d Restricted to men, fluoroquinolones can also be prescribed in accordance with
b.i.d. local susceptibility testing.
SD = single dose; b.i.d. = twice daily; q.i.d. = four times daily; t.i.d = three times daily.

Table 4 – Recommendations for the diagnostic evaluation and treatment of recurrent UTIs

Recommendation Strength
rating
Diagnose recurrent UTI via a urine culture. Strong
Do not perform an extensive routine workup (eg, cystoscopy, full abdominal ultrasound) in women younger than 40 yr with recurrent UTI and Weak
no risk factors.
Advise premenopausal women to increase their fluid intake, as this might reduce the risk of recurrent UTI. Weak
Use vaginal oestrogen replacement in postmenopausal women to prevent recurrent UTI. Strong
Use immunoactive prophylaxis to reduce recurrent UTI in all age groups. Strong
Advise patients on the use of local or oral probiotic-containing strains of proven efficacy for vaginal flora regeneration to prevent UTIs. Weak
Advise patients on the use of cranberry products to reduce recurrent UTI episodes; however, patients should be informed that the quality of Weak
evidence underpinning this is low, with contradictory findings.
Use D-mannose to reduce recurrent UTI episodes, but patients should be informed of the overall weak and contradictory evidence regarding its Weak
effectiveness.
Use methenamine hippurate to reduce recurrent UTI episodes in women without abnormalities of the urinary tract. Strong
Use endovesical instillations of hyaluronic acid or a combination of hyaluronic acid and chondroitin sulfate to prevent recurrent UTIs in Weak
patients for whom less invasive preventive approaches have been unsuccessful. Patients should be informed that further studies are needed
to confirm the results of initial trials.
Use continuous or postcoital antimicrobial prophylaxis to prevent recurrent UTI when non-antimicrobial interventions have failed. Counsel Strong
patients regarding possible side effects.
For patients with good compliance, self-administered short-term antimicrobial therapy should be considered. Strong
UTI = urinary tract infection.

Table 3 – Age-related factors associated with recurrent UTI in women

Young and pre-menopausal women Post-menopausal and elderly women

Sexual intercourse History of UTI before menopause
Use of spermicide Urinary incontinence
A new sexual partner Atrophic vaginitis due to oestrogen deficiency
A mother with a history of UTI Cystocele
History of UTI during childhood High postvoid residual urine volume
Blood group antigen secretory status Blood group antigen secretory status
Urine catheterisation and functional status
deterioration in elderly institutionalised women
UTI = urinary tract infection.

rUTI prevention includes counselling regarding avoid- 3.5. Uncomplicated pyelonephritis

ance of risk factors, non-antimicrobial measures, and
Uncomplicated pyelonephritis is defined as pyelonephritis
antimicrobial prophylaxis [28,30] (Table 4). These interven-
limited to nonpregnant, premenopausal women with no
tions should be attempted in the order listed.
 EUROPEAN UROLOGY 86 (2024) 27–41 31

known relevant urological abnormalities or comorbidities. on the basis of drug susceptibility results. For patients pre-
It typically presents with fever (>38 °C), chills, flank pain, senting with signs of urosepsis, empiric antimicrobial cov-
nausea, vomiting, or tenderness at the costovertebral angle, erage for extended-spectrum b-lactamase–producing
with or without symptoms of cystitis [31]. organisms is warranted [38]. Patients initially treated with
Urinalysis, including assessment of white and red blood parenteral therapy who improve clinically and can tolerate
cells and nitrite, is recommended for routine diagnosis oral fluids may transition to oral antimicrobial therapy [39].
[32]. In addition, a urine culture and antimicrobial suscepti- For pregnant women with pyelonephritis, outpatient
bility testing should be performed in all cases of management with appropriate parenteral antimicrobials
pyelonephritis. Evaluation of the upper urinary tract via may also be considered, provided symptoms are mild and
ultrasound should be performed to rule out urinary tract close follow-up is feasible [40,41]. For more severe cases
obstruction or renal stone disease in patients with a history of pyelonephritis, hospitalisation and supportive care are
of urolithiasis, renal function disturbances or a high urine usually required. After clinical improvement, parenteral
pH [33]. Additional investigations, such as a contrast-
enhanced computed tomography scan, or excretory urogra- Table 6 – Suggested regimens for empirical parenteral antimicrobial
phy, should be considered if the patient remains febrile therapy for uncomplicated pyelonephritis
after 72 h of treatment, or immediately if there is a deteri-
Antimicrobial Daily Comments
oration in clinical status [33]. For diagnosis of complicating dose
factors in pregnant women, ultrasound or magnetic reso- First-line treatment
nance imaging (MRI) should be used preferentially to avoid Ciprofloxacin 400
radiation risk to the foetus [33]. mg b.i.
d.
Prompt differentiation between uncomplicated and Levofloxacin 750
potentially obstructive pyelonephritis is crucial, as the lat- mg q.
ter can swiftly progress to urosepsis. This delineation d.
Cefotaxime 2 g t.i. Not studied as monotherapy in acute
should be established promptly using appropriate imaging d. uncomplicated pyelonephritis.
techniques. Ceftriaxone 1–2 g Lower dose studied, but higher dose
Fluoroquinolones and cephalosporins are the only q.d. recommended.
Second-line treatment
antimicrobial agents that can be recommended for oral Cefepime 1–2 g Lower dose studied, but higher dose
empiric treatment of uncomplicated pyelonephritis [34]; b.i.d. recommended.
oral cephalosporins achieve significantly lower blood and Piperacillin/tazobactam 2.5–
4.5 g t.
urinary concentrations than the intravenous route (Table 5). i.d.
Other agents such as nitrofurantoin, oral fosfomycin, and Gentamicin 5 mg/ Not studied as monotherapy in acute
kg q.d. uncomplicated pyelonephritis.
pivmecillinam should be avoided as there are insufficient
Amikacin 15
data regarding their efficacy [35]. It has been shown that a mg/kg
short outpatient course of antibiotic treatment for acute q.d.
Last-line alternatives
pyelonephritis is equivalent to longer therapy durations in
Imipenem/cilastatin 0.5 g t. Consider only in patients with early
terms of clinical and microbiological success. However, this i.d. culture results indicating the
approach is associated with a higher recurrence rate within presence of multidrug-resistant
organisms.
4–6 wk and needs to be tailored to local policies and resis-
Meropenem 1 g t.i.
tance patterns [36]. d.
Patients with uncomplicated pyelonephritis requiring Ceftolozane/tazobactam 1.5 g t.
i.d.
hospitalisation should be treated initially with an intra-
Ceftazidime/avibactam 2.5 g t.
venous antimicrobial regimen, such as a fluoroquinolone, i.d.
an aminoglycoside (with or without ampicillin), or an Cefiderocol 2g t.i.
d.
extended-spectrum cephalosporin or penicillin [37]
Meropenem- 2g t.i.
(Table 6). Carbapenems and novel broad-spectrum antimi- vaborbactam d.
crobial agents should only be considered in patients with Plazomicin 15mg/
kg o.d.
early culture results indicating the presence of multidrug-
resistant organisms. The choice between these agents b.i.d. = twice daily; t.i.d. = three times daily; q.d. = every day; o.d. = once
daily.
should be based on local resistance patterns and optimised

