Urogenital Infections and Inflammations

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

Spectrum and antibiotic resistance of catheter-associated urinary tract infections

 Béla Köves 1
András Magyar 2
Peter Tenke 2


1 Department of Urology, South Pest Teaching Hospital, Budapest, Hungary
2 Department of Urology, South-Pest Hospital, Budapest, Hungary

Abstract

Catheter associated urinary tract infections (CAUTIs) are amongst the most common nosocomial infections and are also considered among the most common complications associated with indwelling urinary catheters. Most catheter associated infections are derived from the patient’s own perineal flora, however the presence of a catheter increases the chance of being colonised by cross transmission of nosocomial bacteria as well. Most episodes of short-term catheter-associated bacteriuria are asymptomatic and are caused by single organisms, while long-term catheterisation promotes multibacterial infections and colonization. With prolonged duration of catheterization bacteriuria is considered universal because of the formation of biofilms on the surface of the catheter. Chronic indwelling catheters are an important reservoir of different multiresistant gram-negative organisms, therefore they are frequently isolated from CAUTIs. Treatment of catheter associated asymptomatic bacteriuria is not recommended because it will only promote the emergence of resistant organisms without effectively clearing the urine of catheterised patients.


Summary of recommendations

Regarding bacterial spectrum and antimicrobal resistance of catheter associated urinary tract infections the following recommendations should be highlighted:

  • Routine urine culture in asymptomatic catheterised patients is not recommended (Gr: B).
  • Treatment of catheter associated asymptomatic bacteriuria is not recommended (Gr: A).

1 Introduction

Urinary tract infections (UTIs) represent at least 40% of all hospital acquired infections with the majority of cases being catheter associated [1], [2]. In patients without catheters microorganisms that ascend from the urethra are usually of enteric origin (e.g. Escherichia coli and other Enterobacteriaceae). However the presence of a catheter creates a special environment for bacterial colonisation and biofilm formation, which increases the chance of being colonised by non-enteric nosocomial bacteria, like Pseudomonas aeruginosa as well. Therefore it is important to be familiar with the different spectrum of pathogens associated with the presence of an urinary catheter.

2 Methods

We performed a literature search in the PubMed database from 1970 to 2016 regarding the spectrum and antibiotic resistance of catheter-associated urinary tract infections (CAUTIs) using the following keywords in different combinations: catheter, urinary tract infection, bacteriuria, antibiotic resistance. Only publications written in English were selected. A total of 38 publications were identified through the search. Furthermore, data and recommendations of the European Association of Urology [3], the European Centre for Disease Prevention, Control and Centers for Disease Control and Prevention, including Guideline for Prevention of Catheter-associated Urinary Tract Infections from 2009 and recommendations for Healthcare-associated Infections (HAIs) were also collected. The recommendations were based on the level of evidence and the grade of recommendation. For this purpose the system modified from the Oxford Centre for Evidence-based Medicine was used [4].

3 Results

3.1 Routes and incidence of colonisation

3.1.1 Pathogenesis

Transurethral ascent of microorganisms is the most common mechanism of UTI development, which provides a logical explanation for the increased risk of infection following bladder catheterisation or instrumentation. Bacteria can ascend through the lumen of the catheters by reflux of urine from the contaminated bags (intraluminal route) or along the extraluminal catheter-urethral surface. At the time of catheter insertion up to 20% of patients will be colonized immediately [5], [6]. Catheterised patients with catheter associated bacteriuria develop bacteremia in 0.4–4% of cases. In acute care facilities catheter associated UTI is one of the most common causes of bacteremia [7], [8], [9], [10] because of the high frequency of catheterisation. For closed catheter systems the incidence of bacterial colonisation is increased by 3–8% with each day [11], therefore colonisation is considered universal by the end of the month. The development of bacteriuria is universal within 3–4 days in case of catheters with open-drainage systems. Impairment of the natural defense mechanisms (e.g. obstruction, immunsuppresion), leads to reduction of virulence requirements of any bacterial strain to induce infection.

