Urogenital Infections and Inflammations

T.E. Bjerklund Johansen, F. M.E. Wagenlehner, Y.-H. Cho, T. Matsumoto, J. N. Krieger, D. Shoskes, K. Naber

Prevention of catheter-associated UTI

 Paul Anantharajah Tambyah 1
Leyland Chuang 2
Edmund Chiong 3


1 Department of Medicine, Yong Loo Lin School of Medicine, National University Hospital, Singapore, Singapore
2 Department of Medicine, Ng Teng Fong Hospital, National University Health System, Singapore, Singapore
3 Department of Urology, National University Hospital, Singapore

Abstract

We surveyed existing guidelines and literature on the prevention of catheter-associated urinary tract infection (CAUTI). Key principles include avoiding unnecessary urinary catheterization, maintaining a closed aseptic drainage system and minimizing duration of catheterization. Institutional guidelines on appropriate indications for catheterization, reminder and stop-order systems, and policies on restricted urinary catheterization and nurse-directed catheter removal are effective and recommended. Urinary catheter care bundles and infection control interventions described in various guidelines are summarized and should be considered. While routine use of anti-infective coated catheters are not recommended, anti-infective-impregnated catheters may reduce risks of CAUTI for short term catheterization, and may be considered if shown to be cost effective. Evidence for the use of routine systemic antibiotic prophylaxis for the prevention of CAUTI is inconsistent and insufficient. Treatment of symptomatic CAUTI should be guided by local uropathogens, susceptibility patterns and urine culture results, and antibiotic should be deescalated to the narrowest spectrum choice where possible. Routine treatment of catheter-associated asymptomatic bacteriuria in not recommended.


Summary of recommendations

Recommendation LE/GR
Avoiding unnecessary catheterization and prompt removal
1. Establishing institutional guidelines to prevent inappropriate urinary catheterization has been shown to reduce catheter use and CAUTI rates [1], [2], [3], [4]. 2b/B
2. Early removal of IUCs reduces the risks of subsequent CAUTI [1], [3], [5], [6] and other complications [5], [7]. 2b/B
3. Health care workers are often unaware about the presence of IUCs in patients [8], [9]. This should be addressed, in order to minimize inappropriate use of IUCs and reduce duration of catheterization. 3/B
4. Nurse generated or electronic-based reminder and stop-order systems for the removal of urinary catheters reduce utilization of IUCs and rates of CAUTIs [1], [3], [4], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24]. 1a/B
5. A restricted urinary catheterization policy with daily chart review of appropriateness of catheter insertion reduces urinary catheterization rates [25]. 2b/B
6. Nurse-directed urinary catheter removal reduces urinary catheter utilization and rates of CAUTI [16], [20], [22], [26], [27]. 2a/B
7. Alternative methods of bladder drainage such as SPCs and intermittent catheterization may be considered, but evidence of efficacy in preventing symptomatic UTI remains limited [28], [29], [30], [31]. 1b/C
8. Educational interventions may reduce IUC utilization [2], [4], [32]. 2a/B
Care and maintenance of urinary catheter system
9. Maintaining sterility of closed urinary catheter systems is recommended to prevent the development of CAUTIs [33], [34], [35], [36], [37], [38], [39], [40]. 3/B
Urinary catheter types
10. Evidence for various urinary catheter types are as follows: 
  • No recommendations on the use of hydrophilic-coated catheters for intermittent catheterization can be made [41], [42], [43].
1a
  • Anti-infective-impregnated catheters reduce risks of CAUTI slightly in short-term catheterization of 14 days or less, and may be cost effective [44], [45], [46].
1b/B
  • Silver alloy catheters reduce risks of bacteriuria, but not CAUTI, and are unlikely to be cost effective [44], [45], [46].
1a/A
  • There are insufficient data to recommend the use of antibiotic-impregnated or silver alloy catheters for long-term catheterization [47].
1b
CAUTI prophylaxis 
11. No recommendation can be made for the routine use of antibiotic prophylaxis for the prevention of CAUTI due to inconsistent and insufficient evidence, and potential risks of increased antimicrobial resistance. It may be considered where benefits are deemed to outweigh risks. 1a
  • Use of antibiotic prophylaxis during short-term urinary catheterization of up to 14 days in adult patients is associated with significant reduction in asymptomatic bacteriuria, but there is no strong evidence showing reduction in symptomatic UTIs [48], [49].
  • Antibiotic prophylaxis at time of short-term IUC removal is associated with significant reduction in symptomatic UTI, but cannot be recommended routinely due to high numbers needed to treat, and the potential to increase antimicrobial resistance rates [50], [51].
  • There is insufficient evidence to recommend antimicrobial prophylaxis for long-term catheterization of more than 14 days [30].
Treatment of CAUTI 
12. Empiric antimicrobial therapy may be guided by recent prior urine culture results, where possible [52]. Catheter removal and if necessary reinsertion remains the key to treatment. 2b/C
13. Early de-escalation of antibiotic therapy, as guided by urine culture results, to the narrowest spectrum antibiotic available. 4/C
14. Shorter 5 day course of antibiotics with catheter exchange may be considered in the treatment of CAUTI in patients with spinal cord injury [53]. 1b/B
15. Catheter-associated asymptomatic bacteriuria should not be routinely treated with antibiotics [35], [54]. 1b/A

1 Introduction

Urinary tract infections (UTIs) are the commonest cause of nosocomial infections worldwide, and have been estimated to cause approximately 30% of healthcare-associated infections in the acute care setting in the United States [55]. Approximately 75% of healthcare-associated UTIs are associated with an indwelling urinary catheter (IUC), and 12 to 16 percent of hospitalized patients will undergo urinary catheterization [56]. The high frequency of IUC utilization in healthcare highlights the impact and challenge of catheter-associated UTI (CAUTI) in the healthcare system globally [57], [58], [59], [60], [61], [62], [63] (LE: 3).

The aim of this chapter is to highlight key evidence-based recommendations for the prevention of CAUTIs.