Table 5 – Suggested regimens for empirical oral antimicrobial therapy

for uncomplicated pyelonephritis

Antimicrobial Daily dose Therapyduration Comments

Ciprofloxacin 500–750 7d Fluoroquinolone resistance should be <10%.
mg b.i.d
Levofloxacin 750 mg q.d. 5d
Trimethoprim 160/800 14 d If such agents are used empirically, an initial intravenous dose of a long-acting parenteral
sulfamethoxazole mg b.i.d antimicrobial (eg, ceftriaxone) should be administered.
Cefpodoxime 200 mg b.i. 10 d
d
Ceftibuten 400 mg q.d 10 d
32 EUROPEAN UROLOGY 86 (2024) 27–41

Table 7 – Common factors associated with complicated urinary tract toms may be atypical in some clinical situations, such as in
infections [46–49]
neuropathic bladder disturbances, catheter-associated UTI
Obstruction at any site in the Urinary tract infection in (CA-UTI), and previous radical cystectomy with urinary
urinary tract males diversion. Clinical presentation can vary from severe
Foreign body Pregnancy obstructive acute pyelonephritis with imminent urosepsis
Incomplete voiding Diabetes mellitus
to a postoperative CA-UTI. A urine culture is recommended.
Vesicoureteral reflux Immunosuppression
Recent history of instrumentation Health care–associated The microbial spectrum is greater than for uncomplicated
infections UTIs, and antimicrobial resistance is more likely [48,49].
ESBL-producing organisms isolated Multidrug-resistant organisms
isolated
E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serra-
tia spp., and Enterococcus spp. are the most common species
ESBL = extended-spectrum b-lactamase.
found in cultures.
Appropriate management of the urological abnormality
therapy can also be switched to oral therapy for a total or the underlying complicating factor is mandatory. Opti-
treatment duration of 7–10 d. For men with febrile UTI, mal antimicrobial therapy for cUTI depends on the severity
pyelonephritis, or recurrent infection, or whenever a com- of the illness at presentation, as well as local resistance pat-
plicating factor is suspected, a minimum treatment dura- terns and specific host factors (such as allergies). In addi-
tion of 2 wk is recommended, preferably with a tion, a urine culture and susceptibility testing should be
fluoroquinolone, as prostatic involvement is frequent [42]. performed, and initial empiric therapy should be tailored
and followed by (oral) administration of an appropriate
3.6. Complicated UTIs antimicrobial agent for the uropathogen isolated.
Treatment for 7 d [50] to 14 d (14 d for men when pro-
A complicated UTI (cUTI) occurs when an individual has statitis cannot be excluded) [51], is generally recom-
host-related factors or specific anatomic or functional mended, but the duration should be closely related to the
abnormalities in the urinary tract that are believed to make treatment of the underlying abnormality. When the patient
the infection more challenging to eradicate in comparison is haemodynamically stable and has been afebrile for at
to an uncomplicated infection [43–45]. Recent insights into least 48 h, a shorter treatment duration (eg, 7 d) may be
cUTI management highlight the importance of considering considered in cases for which short-course treatment is
infections caused by multidrug-resistant uropathogens desirable owing to relative contraindications to the antibi-
[46]. Table 7 outlines underlying factors commonly associ- otic administered [52].
ated with cUTIs. A cUTI designation encompasses a wide
range of underlying conditions, resulting in a diverse
patient population. Therefore, it is evident that a one-size- 3.7. Catheter-associated UTIs
fits-all approach to cUTI evaluation and treatment is inade-
Catheter-associated (CA)-UTI refers to UTI occurring in an
quate. However, there are general management principles
individual whose urinary tract is currently catheterised or
that can be applied to most patients with cUTIs. The follow-
has been catheterised within the past 48 h. CA-UTIs are
ing recommendations are based on the Stichting Werkgroep
the leading cause of secondary health care–associated bac-
Antibioticabeleid (SWAB) guidelines from the Dutch Work-
teraemia. Approximately 20% of hospital-acquired bacter-
ing Party on Antibiotic Policy [47] (Table 8).
aemias arise from the urinary tract, and the mortality
cUTI is associated with typical clinical symptoms (eg,
associated with this condition is approximately 10% [53].
dysuria, urgency, frequency, flank pain, costovertebral angle
The incidence of bacteriuria associated with indwelling
tenderness, suprapubic pain, and fever), although the symp-
catheterisation is 3–8% per day [54–58]. Catheterisation
duration is the most important risk factor for CA-UTI devel-
Table 8 – Recommendations for the treatment of complicated UTIs opment [59,60]. A systematic review and meta-analysis
Recommendation Strength
demonstrated that patients at high risk of CA-UTI were