3.1.2 Biofilm

Biofilm formation is a universally occuring phenomen on the surface of the catheters in the urinary tract. Biofilms are structured communities of microorganisms encapsulated within a self-developed polymeric matrix adherent to a surface [12]. These bacteria may differ from their planktonic free-floating counterparts in many aspects, such as metabolic rates or antibiotic susceptibility. The formation of biofilms on catheter surfaces is the reason why bacteriuria becomes universal in case of long-term catheterisation.

3.2 Microorganisms and spectrum

3.2.1 Short-term catheterisation

Short-term (<30 days) [13] catheter-associated bacteriuria is generally caused by single organisms and is asymptomatic. However it may be polymicrobial in up to 15% of cases [10], [14]. During initial catheter insertion or catheter exchange, transient asymptomatic bacteraemia is common in chronically catheterised patients [15]. The risk of bacteraemia during initial catheter insertion may be similar, whether there is a pre-existing UTI (7%) or sterile urine (8.2%) [16], [17] (IIa). The incidence of febrile UTI and bacteraemia is relatively low since colonisation of urethral catheters is caused mainly by less virulent organisms and a non-obstructed catheter effectively drains the infection. The bacterial spectrum reflects the locally prevailing flora (eg. community, hospital). According to the European and Asian guidelines on management and prevention of catheter-associated urinary tract infections the most frequently occurring bacteria during short-term catheterisation are E. coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Staphylococcus epidermidis, Enterococcus spp. and Candida spp. [10].

Pyuria, which however varies by organism, has no diagnostic value, and is present in most cases of catheter-associated bacteriuria.

3.2.2 Long-term catheterisation

Indwelling catheterisation lasting 30 days or longer [13] is defined as ‘long-term’ or ‘chronic’. With prolonged duration of catheterisation biofilm formation on the catheter surface occurs universally [18], [19], [20]. As a consequence microorganisms may acquire increased resistance against antimicrobials and become almost impossible to eradicate without removing the catheter. In long-term catheterised patients polymicrobial bacteriuria occures in up to 95% of the cases, with usually 3–5 isolated organisms. During long-term catheterisation, the commonest bacteria is E. coli. Other associated flora include Providencia stuartii, Pseudomonas, Proteus, Morganella and Acinetobacter, Enterococcus and Candida spp. [10].

While the catheter remains in situ, the spectrum of free-floating microorganisms and bacteria in the biofilms shows a dynamic turnover. Bergqvist et al. found that one-quarter of the samples obtained by an indwelling catheter did not show complete agreement with the bladder aspiration samples suggesting that some organisms may colonise the catheter only [21].

3.2.3 Occuring bacteria

Similarly to the bacterial spectrum of uncomplicated UTIs, E. coli is the most common pathogen in the presence of a catheter as well. However in the presence of a catheter we find higher proportions of other bacteria, especially a higher rate of gram-positive pathogens.

The National Healthcare Safety Network (NHSN) is a national surveillance system for patient and healthcare personnel safety in the USA. It aims to surveil selected HAI data at locations other than intensive care units, in hospitals and other types of healthcare facilities. In hospitals reporting to the NHSN between 2006–2007, the most frequent pathogens associated with the presence of an indwelling catheter were E. coli (21.4%) and Candida spp. (21.0%), followed by Enterococcus spp. (14.9%), P. aeruginosa (10.0%), K. pneumoniae (7.7%), and Enterobacter spp. (4.1%) and Acinetobacter baumannii (1,2%). A smaller proportion was caused by other gram-negative bacteria and Staphylococcus spp. [22]. Moreover at one US tertiary care academic centre Enterococcus spp. (28.4%) and Candida spp. (19.7%) were reported to be the most common pathogens [9], [23].