2 Methods

Current published major practice guidelines were reviewed, and their recommendations were summarized. A systematic literature search of studies from the past ten years was also performed in PubMed with the following key words: urinary tract infection, bacteriuria, CAUTI, UTI, catheter. Search criteria were limited by following: availability of abstracts, English language and adults. Publications identified were screened by title and abstracts for relevance, and supplemented by citations and publications known to the authors. A total of 120 publications were included into the review.

The studies were rated according to the level of evidence and the strength of recommendations graded according to the system used in the EAU guidelines (2015) modified from the Oxford Centre for Evidence-based Medicine [37].

3 Pathogenesis and risk factors

The presence of a transurethral catheter predisposes patients to CAUTIs by bypassing or inhibiting natural host defenses [64]. The development of biofilm on the urinary catheters further exacerbates this by providing a favorable environment for bacterial proliferation and invasion [38], [65] (LE: 3).

Bacteria may be introduced into the urinary tract via multiple routes:

  1. Inoculation during catheter insertion (e.g. non-compliance to aseptic technique during catheter insertion).
  2. Intraluminal ascent after contamination of the closed urinary catheter system. This may be related to lapses in aseptic practices while emptying the urinary drainage bag, or after disconnection of catheters from urinary bags.
  3. Extraluminal route of ascent along the external catheter surface into the urethra.

Risk factors for CAUTIs which have been identified in prospective observational studies include [64], [66], [67], [68] (LE: 2b):

  • Duration of catheterization
  • Poor catheter care or breaks in aseptic technique
  • Female gender
  • Diabetes mellitus
  • Anatomical or functional abnormalities of the urinary tract
  • Insertion of the catheter outside the operating room

In particular, longer duration of catheterization was highlighted as a risk factor for CAUTI by Barbadoro et al., who found catheterization of greater than 4 days to be associated with CAUTI (odds ratio 8.21; 95% confidence interval, 3.79–17.73; p<0.05) [68].

4 Summary of current guidelines on CAUTI prevention

Various guidelines on prevention of CAUTI have been published. Current guidelines include those from the Healthcare Infection Control Practices Advisory Committee (HICPAC) [33], the Infectious Diseases Society of America (IDSA) [34], the Society for Healthcare Epidemiology of America (SHEA) [35], the Department of Health of England (epic3 guidelines) [36], the European Association of Urology (EAU) [37], and also the joint European and Asian guidelines [38]. Their recommendations are summarized in table 1.

Table 1: Summary of recommendations from published guidelines
 

European & Asian guidelines 2008 [38

IDSA 2009 [34

CDC/HICPAC 2009 [33

epic3 2014 [36

SHEA/IDSA 2014 [35

EAU 2015 [37

General

Provide guidelines on catheter use, insertion and maintenance

Y

Y

Y

Y

Y

Y

Documentation of urinary catheterization: may include details of catheter insertion and removal, indication for insertion, and daily maintenance care tasks

ND

Y

Y

Y

Y

ND

Educate and train healthcare personnel

ND

Y

Y

Y

Y

ND

Hand hygiene compliance during patient care

Y

ND

Y

Y

Y

Y

Catheter insertion

Evaluate need for catheterization

Consider necessity of catheterization, ensure catheterization only for appropriate indications

ND

Y

Y

Y

Y

ND

Consider alternatives (e.g. condom catheters, intermittent straight catheterization and suprapubic catheters)

Y

Y

Y

Y

Y

Y

Protocol for post-operative urinary retention (e.g. intermittent catheterization, use of bladder scanners)

ND

Y

Y

ND

Y

ND

Choice of catheter

Use smallest gauge urinary catheter possible

Y

ND

Y

Y

Y

Y

Choice of standard catheter material type

U

ND

Y

U

ND

ND

Routine use of antimicrobial/antiseptic-impregnated catheters is not recommended

Y

Y

U

ND

Y

Y

Routine use of silver alloy catheters is not recommended

Y

Y

U

ND

ND

U

Use of hydrophilic catheters for intermittent catheterization recommended

ND

ND

Y

ND

ND

ND

Use of pre-connected urinary system

ND

Y

Y

ND

ND

ND

Catheter insertion

Use aseptic technique and sterile equipment

Y

Y

Y

Y

Y

Y

Use adequate lubricant

Y

ND

Y

Y

Y

Y

Antiseptic solution for cleaning of meatus during catheter insertion

U

ND

U

N

Y

ND

Barrier precaution

ND

U

Y

ND

Y

ND

Insertion of catheter by trained personnel

ND

Y

Y

Y

Y

ND

Train patients and family

ND

ND

Y

Y

ND

ND

Catheter maintenance

Catheter review

Minimize duration of catheterization

Y

Y

Y

Y

Y

Y

Regular review of ongoing need for catheter

ND

ND

Y

Y

Y

ND

System to identify and remove catheters that are no longer necessary: may include electronic or nursing reminders, automatic stop orders, or nurse led catheter removal protocols

ND

Y

Y

Y

Y

Y

Early removal of IUCs post-operatively

Y

ND

Y

ND

ND

Y

Catheter care

Maintain closed drainage system

Y

Y

Y

Y

Y

Y

Replace system if there is any break in asepsis

ND

ND

Y

ND

Y

ND

No routine change in catheter

Y

U

Y

Y

Y

Y

Obtain urine samples aseptically

ND

ND

Y

Y

Y

ND

Routine hygiene for meatal care. Topical antiseptic/antibiotic applied to catheter, urethra or meatus are not recommended.