rating female, had prolonged catheterisation duration, had dia-
Use a combination of: Strong betes, and had longer hospital and intensive care unit stays
 Amoxicillin plus an aminoglycoside [61]. Signs and systemic symptoms compatible with CA-UTI
 A second-generation cephalosporin plus an
aminoglycoside include new onset or worsening of fever, rigor, altered men-
 An intravenous third-generation cephalosporin as tal status, malaise, or lethargy with no other identified
empirical treatment for complicated UTI with systemic cause, flank pain, costovertebral angle tenderness, acute
symptoms
Only use ciprofloxacin if the local resistance rate is <10% Strong haematuria, and pelvic discomfort, as well as dysuria,
when: urgent or frequent urination, and suprapubic pain or ten-
 The entire treatment is given orally
 The patient does not require hospitalisation
derness in those whose catheter has been removed [47].
 The patient has anaphylaxis to b-lactam antimicrobials For catheterised patients, the presence or absence of odor-
Do not use ciprofloxacin and other fluoroquinolones for Strong ous or cloudy urine alone should not be used to differentiate
empirical treatment of complicated UTI in patients
from urology departments or when patients have used
CA-ABU from CA-UTI [47,48]. Microbiologically, CA-UTI is
fluoroquinolones in the last 6 mo. defined by microbial growth of >103 cfu/ml of one or more
Manage any urological abnormality and/or underlying Strong bacterial species in a single catheter urine specimen or in a
complicating factors.
midstream voided urine specimen from a patient whose
UTI = urinary tract infection.
urethral, suprapubic, or condom catheter has been removed
 EUROPEAN UROLOGY 86 (2024) 27–41 33

Table 9 – Recommendations for CA-UTI management and Table 11 – Suggested antimicrobial therapy regimens for urosepsis
prevention
Antimicrobial Daily Therapy duration
Recommendation Strength dose
rating Cefotaxime 2 g t.i.d. 7–10 d
Treat symptomatic CA-UTI according to the Strong Ceftazidime 1–2 g t.i.d. Longer courses are
recommendations for complicated UTI (Table 8). appropriate in patients
Take a urine culture before initiating antimicrobial therapy Strong with a slow clinical
in catheterised patients whose catheter has been response
removed. Ceftriaxone 1–2 g q.d.
Do not treat catheter-associated asymptomatic bacteriuria Strong Cefepime 2 g b.i.d.
in general. Piperacillin/tazobactam 4.5 g t.i.d.
Treat catheter-associated asymptomatic bacteriuria before Strong Ceftolozane/tazobactam 1.5 g t.i.d.
traumatic urinary tract interventions (eg, transurethral Ceftazidime/avibactam 2.5 g t.i.d.
resection of the prostate). Gentamicina 5 mg/kg q.d.
Replace or remove the indwelling catheter before starting Strong Amikacina 15 mg/kg q.d.
antimicrobial therapy. Ertapenem 1 g q.d.
Do not apply topical antiseptics or antimicrobials to the Strong Imipenem/cilastatin 0.5 g t.i.d.
catheter, urethra, or meatus. Meropenem 1 g t.i.d.
Do not use prophylactic antimicrobials to prevent CA-UTI. Strong b.i.d. = twice daily; t.i.d. = three times daily; q.d. = every day.
Do not routinely use antibiotic prophylaxis to prevent Weak a
Not studied as monotherapy in urosepsis.
clinical UTI after urethral catheter removal.
The duration of catheterisation should be minimal. Strong
Use hydrophilic coated catheters to reduce CA-UTI. Strong
Do not routinely use antibiotic prophylaxis to prevent Weak
clinical UTI after urethral catheter removal or in
patients performing intermittent self-catheterisation. For diagnosis of systemic symptoms in sepsis, either the
CA-UTI = catheter-associated urinary tract infection. full SOFA or qSOFA score should be assessed.
Microbiological sampling should encompass urine, two
sets of blood cultures [62], and, when applicable, drainage
within the previous 48 h [48]. For catheterised patients, fluids. Early imaging investigations, including sonography
pyuria is not diagnostic for CA-UTI. The presence, absence, and computed tomography scans, should be conducted
or degree of pyuria should not be used to differentiate CA- [63]. Management of urosepsis necessitates comprehensive
ABU from CA-UTI. Pyuria accompanying CA-ABU should life-supportive measures, timely and suitable antimicrobial
not be interpreted as an indication for antimicrobial treat- therapy, adjunctive interventions, and effective manage-
ment. The absence of pyuria in a symptomatic patient sug- ment of urinary tract abnormalities [64] (Tables 10 and
gests a diagnosis other than CA-UTI [48]. 11). It is crucial to establish source control by alleviating
Recommendations for CA-UTI management and preven- any obstruction and draining significant abscesses within
tion are outlined in Table 9. the urinary tract [64]. Collaborative treatment involving
urologists, intensive care, and infectious disease specialists
3.8. Urosepsis is recommended for optimal patient care.