The persistence of E. coli strains is related to the presence of Type 1 pili, an adhesin for uroepithelium as well as the Tamm-Horsfall protein. Colonising E. coli strains lack P fimbriae in most cases of catheter-associated infections [24].

Enterococcus species, especially Enterococcus faecalis and Enterococcus faecium are among the leading causes of hospital-acquired UTIs [22], [25]. Many enterococcal isolates can produce biofilms. Catheter implantation results bladder inflammation and causes fibrinogen release and accumulation onto the catheter. E. faecalis takes advantage of the presence of fibrinogen and uses it as a resource through the production of proteases [26].

P. mirabilis is an organism of unique importance for CAUTIs. It is not typical in patients undergoing short term catheterization [27], however the longer a catheter is in place the more likely P. mirabilis will be present. It was found in about 40% of urine samples collected from patients with chronic indwelling catheters [9]. P. mirabilis has a uniquely strong biofilm forming activity compared to other uropathogens [28], and it is also a very potent urease producer. P. mirabilis hydrolyzes urea several times faster than other pathogens with urease activity [29]. Organisms producing urease may cause a crystalline biofilm [30], [31], which is similar to struvite stones, and it is frequently associated  with catheter encrustation and obstruction [32]. Other urease producing species include P. aeruginosa, K. pneumoniae, Morganella morganii, other Proteus species, some Providencia spp. and some strains of Staphylococcus aureus and coagulase negative staphylococci [33].

Patients with urinary catheter also have an increased risk of UTI due to Pseudomonas spp. [8]. P. aeruginosa is an opportunistic human pathogen, which causes infections through biofilm formation on the surface of indwelling catheters. It utilizes a distinct mechanism to form biofilms, independent of exopolysaccharides during CAUTIs [34].

Another organism rarely found outside of the catheterised urinary tract is Providencia stuartii [20]. For this organism, the adhesins MR/K are more common [35], [36]. Acinetobacter is a group of bacteria commonly found in soil and water. Outbreaks of Acinetobacter infections including occasionally urinary tract infections typically occur healthcare settings treating very ill patients and rarely occur outside of healthcare settings [37].

Candida albicans readily causes a clinical UTI via the haematogenous route, but this is also can cause ascending infection if an indwelling catheter is present, or following antibiotic therapy [10].

Candiduria develops in 3%–32% of patients with short-term catheterisation [13]. In case of long-term catheterization the incidence of candiduria was 17% in a single study reporting on a population of individuals with spinal cord injury or multiple sclerosis [38]. The US NHSN no longer counts candida CAUTI in its surveillance definitions.

3.3 Antimicrobial resistance in the presence of a catheter

The increasing antimicrobial resistance against different antimicrobials is a common problem with urinary pathogens. Chronic indwelling catheters are an important reservoir of different multiresistant gram-negative organisms, such as extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae [39] or carbapenem-resistant Enterobacteriaceae (CRE) [40]. Therefore multiresistant organisms are often causes of CAUTIs.

One of the most important factors leading to increasing bacterial resistance is the fact that patients with indwelling urinary catheters often receive antimicrobials, usually for indications other than urinary tract infection [9]. Due to this intense antimicrobial exposure, antimicrobial resistant bacteria are frequently isolated from catheterised urine samples. Conversely, pathogens colonizing the drainage bags of catheterized patients were found to be a source for outbreaks of resistant organisms in acute care facilities [13], [41]. The urine of residents with chronic indwelling catheters was found to be the most common site of isolation of resistant gram-negative organisms in nursing home setting as well [39], [42]. Consequently, current data do not support the treatment of catheter associated asymptomatic bacteriuria because it will only promote the emergence of resistant organisms [43], [44] without effectively clearing the urine of catheterised patients.