Y

Y

Y

Y

Y

Y

Secure catheter

ND

ND

Y

Y

Y

ND

Avoid irrigation for purpose of preventing infection

ND

Y

Y

Y

Y

Y

Maintain unobstructed urine flow

ND

ND

Y

ND

Y

ND

Keep collecting bag below level of bladder

ND

Y

Y

Y

Y

Y

Keep collecting bag off the floor

ND

ND

Y

Y

Y

ND

Empty collecting bag regularly using separate collecting container for each patient, avoid touching the draining spigot to the container

ND

ND

Y

Y

Y

ND

Separate patients with catheters

ND

U

U

ND

U

ND

Asymptomatic bacteriuria

Do not routinely screen for bacteriuria in asymptomatic catheterized patients

Y

Y

Y

ND

Y

Y

Do not routinely treat asymptomatic bacteriuria in catheterized patients

Y

Y

ND

ND

Y

Y

Antiseptic & antimicrobial prophylaxis

Routine use of systemic antimicrobial prophylaxis not recommended

 

Y

Y

ND

Y

 

     Short-term catheterization 

ND

     Intermittent catheterization

Y

     Long-term catheterization

U

U

Routine use of long term antibiotic suppressive therapy not recommended

Y

ND

ND

ND

ND

Y

Routine use of urinary antiseptics (e.g. methenamine) not recommended

Y

Y

U

ND

U

Y

Routine addition of antiseptic or antimicrobial solutions to urinary drainage bags not recommended

ND

Y

Y

Y

ND

ND

Surveillance & audit

Performance feedback to clinical staff

ND

Y

Y

Y

Y

ND

Surveillance: may include CAUTI rates and catheter utilization rates

ND

ND

Y

ND

Y

ND

Legend: Y: Recommended; N: Not recommended; U: Unresolved; ND: Not discussed

 

5 Recommendations for CAUTI prevention

5.1 Principles of CAUTI prevention

Principles for prevention of CAUTI may be broadly classified under the following categories:

  • Avoiding unnecessary urinary catheterization and minimizing duration of catheterization;
  • Preserving closed aseptic drainage of the urinary catheter system;
  • Implementing urinary catheter care bundles and infection prevention programs.

In an American multicenter prospective surveillance study, Lewis et. al. found that 72% of CAUTIs occurred in patients not in intensive care units [69]. Hence, CAUTI prevention efforts should include patients in general wards.

5.2 Avoiding unnecessary catheterization and prompt removal

Establishing institutional guidelines to prevent inappropriate urinary catheterization reduces catheter use and CAUTI rates [1], [2], [3], [4] (LE/GR: 2b/B). Indications for catheterization which are considered appropriate by expert panels include the following [33], [35], [36], [70] (LE/GR: 4/B):

  1. Acute urinary retention or bladder outlet obstruction;
  2. Management of open sacral or perineal wounds in incontinent patients;
  3. Urinary incontinence in patients for whom nurses find it difficult to provide skin care despite other urinary management strategies (e.g. hemodynamic or respiratory instability with movement, conditions requiring strict prolonged immobility);
  4. Frequent measurement (e.g. in critically ill patients) and/or precise measurement of urine volumes required to provide treatment, that cannot be assessed by other strategies;
  5. Single 24 hour urine sample collection for diagnostic tests that cannot be obtained by other strategies;
  6. Reduce acute, severe pain with movement when other urine management strategies are difficult;
  7. Improvement in comfort in end of life care if needed;
  8. Management of gross hematuria with blood clots in urine;
  9. Clinical conditions where non-indwelling strategies are inadequate, or where intermittent straight catheterization or external catheter placement are difficult;
  10. Perioperative use in selected surgical procedures (e.g. urologic surgery, prolonged duration of surgery).

Reduction in utilization of IUCs and their early removal have been shown to reduce the risks of CAUTI [1], [3], [5], [6] and other complications, such as mortality [5] and bladder cancers [7] (LE/GR: 2b/B). A Cochrane study on early removal in patients with short-term IUCs showed lower risks of UTI and shorter hospitalization [71]. However, healthcare workers are often unaware about the presence of IUCs in patients [8], [9], contributing to unnecessary or inappropriate catheterization (LE/GR: 3/B). This may be prevented by nurse generated or electronic-based reminders and stop-order systems for the removal of urinary catheters, which have been shown in multiple studies and a systematic review to reduce utilization of IUCs and rates of CAUTIs [1], [3], [4], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24] (LE/GR: 1a/B). A restricted urinary catheterization policy together with daily chart review of appropriateness of new catheter insertions has also been shown to reduce catheterization rates [25] (LE/GR: 2b/B). Nurse-directed urinary catheter removal has also been shown to reduce catheter utilization and CAUTI rates [16], [20], [22], [26], [27] (LE/GR: 2a/B).

Alternative methods of bladder drainage other than IUCs may be considered, but evidence of efficacy in preventing CAUTI is limited (LE/GR: 1b/C). Recent trials were directed mostly at the use of suprapubic catheters (SPCs) and intermittent catheterization. A Cochrane review by Kidd et al. on short-term catheterization (of ≤14 days) in hospitalized adults found no conclusive evidence of reduction in symptomatic UTI with SPC compared to IUCs (LE: 1a), while results comparing IUC against intermittent catheterization were inconclusive and of low quality [28]. Two Cochrane reviews, one on alternative methods of long-term management of neurogenic bladder, and another comparing IUCs against intermittent and suprapubic catheterization for long term bladder drainage, could find no definitive evidence from randomized trials [29], [30]. A review by Hunter et al. found five non-randomized or retrospective studies showing no evidence of difference in UTI prevalence between IUC and SPC management of long term bladder drainage [31]. Despite these, there may be some evidence of benefit in reduction of asymptomatic bacteriuria and pain with the use of SPC [28] (LE: 1a), and more rapid return to normal micturition after urogynaecological surgery (LE: 1b) and acute urinary retention (LE: 2a) with the use of intermittent catheterization compared to IUCs [72], [73]. The weighing of incontinence pads for monitoring of urine output has also been shown to allow the removal of IUCs used for those purposes [74].

Education interventions (alone or as part of a bundle) are associated with reduction in IUC utilization, and may reduce inappropriate antimicrobial therapy for asymptomatic bacteriuria and CAUTI rates [2], [4], [32] (LE/GR: 2a/B).