Sepsis is defined as life-threatening organ dysfunction

resulting from a dysregulated host response to infection. 3.9. Urethritis
Clinically, organ dysfunction can be indicated by an increase
in Sequential (Sepsis-related) Organ Failure Assessment Urethritis can arise from infectious or noninfectious causes.
(SOFA) score of 2 points. A quick SOFA (qSOFA) score has It is important to differentiate urethral inflammation from
been developed for rapid identification: a respiratory rate other lower urinary tract infections. Urethral infections
of 22 breaths/min, altered mental status, or systolic blood are commonly transmitted via sexual contact. It is crucial
pressure of 100 mm Hg. to differentiate between gonococcal urethritis (GU) and
non-gonococcal urethritis (NGU). NGU is a nonspecific diag-
nosis with various infectious aetiologies, including Chlamy-
Table 10 – Recommendations for the diagnosis and treatment of
dia trachomatis, Mycoplasma genitalium, Ureaplasma
urosepsis
urealyticum, and Trichomonas vaginalis. The role of Urea-
Recommendation Strength plasma spp. in causing urethritis is debated, with recent
rating
data suggesting that U. urealyticum, but not U. parvum, is
Assess the quick SOFA score to identify patients with Strong
potential sepsis.
an aetiological agent in NGU [65]. Symptoms of urethritis
Take a urine culture and two sets of blood cultures before Strong include mucopurulent or purulent discharge, dysuria, and
starting antimicrobial treatment. urethral pruritus, although many urethral infections are
Administer parenteral high-dose broad-spectrum Strong
antimicrobials within the first hour after clinical
asymptomatic.
assumption of sepsis. In cases of severe urethritis, empiric treatment should
Adapt the initial empiric antimicrobial therapy on the Strong commence on diagnosis (Tables 12 and 13). However, if
basis of culture results.
Initiate source control, including removal of foreign Strong
the patient’s symptoms are mild, it is advisable to delay
bodies, decompression of obstruction, and drainage of treatment until guided by the results of the nucleic acid
abscesses in the urinary tract. amplification tests. It is crucial to evaluate and treat all at-
Provide immediate adequate life-support measures. Strong
risk sexual partners while upholding patient confidentiality
SOFA = Sequential (Sepsis-related) Organ Failure Assessment.
[66,67].
34 EUROPEAN UROLOGY 86 (2024) 27–41

Table 12 – Recommendations for diagnostic evaluation and antimi- 73]. Acute bacterial prostatitis usually presents abruptly
crobial treatment of urethritis
with voiding symptoms and distressing but poorly localised
Recommendation Strength pain. It is often associated with malaise and fever. Chronic
rating bacterial prostatitis is defined by symptoms that persist
Perform a Gram stain of urethral discharge or a urethral Strong for at least 3 mo [74–76]. The predominant symptoms are
smear for a preliminary diagnosis of gonococcal
pain at various locations including the perineum, scrotum,
urethritis.
Perform a validated NAAT on a first-void urine sample or Strong penis, and inner part of the leg, as well as lower urinary
urethral smear before empirical treatment to diagnose tract symptoms [71–73]. Table 14 outlines recommenda-
chlamydial and gonococcal infections.
Delay treatment until NAAT results are available to guide Strong
tions for the diagnosis of bacterial prostatitis.
treatment choice in patients with mild symptoms. In ABP, parenteral administration of high doses of bacte-
Perform a urethral swab culture before initiation of Strong ricidal antimicrobials, such as broad-spectrum penicillins, a
treatment in patients with a positive NAAT for
gonorrhoea to assess the antimicrobial resistance
third-generation cephalosporin, or a fluoroquinolone, is rec-
profile of the infective strain. ommended [77]. For initial therapy, any of these antimicro-
Use a pathogen-directed treatment based on local Strong bials may be combined with an aminoglycoside [69,74–87].
resistance data.
Sexual partners should be treated while maintaining Strong
After normalisation of infection parameters, oral therapy
patient confidentiality. can be substituted and continued for a total of 2–4 wk [88].
NAAT = nucleic acid amplification test. Fluoroquinolones are recommended as first-line agents
in the empiric treatment of CBP because of their favourable
pharmacokinetic properties [89], generally good safety pro-
3.10. Bacterial prostatitis file, and antibacterial activity against Gram-negative patho-
gens including Pseudomonas aeruginosa and C. trachomatis
Prostatitis is a frequent diagnosis, yet fewer than 10% of [90,91] (Table 15).
cases are confirmed to have bacterial infection . Enterobac- Approximately 10% of men with ABP will experience uri-
terales are the primary pathogens in acute bacterial pro- nary retention [92], which can be managed by urethral or
statitis (ABP) [69]. Chronic bacterial prostatitis (CBP) suprapubic catheterisation. However, recent evidence sug-
encompasses a broader spectrum of species, which may gests that suprapubic catheterisation can reduce the risk
include atypical microorganisms [70]. Urologists are of development of CBP [93]. In cases of prostatic abscess,
advised to use the classification proposed by the National both drainage and conservative treatment strategies appear
Institute of Diabetes, Digestive, and Kidney Diseases, which feasible [94]; if the abscess cavity is <1 cm in diameter, con-
distinguishes bacterial prostatitis, with confirmed or sus- servative treatment might be effective, while larger
pected infection, from chronic pelvic pain syndrome [71–