In the annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention (2006–2007) 24,8% of E. coli isolates and 33,8% of P. aeruginosa isolates from CAUTI cases were fluoroquinolone-resistant. Against ceftriaxone, resistances of E. coli and K. pneumoniae were 5,5% and 21,2%, respectively. Resistance rates were relatively high even against carbapenems in the presence of a catheter: E. coli 4%, K. pneumoniae 10%, P. aeruginosa 25% and A. baumannii 25,6%. Significant resistance was found against vancomycin (6,1%) and ampicillin (3,1%) in case of E. faecalis as well.

4 Further research

Further research has to be aimed to develop antimicrobial agents that are also effective against bacteria enclosed in the biofilms. Creating an ideal catheter surface modification which can resist bacterial adhesion and biofilm formation in long-term catheterisation is also a challenge of the future.   

5 Conclusion

Urinary catheters have long been recognized as major risk factor for developing healthcare associated UTIs. There is different spectrum of causative pathogens in the presence of a catheter due to biofilm formation and different resistance patterns from what we see in the urinary tract without a foreign body. Pathogens within the biofilm are well protected from antibiotics and from the host defense. Traditional microbiologic laboratory testing can detect planktonic free-floating bacteria within the urine, but pathogens within the biofilm will not be easily detected with routine methods. Since antimicrobal therapy in catheterised patients induces bacterial resistance and will be associated with the development of multi-resistant organisms, prudent antibiotic administration strategy, catheter management and prevention of CAUTIs should be considered high priority. Treatment of asymptomatic bacteriuria in catheterized patients should be avoided as this can only aggravate the problem of antimicrobial resistance in healthcare.

Note

This chapter was primarily published in the journal GMS Infectious Diseases [45].