Recommendation LE/GR
1. Establishing institutional guidelines to prevent inappropriate urinary catheterization has been shown to reduce catheter use and CAUTI rates [1], [2], [3], [4]. 2b/B
2. Early removal of IUCs reduces the risks of subsequent CAUTI [1], [3], [5], [6] and other complications [5], [7]. 2b/B
3. Health care workers are often unaware about the presence of IUCs in patients [8], [9]. This should be addressed, in order to minimize inappropriate use of IUCs and reduce duration of catheterization. 3/B
4. Nurse generated or electronic-based reminder and stop-order systems for the removal of urinary catheters reduce utilization of IUCs and rates of CAUTIs [1], [3], [4], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24]. 1a/B
5. A restricted urinary catheterization policy with daily chart review of appropriateness of catheter insertion reduces urinary catheterization rates [25]. 2b/B
6. Nurse-directed urinary catheter removal reduces urinary catheter utilization and rates of CAUTI [16], [20], [22], [26], [27]. 2a/B
7. Alternative methods of bladder drainage such as SPCs and intermittent catheterization may be considered, but evidence of efficacy in preventing symptomatic UTI remains limited [28], [29], [30], [31]. 1b/C
8. Educational interventions may reduce IUC utilization [2], [4], [32]. 2a/B

5.3 Care and maintenance of urinary catheter system

Maintaining sterility of urinary catheter systems is recommended, with all current guidelines reviewed above recommending aseptic catheterization technique and maintenance of closed drainage system [33], [34], [35], [36], [37], [38] (LE/GR: 3/B). Data from the Spanish national database of hospital infections and a Japanese multicenter prospective observational study showed closed urinary drainage systems were associated with significant reductions in CAUTI incidence [39], [40] (LE: 3). However, three randomized controlled trials examining the effect of pre-connected or sealed urinary catheter drainage systems on preventing bacteriuria showed differing outcomes [75], [76], [77] (LE: 1b). Also, a Cochrane systematic review [41] and multiple randomized controlled trials [78], [79], [80] comparing aseptic against clean techniques of catheterization have not shown differences in CAUTI rates (LE: 1a). All these studies however, had closed drainage in all systems.

The use of catheter securing devices has not been shown to reduce UTI rates [81] (LE: 1b), but should be considered to prevent catheter movement and urethral traction. Bladder irrigation [82], [83] (LE: 1b), antimicrobial additives to drainage bags [84] (LE: 1b), perineal cleansing with topical antiseptic agents [85], [86] (LE: 1b), daily bath with chlorhexidine washcloths [87], [88], [89] (LE: 2a) and complicated urinary drainage systems (e.g. anti-reflux valves and antiseptic release cartridge) [90], [91] (LE: 1b) have also not been shown to prevent CAUTI or bacteriuria and are not recommended (LE/GR: 1b/A). There is insufficient evidence to make recommendations on optimal time between catheter replacements [92].

Recommendation LE/GR
1. Maintaining sterility of closed urinary catheter systems is recommended to prevent the development of CAUTIs [33], [34], [35], [36], [37], [38], [39], [40]. 3/B

5.4 Urinary catheter types

Large numbers of recent studies have looked at the use of various catheter materials for the prevention of CAUTI, and anti-infective-impregnated catheters may be considered in some settings if cost-effective.

Hydrophilic-coated catheters have been studied mainly for intermittent catheterization in patients with spinal cord injury (SCI) or neurogenic bladder, and conclusions by three systematic reviews were inconsistent. The reviews for The Cochrane Collaboration [41] and National Institute for Health and Clinical Excellence (NICE) [42] did not show reduction in CAUTI, while Li et al. [43] found significantly lower incidence of UTIs. As such, no recommendation can be made (LE: 1a).

A Cochrane review on short-term catheterization (of ≤14 days) in adult hospitalized patients showed slight reduction in risks of CAUTI with the use of nitrofurazone-impregnated catheters, and slight reduction in risks of bacteriuria but not symptomatic CAUTI with silver alloy catheters [44] (LE: 1a). Trials with economic analysis funded by the United Kingdoms (UK) National Institute for Health Research found that the chances of cost-effectiveness are greater than 70% for nitrofurazone-impregnated catheters, and very unlikely for silver alloy catheters, in the setting of the UK National Health Service [45], [46]. This may not apply to all health systems.

The Cochrane review by Jahn et al. on IUC choice for long-term bladder drainage (>30 days) in adults was unable to find sufficient quality trials to provide reliable recommendations [47] (LE: 1b).

Trials exploring the use of various novel catheter coatings with other anti-septics [93], [94], [95], [96], [97], [98], [99], [100], non-pathogenic Escherichia coli [101], [102], [103], anti-biofilm agents [104] and anti-quorum sensing agents [105], [106] have been published, and await further confirmatory clinical outcome results.

Recommendation LE/GR
1.  Evidence for various urinary catheter types are as follows: 
  • No recommendations on the use of hydrophilic-coated catheters for intermittent catheterization can be made [41], [42], [43].
1a
  • Anti-infective-impregnated catheters reduce risks of CAUTI slightly in short-term catheterization of 14 days or less, and may be cost effective [44], [45], [46].
1b/B
  • Silver alloy catheters reduce risks of bacteriuria, but not CAUTI, and are unlikely to be cost effective [44], [45], [46].
1a/A
  • There are insufficient data to recommend the use of antibiotic-impregnated or silver alloy catheters for long-term catheterization [47].
1b

5.5 CAUTI prophylaxis

Multiple systematic reviews have examined the use of antibiotic prophylaxis in CAUTI prevention. Lusardi et al. examined adults on short-term catheters (≤14 days) [48], while Morton et al. examined persons with neurogenic bladder due to SCI [49], of whom many were on intermittent catheterization. Both studies found significant reduction in asymptomatic bacteriuria, but no strong evidence of reduction in symptomatic UTIs. In addition, Morton et al. found 4 of 5 trials reporting increase in proportion of antimicrobial resistance bacteria.