Table 13 – Suggested antimicrobial therapy regimens for urethritis

Pathogen Antimicrobial Dosage and therapy duration Alternative regimens

Gonococcal infection Ceftriaxone 1 g i.m. or i.v.a SD  Cefixime 400 mg p.o. SD plus azithromycin 1 g
Azithromycin 1 g p.o. SD p.o. SD
 In cases of cephalosporin allergy:
 Gentamicin 240 mg i.m. SD plus azithromycin 2
g p.o. SD
 Gemifloxacin 320 mg p.o. SD plus azithromycin
2 g p.o. SD
 Spectinomycin 2 g i.m. SD
 Fosfomycin trometamol 3 g p.o. on days 1, 3,
and 5In cases of azithromycin allergy, in combi-
nation with ceftriaxone or cefixime:
 Doxycycline 100 mg b.i.d, p.o. 7 d
Non-gonococcal infection Doxycycline 100 mg b.i.d, p.o. 7 d Azithromycin
(unidentified pathogen) 500 mg p.o. on day 1
250 mg p.o. for 4 d
Chlamydia trachomatis Azithromycin 1.0–1.5 g p.o. SD  Levofloxacin 500 mg p.o. q.d. 7 d
or  Ofloxacin 200 mg p.o. b.i.d. 7 d
Doxycycline 100 mg b.i.d. p.o. for 7 d
Mycoplasma genitalium Azithromycin 500 mg p.o. on day 1 In cases of macrolide resistance:
250 mg p.o. for 4 d  Moxifloxacin 400 mg q.d. 7–14 d
Ureaplasma urealyticum Doxycycline 100 mg b.i.d, p.o. 7 d Azithromycin 1.0–1.5 g p.o. SD
Trichomonas vaginalis MetronidazoleTinidazole 2 g p.o. SD Metronidazole 500 mg p.o. b.i.d. 7 d
2 g p.o. SD
Persistent non-gonococcal urethritis
After first-line doxycycline Azithromycin 500 mg p.o. on day 1 If macrolide-resistant M. genitalium is detected,
plus 250 mg p.o. for 4 d moxifloxacin should be substituted for
Metronidazole azithromycin
400 mg b.i.d. p.o. 5 d
After first-line azithromycin Moxifloxacin 400 mg p.o. q.d. 7–14 d
plus
Metronidazole 400 mg b.i.d. p.o. 5 d
SD = single dose; b.i.d. = twice daily; q.d. = every day; p.o. = oral; i.m. = intramuscular; i.v. = intravenous.
a
Despite a lack of randomised controlled trials there is increasing evidence that i.v. ceftriaxone is safe and effective for the treatment of gonorrhoeal
infections and avoids the discomfort of an i.m. injection for patients [68].
 EUROPEAN UROLOGY 86 (2024) 27–41 35