References

[1] Weinstein JW, Mazon D, Pantelick E, Reagan-Cirincione P, Dembry LM, Hierholzer WJ Jr. A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity. Infect Control Hosp Epidemiol. 1999 Aug;20(8):543-8. DOI: 10.1086/501675
[2] Kalsi J, Arya M, Wilson P, Mundy A. Hospital-acquired urinary tract infection. Int J Clin Pract. 2003 Jun;57(5):388-91.
[3] European Association of Urology. Guidelines on urological infections. (cited 2015 Dec 01). Available from: http://uroweb.org/guideline/urological-infections
[4] Phillips B, Ball C, Sackett D, Badenoch D, Straus S, Haynes B, Dawes M, Howick J. Oxford Centre for Evidence-Based Medicine – Levels of Evidence (March 2009). Available from: http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/
[5] Rösch W, Lugauer S. Catheter-associated infections in urology: possible use of silver-impregnated catheters and the Erlanger silver catheter. Infection. 1999;27 Suppl 1:S74-7. DOI: 10.1007/BF02561624
[6] Stamm WE. Catheter-associated urinary tract infections: epidemiology, pathogenesis, and prevention. Am J Med. 1991 Sep 16;91(3B):65S-71S. DOI: 10.1016/0002-9343(91)90345-X
[7] Conway LJ, Liu J, Harris AD, Larson EL. Risk Factors for Bacteremia in Patients With Urinary Catheter-Associated Bacteriuria. Am J Crit Care. 2016 Dec;26(1):43-52. DOI: 10.4037/ajcc2017220
[8] Platt R, Polk BF, Murdock B, Rosner B. Risk factors for nosocomial urinary tract infection. Am J Epidemiol. 1986 Dec;124(6):977-85. DOI: 10.1093/oxfordjournals.aje.a114487
[9] Nicolle LE. Catheter associated urinary tract infections. Antimicrob Resist Infect Control. 2014;3:23. DOI: 10.1186/2047-2994-3-23
[10] Tenke P, Kovacs B, Bjerklund Johansen TE, Matsumoto T, Tambyah PA, Naber KG. European and Asian guidelines on management and prevention of catheter-associated urinary tract infections. Int J Antimicrob Agents. 2008 Feb;31 Suppl 1:S68-78. DOI: 10.1016/j.ijantimicag.2007.07.033
[11] Grabe M, Bartoletti R, Bjerklund Johansen TE, Cai T, Çek M, Köves B, Naber KG, Pickard RS, Tenke P, Wagenlehner F, Wullt B. Guidelines on urological infections. European Association of Urology; 2015. Available from: http://uroweb.org/wp-content/uploads/EAU-Guidelines-Urological-Infections-v2.pdf
[12] Tenke P, Köves B, Nagy K, Hultgren SJ, Mendling W, Wullt B, Grabe M, Wagenlehner FM, Cek M, Pickard R, Botto H, Naber KG, Bjerklund Johansen TE. Update on biofilm infections in the urinary tract. World J Urol. 2012 Feb;30(1):51-7. DOI: 10.1007/s00345-011-0689-9
[13] Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, Saint S, Schaeffer AJ, Tambayh PA, Tenke P, Nicolle LE; Infectious Diseases Society of America. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010 Mar;50(5):625-63. DOI: 10.1086/650482
[14] Asher EF, Oliver BG, Fry DE. Urinary tract infections in the surgical patient. Am Surg. 1988 Jul;54(7):466-9.
[15] Jewes LA, Gillespie WA, Leadbetter A, Myers B, Simpson RA, Stower MJ, Viant AC. Bacteriuria and bacteraemia in patients with long-term indwelling catheters--a domiciliary study. J Med Microbiol. 1988 May;26(1):61-5. DOI: 10.1099/00222615-26-1-61
[16] Bregenzer T, Frei R, Widmer AF, Seiler W, Probst W, Mattarelli G, Zimmerli W. Low risk of bacteremia during catheter replacement in patients with long-term urinary catheters. Arch Intern Med. 1997 Mar;157(5):521-5. DOI: 10.1001/archinte.1997.00440260067010
[17] Sullivan NM, Sutter VL, Mims MM, Marsh VH, Finegold SM. Clinical aspects of bacteremia after manipulation of the genitourinary tract. J Infect Dis. 1973 Jan;127(1):49-55. DOI: 10.1093/infdis/127.1.49
[18] Saint S, Chenoweth CE. Biofilms and catheter-associated urinary tract infections. Infect Dis Clin North Am. 2003 Jun;17(2):411-32. DOI: 10.1016/S0891-5520(03)00011-4
[19] Steward DK, Wood GL, Cohen RL, Smith JW, Mackowiak PA. Failure of the urinalysis and quantitative urine culture in diagnosing symptomatic urinary tract infections in patients with long-term urinary catheters. Am J Infect Control. 1985 Aug;13(4):154-60. DOI: 10.1016/0196-6553(85)90102-6