Marschall et al. performed a meta-analysis on the effects of antibiotic prophylaxis given upon removal of short-term IUC, and found a 5.8% absolute risk reduction in symptomatic UTI (number needed to treat to prevent one symptomatic UTI of 17) [50] (LE: 1a). However, the study authors and other reviews [51] have expressed reservations about routine antimicrobial prophylaxis upon catheter removal, in light of the likely increase in antibiotic consumption and its association with increased antimicrobial resistance. More research is needed to identify patient groups who will best benefit from this, such as kidney transplant recipients after transplant surgery [110] (LE: 2a).

Niël-Weise et al. performed a systematic review on antimicrobial prophylaxis for long-term catheterization of greater than 14 days, but data were sparse and outcomes inconsistent (LE: 1b) [30]. One observational prospective study examined prophylaxis with weekly high dose oral cycling antibiotic in adult patients with SCI and recurrent UTIs who are on long-term clean intermittent catheterization [111]. It found significant reduction in frequency of UTIs, mean duration of antimicrobial therapy for UTIs, and hospitalization days over a median follow-up duration of 29 months (LE: 2b), but routine use for long term prophylaxis remains controversial.

Studies on cranberry extract [112], [113] and oral vinegar [114] found no evidence of effect on CAUTI prevention (LE: 1b). Methenamine hippurate may have some benefit in UTI prevention in patients without renal tract abnormalities (LE: 1a) [115], and bacterial interference may reduce risk of UTI in patients with SCI (LE: 1b) [116], [117].

Recommendation LE/GR
1.  No recommendation can be made for the routine use of antibiotic prophylaxis for the prevention of CAUTI due to inconsistent and insufficient evidence, and potential risks of increased antimicrobial resistance. It may be considered where benefits are deemed to outweigh risks. 1a   
  • Use of antibiotic prophylaxis during short-term urinary catheterization of up to 14 days in adult patients is associated with significant reduction in asymptomatic bacteriuria, but there is no strong evidence showing reduction in symptomatic UTIs [48], [49].
  • Antibiotic prophylaxis at time of short-term IUC removal is associated with significant reduction in symptomatic UTI, but cannot be recommended routinely due to high numbers needed to treat, and the potential to increase antimicrobial resistance rates [50], [51].
  • There is insufficient evidence to recommend antimicrobial prophylaxis for long-term catheterization of more than 14 days [30].

6 Treatment of CAUTI

Choice of empiric antibiotic therapy may be guided by local uropathogens susceptibility patterns, and also recent prior urine culture results [52] (LE/GR: 2b/C). This should be de-escalated to culture guided narrow-spectrum antibiotics when possible (LE/GR: 4/C). Duration of treatment remains controversial, and guideline recommendations vary from 5 to 21 days [34], [38], [118], [119]. A shorter 5 day course of antibiotics with catheter exchange may be considered in the treatment of CAUTI in patients with SCI [53] (LE/GR: 1b/B). Routine treatment of catheter-associated asymptomatic bacteriuria is not recommended (LE/GR: 1b/B), with the exception of pregnancy and prior to traumatic genitourinary procedures [34], [54], [120].

Recommendation LE/GR
1. Empiric antimicrobial therapy may be guided by recent prior urine culture results, where possible [52]. Catheter removal and if necessary reinsertion remains the key to treatment. 2b/C
2. Early de-escalation of antibiotic therapy, as guided by urine culture results, to the narrowest spectrum antibiotic available. 4/C
3. Shorter 5 day course of antibiotics with catheter exchange may be considered in the treatment of CAUTI in patients with spinal cord injury [53]. 1b/B
4. Catheter-associated asymptomatic bacteriuria should not be routinely treated with antibiotics [35], [54]. 1b/A

Conflicts of interest

Paul Anantharajah Tambyah has received research support from GlaxoSmithKline, Sanofi, Fab’entech, Teleflex, and Inviragen.

Edmund Chiong has had advisory roles too, and received conference support from Bayer, Janssen, GlaxoSmithKline, and Sanofi.

Leyland Chuang declares no conflict of interest.

Glossary

CAUTI: Catheter-associated urinary tract infection

EAU: European Association of Urology

HICPAC: Healthcare Infection Control Practices Advisory Committee (HICPAC)