Table 14 – Recommendations for the diagnosis of bacterial often resulting in delayed treatment [100]. A high index of
prostatitis
suspicion and careful examination, particularly of obese
Recommendation Strength patients, is required. Computed tomography or MRI can
rating help in defining pararectal involvement, suggesting the
Do not perform prostatic massage in ABP. Strong need for bowel diversion [99]. A broad-spectrum antibiotic
Take a midstream urine dipstick to check nitrite and Weak
on presentation (Table 16 [101]), with subsequent refine-
leukocytes in patients with clinical suspicion of ABP.
Take a midstream urine culture in patients with ABP Weak ment according to culture results and the clinical response,
symptoms to guide diagnosis and tailor antibiotic is recommended. The degree of internal necrosis is usually
treatment.
Take a blood culture and a total blood count in patients Weak
vastly greater than suggested by external signs, and conse-
presenting with ABP. quently adequate repeated surgical debridement with uri-
Perform accurate microbiological evaluation for atypical Weak nary diversion via a suprapubic catheter is necessary to
pathogens such as Chlamydia trachomatis and
Mycoplasma species in patients with CBP.
reduce mortality [99]. Adjunctive treatments for Fournier’s
Perform the Meares and Stamey 2- or 4-glass test in Strong gangrene should not be used except in the context of clini-
patients with CBP. cal trials.
Perform transrectal ultrasound in selected cases to rule out Weak
the presence of prostatic abscess.
Do not routinely perform microbiological analysis of the Weak 3.13. Management of human papillomavirus in men
ejaculate alone to diagnose CBP.
ABP = acute bacterial prostatitis; CBP = chronic bacterial prostatitis. Human papillomavirus is one of the most frequently sexu-
ally transmitted viruses and encompasses both oncogenic
(low- and high-risk variants) and non-oncogenic viruses.
Table 15 – Suggested antimicrobial therapy regimens for chronic The most important information regarding diagnosis and
bacterial prostatitis therapy can be found in Figure 3. For further details, please
Antimicrobial Daily dose Therapy Comments refer to the full version of the guideline online (https://uro-
duration web.org/guidelines/urological-infections).
Fluoroquinolone Optimal oral 4–6 wk
daily dose 3.14. Genitourinary tuberculosis
Doxycycline 100 mg b.i.d 10 d Only for C. trachomatis or
Mycoplasma infections
Although tuberculosis (TB) is one of the most common
Azithromycin 500 mg once 3 wk Only for C. trachomatis
daily infections infectious diseases worldwide, its extrapulmonary manifes-
Metronidazole 500 mg t.i.d. 14 d Only for T. vaginalis tation, genitourinary TB (GUTB), is often underestimated by
infections
urologists, especially in non-endemic regions such as Eur-
b.i.d. = twice daily; t.i.d. = three times daily.
ope. GUTB represented 4.6% of extrapulmonary TB cases in
the EU between 1997 and 2017 [102]. The disease can affect
all the genitourinary organs and is almost always secondary
abscesses are better treated by single aspiration or continu-
to the haematogenous spread of chronic latent TB infection
ous drainage [95].
(LTBI) [103]. Risk factors include primary TB and LTBI, dia-
betes, advanced age, low body mass index, oncological
3.11. Acute infective epididymitis comorbidities, immunosuppression (including human
Epididymitis is a prevalent condition that can manifest as immunodeficiency virus), renal failure, and poor socioeco-
acute, chronic, or recurrent episodes [96]. Acute epididymi- nomic conditions. The risk of reactivation is estimated to
tis is clinically characterised by pain, swelling, and elevated be up to 15% during an individual’s lifetime [104]. Diagnosis
temperature of the epididymis, potentially involving the of GUTB is challenging owing to the lack of a single diagnos-
testis and scrotal skin. In up to 90% of cases, the condition tic test (Table 17). Diagnosis relies on a high index of suspi-
is caused by migration of pathogens from the urethra or cion according to patient history, along with
bladder, which can be identified via appropriate diagnostics microbiological, molecular, and histological testing, as well
[97]. The predominant pathogens isolated are Enterobac- as imaging findings . Patients typically present with non-
terales, C. trachomatis, and Neisseria gonorrhoeae [98]. Fig- specific urological symptoms such as haematuria, an
ure 2 outlines the diagnostic and treatment algorithm for increase in urinary frequency, difficulty in voiding, and
men with acute epididymitis. abdominal, lumbar, and suprapubic pain. Among female
patients, symptoms may include menstrual irregularities
and pelvic pain. Patients may also present for infertility
3.12. Fournier’s gangrene
issues; however, infertility and TB are not addressed in
Fournier’s gangrene is an aggressive and frequently fatal detail here.
polymicrobial soft-tissue infection of the perineum, peri- Combination drug therapy is the first-line treatment for
anal region, and external genitalia [99]. Typically, there is GUTB (Table 18). The World Health Organisation advises a
painful swelling of the scrotum or perineum with sepsis daily regimen for 6 mo for newly diagnosed extrapul-
[99]. Patient risk factors for occurrence and mortality monary TB, involving an initial intensive phase of 2 mo with
include immunocompromised status, most commonly isoniazid, rifampicin, pyrazinamide, and ethambutol, fol-
because of diabetes or malnutrition, recent urethral or per- lowed by a 4-mo continuation phase with isoniazid and
ineal surgery, and high body mass index. In up to 40% of rifampicin [105]. In cases of multidrug-resistant TB (resis-
cases, the onset is more insidious, with undiagnosed pain tance to rifampicin and isoniazid), a personalised treatment
36 EUROPEAN UROLOGY 86 (2024) 27–41

Acute scrotal pain, and

swelling in adult male

Torsion suspected Suspected epididymitis

Urgent surgical exploration

Gonorrhoea Gonorrhoea
unlikely likely

Midstream urine for culture

Urethral swab/smear

Failure to respond or
First voided urine for nucleic acid
abscess present
amplification test (NAAT)

Scrotal
ultrasound
examination
Clinical Single antibiotic or a combination of Ceftriaxone 1000 mg
assesment i.m. or i.v. plus a course
two antibiotics active against
Chlamydia trachomatis and of an antibiotic active
Enterobacterales against Chlamydia
Consider parenteral therapy if severe trchomatics
infection