IDSA: Infectious Diseases Society of America

IUC: Indwelling urinary catheter

NICE: National Institute for Health and Clinical Excellence

SCI: Spinal cord injury

SHEA: Society for Healthcare Epidemiology of America

SPC: Suprapubic catheters

UK: United Kingdoms

UTI: Urinary tract infection


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[108] Pickard R, Lam T, MacLennan G, Starr K, Kilonzo M, McPherson G, Gillies K, McDonald A, Walton K, Buckley B, Glazener C, Boachie C, Burr J, Norrie J, Vale L, Grant A, N'Dow J. Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial. Lancet. 2012 Dec 1;380(9857):1927-35. DOI: 10.1016/S0140-6736(12)61380-4
[109] Makuta G, Chrysafis M, Lam T. Measuring the efficacy of antimicrobial catheters. Nurs Times. 2013 Nov 6-12;109(44):16, 18-9.
[110] Wolters HH, Palmes D, Lordugin E, Bahde R, Senninger N, Hölzen JP, Kebschull L. Antibiotic prophylaxis at urinary catheter removal prevents urinary tract infection after kidney transplantation. Transplant Proc. 2014 Dec;46(10):3463-5. DOI: 10.1016/j.transproceed.2014.04.019
[111] Salomon J, Denys P, Merle C, Chartier-Kastler E, Perronne C, Gaillard JL, Bernard L. Prevention of urinary tract infection in spinal cord-injured patients: safety and efficacy of a weekly oral cyclic antibiotic (WOCA) programme with a 2 year follow-up--an observational prospective study. J Antimicrob Chemother. 2006 Apr;57(4):784-8. DOI: 10.1093/jac/dkl010
[112] McMurdo ME, Bissett LY, Price RJ, Phillips G, Crombie IK. Does ingestion of cranberry juice reduce symptomatic urinary tract infections in older people in hospital? A double-blind, placebo-controlled trial. Age Ageing. 2005 May;34(3):256-61. DOI: 10.1093/ageing/afi101
[113] Opperman EA. Cranberry is not effective for the prevention or treatment of urinary tract infections in individuals with spinal cord injury. Spinal Cord. 2010 Jun;48(6):451-6. DOI: 10.1038/sc.2009.159
[114] Chung YC, Chen HH, Yeh ML. Vinegar for decreasing catheter-associated bacteriuria in long-term catheterized patients: a randomized controlled trial. Biol Res Nurs. 2012 Jul;14(3):294-301. DOI: 10.1177/1099800411412767
[115] Lee BS, Bhuta T, Simpson JM, Craig JC. Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev. 2012 Oct 17;10:CD003265. DOI: 10.1002/14651858.CD003265.pub3
[116] Darouiche RO, Green BG, Donovan WH, Chen D, Schwartz M, Merritt J, Mendez M, Hull RA. Multicenter randomized controlled trial of bacterial interference for prevention of urinary tract infection in patients with neurogenic bladder. Urology. 2011 Aug;78(2):341-6. DOI: 10.1016/j.urology.2011.03.062
[117] Hull R, Rudy D, Donovan W, Svanborg C, Wieser I, Stewart C, Darouiche R. Urinary tract infection prophylaxis using Escherichia coli 83972 in spinal cord injured patients. J Urol. 2000 Mar;163(3):872-7. DOI: 10.1016/S0022-5347(05)67823-8
[118] Harding GK, Nicolle LE, Ronald AR, Preiksaitis JK, Forward KR, Low DE, Cheang M. How long should catheter-acquired urinary tract infection in women be treated? A randomized controlled study. Ann Intern Med. 1991 May;114(9):713-9. DOI: 10.7326/0003-4819-114-9-713
[119] Dow G, Rao P, Harding G, Brunka J, Kennedy J, Alfa M, Nicolle LE. A prospective, randomized trial of 3 or 14 days of ciprofloxacin treatment for acute urinary tract infection in patients with spinal cord injury. Clin Infect Dis. 2004 Sep;39(5):658-64. DOI: 10.1086/423000
[120] Leone M, Perrin AS, Granier I, Visintini P, Blasco V, Antonini F, Albanèse J, Martin C. A randomized trial of catheter change and short course of antibiotics for asymptomatic bacteriuria in catheterized ICU patients. Intensive Care Med. 2007 Apr;33(4):726-9. DOI: 10.1007/s00134-007-0534-1

The ZB MED – Information Center for Life Sciences, Germany, together with the European Association of Urology (EAU) provided the opportunity to publish a “Living Textbook” on “Urogenital Infections and Inflammations” in an open access form. This “Living Textbook” represents also an update of the Textbook on Urogenital Infections published 2010 by the International Consultation on Urological Infections and the EAU: http://www.icud.info/urogenitalinfections.html.

The “Living Textbook” will cover infections and inflammations of the kidney, the urinary tract, as well as the male and female genital tract considering pathogenesis, diagnostics, treatment, prophylaxis and future aspects. The “Living Textbook” will be structured into about 26 Sections each with two section co-chairs responsible for peer review of the chapters of each section. Each chapter should reflect the background to the topic and highlight all of the critical evidence relating to the subject. The intention is to provide an up to date, concise synthesis of the literature on that topic, and for clinical topics also recommendations based on levels of evidence for contemporary clinical practice, as well as suggested research recommendations.

The editors hope that this “Living Textbook” may become a useful instrument for physicians of different specialties taking care about patients suffering from these diseases.

Truls E. Bjerklund Johansen (Norway),

Florian ME Wagenlehner (Germany),

Yong-Hyun Cho (South Korea),

Tetsuro Matsumoto (Japan),

John N Krieger (USA),

Daniel Shoskes (USA),

Kurt G. Naber (Germany).

Publishing at PUBLISSO

Your chapter will be published at the PUBLISSO platform (https://books.publisso.de).

Information for corresponding authors

It is necessary for all corresponding authors to register at PUBLISSO.
To register at PUBLISSO please click the following link: http://books.publisso.de/publisso_gold/register

After registration, please complete your user profile. Information from your user profile will appear in the published chapter and the authors board of the book (http://books.publisso.de/publisso_gold/book/52). If you are displayed in the authors board, you can be contacted by readers and other professionals. You can also contact other authors of the book for exchange and to build a network.
(If you do not want to be displayed in the authors board, but stay registered, you can disable this feature in your profile settings. In this case, your affiliation (publication data) will be displayed in the published chapter only.)

We kindly ask you to provide the co-authors email addresses in the manuscript so that we can contact them in case of queries.

Information for co-authors

After publication of your chapter, your affiliation (publication data) will be displayed in the published chapter.

If you also want to be displayed in the authors board of the book (http://books.publisso.de/publisso_gold/book/52), we kindly ask you to register at PUBLISSO. If you are displayed in the authors board, you can be contacted by readers and other professionals. You can also contact other authors of the book for exchange and to build a network.

To register at PUBLISSO please click the following link: http://books.publisso.de/publisso_gold/register

If you do not want to be displayed in the authors board of the book, you do not have to register. Your affiliation (publication data) will be displayed in the published chapter only.

Support

If you have any further questions please don’t hesitate to contact the PUBLISSO editorial office:

E-Mail: livingbooks@zbmed.de
Phone: +49 221 478-7093

General

The textbook will be structured in sections with two co-chairs each. Each section will start with an introductory chapter written by the two respective co-chairs presented like an editorial commentary in regard to the following chapters (see proposed contents of the book). The two co-chairs of each section will also peer review all chapters in their section and stimulate a consensus discussion within their section together with the authors and the main editors if needed.

Chapters

Each chapter should reflect the background to the topic and highlight all of the critical evidence relating to the subject. The intention is to provide an up to date, concise synthesis of the literature on that topic, and for clinical topics also recommendations based on levels of evidence for contemporary clinical practice, as well as suggested research recommendations.

Manuscript

Each manuscript should have up to approximately 3,000 words (excluding abstract, tables/figures and references). The abstract should count about 300 words.

Structure

The outline of each chapter should be structured as follows (similar as in the edition 2010, which can be downloaded for free: http://www.icud.info/urogenitalinfections.html):

  1. Abstract
  2. Summary of recommendations*/key notes*
    (*which ever term is more appropriate)
  3. Introduction
  4. Methods
  5. Results
  6. Further research
  7. Conclusions
  8. Acknowledgement
  9. Conflict of interest of each author
  10. References

Citation style

As a citation style, the Vancouver style is preferred.

Please mark your references in the text with square brackets ([1], [2], ...).

Summary of recommendations

We would like to have the Summary of recommendations at the beginning after the abstract (as in the edition 2010). However, we do not expect as in the edition 2010, that each recommendation is also specified according to Level of Evidence and Grade of Recommendation, because such a claim would not only need a systematic literature search (see below), but also a structured discussion in a defined group of experts.

Systematic literature search

A systematic literature search should be performed, at least of PUBMED/MEDLINE but ideally of several relevant databases in addition (like Cochrane CENTRAL) to find recent, high quality systematic reviews and/or primary research studies. It is not expected to perform for all chapters a de novo systematic review, if such reviews are already published recently, but it still may be indicated for some items. For questions relating therapy, it should be focused on evidence from (systematic reviews of) randomized controlled trials if available.

The method of the systematic literature search needs to be fully described in the section “Methods”, e.g.:

“A systematic literature search was performed for the last ... (usually 10) years in MEDLINE, Cochrane etc. with the following key words ... and the following limitations: e.g. UTI, age (adult?), ... clinical studies ... English ... abstract available ... only peer reviewed ...

A total of ... publications were identified, which were screened by title and abstract ... After exclusion of duplicates ... a total of ... were included into the review (analysis), supplemented by citations or known to the authors ... ”.

Clinical topics

Clinical topics should be focused on the importance to clinical practice according to the up to date scientific knowledge as presented in the literature. It should relate to questions/complaints/symptoms of patient/population concerning definition, diagnosis, therapy/prevention, intervention, and outcome in comparison, if different approaches are feasible. Please choose patient-important outcomes and focus on those, which you deem critical for decision-making.

Level of evidence and grade of recommendations

Any recommendation should be based on the level of evidence and the grade of recommendation. For this purpose the following system, modified from the Oxford Centre for Evidence-based Medicine should be used (EAU guidelines 2015):

Level of evidence (LE)

Level Type of evidence
1a Evidence obtained from meta-analysis of randomised trials
1b Evidence obtained from at least one randomised trial
2a Evidence obtained from one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports.
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities.

Grade of Recommendations (GoR)

Grade Nature of recommendations
A Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial
B Based on well-conducted clinical studies, but without randomised clinical trials
C Made despite the absence of directly applicable clinical studies of good quality

Comments (EAU guidelines 2015)

The aim of assigning a LE and grading recommendations is to provide transparency between the underlying evidence and the recommendation given.

It should be noted that when recommendations are graded, the link between the level of evidence and grade of recommendation is not directly linear. Availability of randomized controlled trials may not necessarily translate into a grade “A” recommendation where there are methodological limitations or disparity in published results.

Alternatively, absence of high level evidence does not necessarily preclude a grade A recommendation, if there is overwhelming clinical experience and consensus. In addition, there may be exceptional situations where corroborating studies cannot be performed, perhaps for ethical or other reasons and in this case unequivocal recommendations are considered helpful for the reader. The quality of the underlying scientific evidence - although a very important factor – has to be balanced against benefits and burdens, values and preferences and costs when a grade is assigned.

Since the same rating system should be used in all chapters, for the sake of brevity the same sentence could be used in “Methods” for all manuscripts, because the rating system will be described in details in the Preface of the book:

“The studies were rated according to the level of evidence and the strength of recommendations graded according to a system used in the EAU guidelines modified from the Oxford Centre for Evidence-based Medicine [1].”

References

[1] European Association of Urology. Guidelines. Methodology section. 2015 ed. Arnhem: European Association of Urology; 2015. p. 3. ISBN/EAN: 978-90-79754-80-9. Available from: http://uroweb.org/wp-content/uploads/EAU-Extended-Guidelines-2015-Edn..pdf

The Living Handbook of Urogenital Infections and Inflammations is issued by:

European Association of Urology
att. Maurice Schlief, EAU executive manager business affairs

P.O.Box 30016
NL-6803 AA Arnhem, The Netherlands

Phone: 0031-26-38.90.680
E-mail: m.schlief@uroweb.org

Editor in Chief

responsible for the contents according to § 5 TMG and § 55 Abs. 2 RStV (Germany):

Kurt G. Naber, MD, PhD
Assoc. Professor of Urology

Technical University of Munich
Karl-Bickleder-Str. 44c
94315 Straubing, Germany

E-mail: kurt.naber@nabers.de

John N. Krieger MD, PhD

University of Washington Section of Urology

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Daniel Shoskes MD, PhD

Cleveland Clinic Glickman Urological and Kidney Institute

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Yong-Hyun Cho MD, PhD

St. Mary's Hospital, The Catholic University of Korea Department of Urology

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Tetsuro Matsumoto MD, PhD

University of Occupational and Environmental Health Department of Urology

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Florian M. E. Wagenlehner MD, PhD

Justus-Liebig University of Giessen Clinic of Urology and Andrology

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Truls Erik Bjerklund Johansen MD, PhD

Oslo University Hospital Urology Department

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Kurt G. Naber MD, PhD

Technical University of Munich

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Punit Bansal MD, PhD

R G Stone and Super Specialty Hospital
Department of Urology

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Riccardo Bartoletti

University of Pisa
Department of Translational Research and New Technologies

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Truls Erik Bjerklund Johansen MD, PhD