Proven sexually transmitted

infection
• Reporting
• Check cure
• Trace and treat contacts

Diagnosis Treatment Follow-up

Fig. 2 – Diagnosis and treatment algorithm for epididymitis. i.m. = intramuscular; i.v. = intravenous. * Despite a lack of randomised controlled trials, there is
increasing evidence that intravenous ceftriaxone is safe and effective for the treatment of gonorrhoeal infections and avoids the discomfort of an
intramuscular injection for patients [68].

approach is recommended, which should include at least Nevertheless, more than 50% of patients may require
five effective TB medications during the intensive phase, ablative, endoscopic, or reconstructive surgery owing to
including pyrazinamide and four core second-line TB the destructive nature of TB infection, which is often com-
medicines [106]. pounded by delayed initial diagnosis [107–109]. Some
 EUROPEAN UROLOGY 86 (2024) 27–41 37

Table 16 – Suggested antimicrobial therapy regimens for Fournier’s sion to operate taken depending on the location, extent of
gangrene of mixed microbiological aetiology (adapted from [101])
disease progression and damage to the genitourinary
Antimicrobial Dosage system.
Piperacillin-tazobactam plus 4.5 g every 6–8 h i.v.
Vancomycin 15 mg/kg every 12 h 3.15. Periprocedural antibiotic prophylaxis
Imipenem-cilastatin 1 g every 6–8 h i.v.
Meropenem 1 g every 8 h i.v. Urological surgeons should prioritise and vigilantly main-
Ertapenem 1 g once daily
Gentamicin 5 mg/kg daily tain an aseptic environment to minimise the risk of infec-
Cefotaxime plus 2 g every 6 h i.v. tions originating from both endogenous (patient
Metronidazole or 500 mg every 6 h i.v. microbiome) and exogenous (nosocomial/health care–asso-
Clindamycin 600–900 mg every 8 h i.v.
Cefotaxime plus 2 g every 6 h i.v. ciated) sources. This entails the use of proper methods for
Fosfomycin plus 5 g every 8 h i.v. instrument cleaning and sterilisation, implementation of
Metronidazole 500 mg every 6 h i.v. regular and thorough cleaning protocols for operating
i.v. = intravenous. rooms and recovery areas, and meticulous disinfection of
any potential sources of contamination. They should also
26.9% of GUTB cases have a nonfunctioning unilateral kid- have knowledge of the local pathogen prevalence for each
ney and 7.4% have renal failure [109]. Owing to the scarcity type of procedure, their antibiotic susceptibility profiles,
of high-quality evidence regarding surgical management of and their virulence to establish written local guidelines.
GUTB, the panel was unable to make a definitive recom- The available evidence enabled the panel to make rec-
mendation on surgical intervention. Patients with GUTB ommendations concerning urodynamics, cystoscopy, stone
should be assessed on an individualised basis and the deci- procedures (extracorporeal shockwave lithotripsy, uretero-

Diagnosis Treatment of HPV lesion Diagnosis

Physical examination to Patient-applied treatments - imiquimod 5%;
identify HPV lesion: sinecatechins 15% and 10%; and Treatment

Use a good light scource podophyllotoxin 0.5%

Follow-up
Positive
Magnification with a lens Physician-administered treatment -
may be useful cryotherapy and surgical treatment including
excision, electrosurgery, electrocautery, and
Inspect the urethral
laser therapy
meatus

Physical diagnosis
uncertain
Switch Follow-up visit
treatment when
Acetic acid test to treatment
diagnose subclinical complete;
HPV lesions
and again at
Biopsy if there is 6 mo
diagnostic Persistent
uncertainty or Recurrence
/relapse
suspicion of precancer
or cancer

Consider a Persistent
dermatological infection, relapse,
consultation or recurrence
Yes

Negative No

Discuss:
HPV natural history, onward transmission and the partial protection of condoms against HPV
Self-surveillance for new lesions
partial protection against HPV provided by condoms

Fig. 3 – Diagnosis and treatment algorithm for management of human papillomavirus (HPV) in men.
38 EUROPEAN UROLOGY 86 (2024) 27–41

Table 17 – Recommendations for the diagnosis of GUTB

Recommendation Strength
rating
Take a full medical history including history of previous tuberculosis infection (pulmonary and extrapulmonary) form all patients presenting Strong
with persistent nonspecific genitourinary symptoms and no identifiable cause.
Perform smear microscopy on urine, semen, tissue specimens, discharged or prostatic massage fluid using Ziehl-Neelsen or auramine staining Weak
in patients with suspected GUTB.
Perform an acid-fast bacillus culture on three midstream first-void urine samples on three consecutive days for Mycobacterium tuberculosis Strong
isolation in patients with suspected GUTB.
Use a recommended PCR test system in addition to a microbiological reference standard for urine specimens as a diagnostic test in patients Weak
with signs and symptoms of GUTB.
Use imaging modalities in combination with culture and/or PCR to aid in the diagnosis of GUTB and to assess the location and extent of damage Weak
to the genitourinary system.
GUTB = genitourinary tuberculosis; PCR = polymerase chain reaction.