Oslo University Hospital
Urology Department

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PD Dr. med. Gernot Bonkat

University Basel
alta uro AG, Merian Iselin Klinik, Center of Biomechanics & Calorimetry (COB)

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Prof. Tommaso Cai MD

Santa Chiara Regional Hospital
Dept. of Urology

more

Dr Leyland Chuang

Ng Teng Fong Hospital, National University Health System
Department of Medicine

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Prof. Milan Cizman

University Medical Centre
Department of Infectious Diseases

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Alison Crawford MSc

Queen's University
Department of Psychology

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Pfofessor Svetlana Dubrovina MD, PhD

Rostov Medical State University
Obstetrics and Gynaecology

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Dr Valerie Huei Li Gan MBBS (S'pore), MRCS (Edin), MMed (Surg), FAMS (Urology)

Singapore General Hospital
Department of Urology

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Philip Hanno

University of Pennsylvania

more

Ass prof MD Gundela Holmdahl

Queen Silvia Childrens Hospital, Sahlgrens Academy
Pediatric surgery and urology

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Udo B. Hoyme

HELIOS Hospital Erfurt Ltd.
Department of Gynecology and Obstetrics

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David Hunstad

Washington University School of Medicine
Pediatrics / Molecular Microbiology

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Gitte M. Hvistendahl

Aarhus University Hospital

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Prof. Michael KOGAN M.D., PhD

Rostov State Medical University
Department of Urology

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Dr Akihiro Kanematsu

Hyogo College of Medicine
Department of Urology

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Frieder Keller

University Hospital Ulm
Department Internal Medicine 1, Nephrology

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Professor Katarzyna Kilis-Pstrusinska PhD, MD

Wroclaw Medical University
Department of Pediatric Nephrology

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MD, PhD Tae-Hyoung Kim

Chung-Ang University
Urology

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John N. Krieger MD, PhD

University of Washington
Section of Urology

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Prof Ekaterina Kulchavenya

Novosibirsk Research TB Institute, Novosibirsk State Medical University

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Dr Christina Kåbjörn Gustafsson

Ryhov Hospital Jönköping
Pathology

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Dr. Bela Köves

South Pest Teaching Hospital
Department of Urology

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Dr. med. Giuseppe Magistro

Ludwig-Maximilians-University of Munich
Department of Urology

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Vittorio Magri

ASST-North
Urologic Clinic

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András Magyar

South-Pest Hospital
Department of Urology

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Professor Emeritus Brian Morris

University of Sydney
School of Medical Sciences

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Baerbel Muendner-Hensen

ICA-Deutschland e.V.

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Stephen F. Murphy

Feinberg School of Medicine, Northwestern University
Department of Urology

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Kurt G. Naber MD, PhD

Technical University of Munich

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Prof. Yulia Naboka

Rostov State Medical University
Department of Microbiology

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Dr. J. Curtis Nickel MD

Queen's University
Department of Urology

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Professor Ralph Peeker MD PhD

University of Gothenburg
Department of Urology

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Tamara Perepanova

N.A. Lopatkin Research Institute of Urology and Interventional Radiology

more

Prof. Gianpaolo Perletti M. Clin. Pharmacol.

University of Insubria
Department of Biotechnology and Life Sciences

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Felice Petraglia

Department of Biomedical, Experimental and Clinical Sciences, University of Florence
Obstetrics and Gynecology

more

Michel Pontari

Temple University School of Medicine
Department of Urology

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Dr. Jörgen Quaghebeur PhD. Med. Sci.

University Hospital Antwerp and University Antwerp
Department of Urology

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Yazan F. Rawashdeh

Aarhus University Hospital
Paediatric Urology Section, Department of Urology

more

Professor Claus Riedl MD

-
Urology

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Matthew Roberts

The University of Queensland
Faculty of Medicine

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PD Dr. med Guido Schmiemann MPH

Institut für Public Health und Pflegeforschung, Universität Bremen
Abteilung Versorgungsforschung

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Caroline Schneeberger MD PhD

Academic Medical Center (AMC)

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Prof. Dr. med. Peter Schneede

Klinikum Memmingen
Department of Urology

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Aaron C. Shoskes

Des Moines University Medical College of Ostheopathic Medicine

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Daniel Shoskes MD, PhD

Cleveland Clinic
Glickman Urological and Kidney Institute

more

Prof. Dr. Roswitha Siener

University of Bonn
University Stone Centre, Department of Urology

more

Sofia Sjöström

Queen Silvia Childrens Hospital, Sahlgrens Academy
Pediatric surgery and urology

more

Mathew Sorensen

University of Washington School of Medicine
Department of Urology

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Prof. Dr. Dr. Walter Ludwig Strohmaier FEBU

Regiomed-Klinikum Coburg. Medical School Regiomed
Urology and Paediatric Urology

more

Satoshi Takahashi

Sapporo Medical University School of Medicine
Department of Infection Control and Laboratory Medicine

more

Professor Paul Anantharajah Tambyah

Yong Loo Lin School of Medicine, National University Hospital
Department of Medicine

more

Peter Tenke

Jahn Ferenc South Pest Teaching Hospital
Department of Urology

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Praveen Thumbikat


Department of Urology

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Dr. Jose Tiran Saucedo

IMIGO / Universidad de Monterrey
Obstetrics and Gynaecology

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Dominic Tran-Nguyen

Des Moines University

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Dean Tripp

Queen's University
Psychology, Anesthesia & Urology

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Prof. SEONGHEON WIE

The Catholic University of Korea, St. Vincent's Hospital
Division of Infectious Diseases, Department of Internal Medicine

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Florian M. E. Wagenlehner MD, PhD

Justus-Liebig University of Giessen
Clinic of Urology and Andrology

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Assoc. Prof. Christian Wejse

Aarhus University, Aarhus University Hospital
Department of Infectious Diseases/Center for Global Health, Dept of Public Health

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Prof. Dr. Mete Çek

Trakya University, School of Medicine
Urology

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