Table 18 – Treatment regimens for newly diagnosed GUTB and MDR-TB [106]

Antimicrobial Dosage
6-mo regimen for newly diagnosed GUTB
Intensive 2-mo phase
Isoniazid 5 mg/kg every 24 h; maximum daily dose 300 mg
Rifampicin 10 mg/kg every 24 h; maximum daily dose 600 mg
Pyrazinamide 25 mg/kg every 24 h; max daily dosage 2000 mg
Ethambutol 15–20 mg/kg every 24 h; maximum daily dose 800–1600 mg, depending on body weight
Continuation 4-mo phase
Isoniazid 5 mg/kg every 24 h; maximum daily dose 300 mg
Rifampicin 10 mg/kg every 24 h; maximum daily dose 600 mg
Treatment regimen for MDR-TB
Treat MDR-TB with an individualised treatment regimen including at least 5 effective TB medicines during the intensive phase, including pyrazinamide and 4
core second-line TB medicines.a
Group A: fluoroquinolones Levofloxacin, moxifloxacin, and gatifloxacin
Group B: second-line injectables Amikacin, capreomycin, kanamycin, and streptomycinb
Group C: other second-line agents Ethionamide/prothionamide, cycloserine/terizidone, linezolid, and clofazimine
Group D: add-on agents (not part of the core MDR-TB D1: Pyrazinamide, ethambutol, and high-dose isoniazid
regimen) D2: Bedaquiline and delamamid
D3: p-Aminosalicylic acid, imipenem-cilastatin, meropenem, amoxicillin-clavulanate, and
thioacetazonec
GUTB = genitourinary tuberculosis; MDR-TB = multidrug-resistant tuberculosis.
a
Drugs should be chosen as follows: 1 from group A, 1 from group B, and at least 2 from group C. If the minimum number of five TB medicines cannot be
composed of drugs included in groups A–C, an agent from group D2 and other agents from group D3 may be added to bring the total to five [106].
b
Streptomycin can substitute for other injectable drugs if none of these agents can be used and if the strain is not resistant [106].
c
Thioacetazone should not be used if the patient is seropositive for human immunodeficiency virus [106].

Table 19 – Suggested antimicrobial prophylaxis regimens before urological procedures

Procedure Prophylaxis recommended Antimicrobial

Urodynamics No N/A
Cystoscopy No
Extracorporeal shockwave No
lithotripsy
Ureteroscopy Yes Trimethoprim
Percutaneous Yes (single dose) Trimethoprim-sulfamethoxazole
nephrolithotomy
TUR of the prostate Yes Cephalosporin group 2 or 3
TUR of the bladder Yes, in patients with high risk of Aminopenicillin plus a b-lactamase inhibitor
postoperative sepsis.
Transrectal prostate biopsy Yes 1. Targeted prophylaxis on the basis of a rectal swab or stool culture.
2. Augmented prophylaxis with two or more different antibiotic classes.a
3. Alternative antibiotics
 Fosfomycin trometamolb (eg, 3 g before and 3 g 24–48 h after biopsy)
 Cephalosporin (eg, ceftriaxone 1 g i.m.; cefixime 400 mg p.o. for 3 d start-
ing 24 h before biopsy)
 Aminoglycoside (eg, gentamicin 3mg/kg i.v.; amikacin 15mg/kg i.m.)
TUR = transurethral resection; i.m. = intramuscular; i.v. = intravenous; p.o. = oral.
a
This option contravenes antibiotic stewardship principles.
b
The indication for fosfomycin trometamol for prostate biopsy has been withdrawn in Germany as the manufacturers did not submit the necessary
pharmacokinetic data in support of this indication. Urologists are advised to check their local guidance in relation to the use of fosfomycin trometamol for
prostate biopsy.
 EUROPEAN UROLOGY 86 (2024) 27–41 39

scopy, and percutaneous nephrolithotomy), transurethral Limited. Prof. Dr. F. Wagenlehner holds the position of Director Clinic of
resection of the prostate, and transurethral resection of Urology, Pediatric Urology and Andrology for Justs Liebig University. He
the bladder. For nephrectomy and prostatectomy, the scien- received consultation fee from Achaogen, Bionorica, GSK, Janssen, Kloster-
tific evidence was too weak to allow the panel to make rec- frau, Pfizer, MIP Pharma, Shionogi, Spero and VenatorRX, OM-Pharma. He

ommendations either for or against antibiotic prophylaxis also received company speaker honorarium from Astellas, AstraZeneca,
Bionorica, GSK, Janssen, Klosterfrau, MSD, Pfizer, MIP Pharma and OM-
(Table 19).
Pharma. Addtionally, he has trial participation with GSK, Klosterfrau,
Select Immune, Janssen and VenatoRx. He also received research grants
from DFG and DZIF. Nothing to disclose: Riccardo Bartoletti, Katharin
4. Conclusions
Bausch, Tomasso Cai, Wout Devlies, József Horváth, Béla Köves, Lorenz
Leitner, Guglielmo Mantica, Tünde Mezei, Sören Schubert, Emma J. Smith,
This summary of the EAU guidelines on urological infections Adrian Pilatz
provides current insights into the diagnosis, treatment, and
prevention of urological infections, and can facilitate imple-
mentation of the recommendations in clinical practice, par- Funding/Support and role of the sponsor: None.

ticularly focusing on antimicrobial stewardship in response

to the escalating global threat of antimicrobial resistance.
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