[20] Warren JW, Damron D, Tenney JH, Hoopes JM, Deforge B, Muncie HL Jr. Fever, bacteremia, and death as complications of bacteriuria in women with long-term urethral catheters. J Infect Dis. 1987 Jun;155(6):1151-8. DOI: 10.1093/infdis/155.6.1151
[21] Bergqvist D, Brönnestam R, Hedelin H, Ståhl A. The relevance of urinary sampling methods in patients with indwelling Foley catheters. Br J Urol. 1980 Apr;52(2):92-5. DOI: 10.1111/j.1464-410X.1980.tb02936.x
[22] Hidron AI, Edwards JR, Patel J, Horan TC, Sievert DM, Pollock DA, Fridkin SK; National Healthcare Safety Network Team; Participating National Healthcare Safety Network Facilities. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol. 2008 Nov;29(11):996-1011. DOI: 10.1086/591861
[23] Chang R, Greene MT, Chenoweth CE, Kuhn L, Shuman E, Rogers MA, Saint S. Epidemiology of hospital-acquired urinary tract-related bloodstream infection at a university hospital. Infect Control Hosp Epidemiol. 2011 Nov;32(11):1127-9. DOI: 10.1086/662378
[24] Ikäheimo R, Siitonen A, Kärkkäinen U, Mäkelä PH. Virulence characteristics of Escherichia coli in nosocomial urinary tract infection. Clin Infect Dis. 1993 Jun;16(6):785-91. DOI: 10.1093/clind/16.6.785
[25] Guiton PS, Hannan TJ, Ford B, Caparon MG, Hultgren SJ. Enterococcus faecalis overcomes foreign body-mediated inflammation to establish urinary tract infections. Infect Immun. 2013 Jan;81(1):329-39. DOI: 10.1128/IAI.00856-12
[26] Nielsen HV, Guiton PS, Kline KA, Port GC, Pinkner JS, Neiers F, Normark S, Henriques-Normark B, Caparon MG, Hultgren SJ. The metal ion-dependent adhesion site motif of the Enterococcus faecalis EbpA pilin mediates pilus function in catheter-associated urinary tract infection. MBio. 2012;3(4):e00177-12. DOI: 10.1128/mBio.00177-12
[27] Matsukawa M, Kunishima Y, Takahashi S, Takeyama K, Tsukamoto T. Bacterial colonization on intraluminal surface of urethral catheter. Urology. 2005 Mar;65(3):440-4. DOI: 10.1016/j.urology.2004.10.065
[28] Warren JW, Tenney JH, Hoopes JM, Muncie HL, Anthony WC. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis. 1982 Dec;146(6):719-23. DOI: 10.1093/infdis/146.6.719
[29] Jones BD, Mobley HL. Genetic and biochemical diversity of ureases of Proteus, Providencia, and Morganella species isolated from urinary tract infection. Infect Immun. 1987 Sep;55(9):2198-203.
[30] Getliffe KA, Mulhall AB. The encrustation of indwelling catheters. Br J Urol. 1991 Apr;67(4):337-41. DOI: 10.1111/j.1464-410X.1991.tb15157.x
[31] Stickler DJ, Zimakoff J. Complications of urinary tract infections associated with devices used for long-term bladder management. J Hosp Infect. 1994 Nov;28(3):177-94. DOI: 10.1016/0195-6701(94)90101-5
[32] Jacobsen SM, Stickler DJ, Mobley HL, Shirtliff ME. Complicated catheter-associated urinary tract infections due to Escherichia coli and Proteus mirabilis. Clin Microbiol Rev. 2008 Jan;21(1):26-59. DOI: 10.1128/CMR.00019-07
[33] Stickler D, Morris N, Moreno MC, Sabbuba N. Studies on the formation of crystalline bacterial biofilms on urethral catheters. Eur J Clin Microbiol Infect Dis. 1998 Sep;17(9):649-52. DOI: 10.1007/s100960050150
[34] Cole SJ, Records AR, Orr MW, Linden SB, Lee VT. Catheter-associated urinary tract infection by Pseudomonas aeruginosa is mediated by exopolysaccharide-independent biofilms. Infect Immun. 2014 May;82(5):2048-58. DOI: 10.1128/IAI.01652-14
[35] Tenney JH, Warren JW. Bacteriuria in women with long-term catheters: paired comparison of indwelling and replacement catheters. J Infect Dis. 1988 Jan;157(1):199-202. DOI: 10.1093/infdis/157.1.199
[36] Warren JW. Providencia stuartii: a common cause of antibiotic-resistant bacteriuria in patients with long-term indwelling catheters. Rev Infect Dis. 1986 Jan-Feb;8(1):61-7. DOI: 10.1093/clinids/8.1.61
[37] Centers for Disease Control and Prevention. Healthcare-associated Infections. Acinetobacter in Healthcare Settings. (last updated 2010 Nov 24, cited 2017 May 01). Available from: http://www.cdc.gov/HAI/organisms/acinetobacter.html
[38] Goetz LL, Howard M, Cipher D, Revankar SG. Occurrence of candiduria in a population of chronically catheterized patients with spinal cord injury. Spinal Cord. 2010 Jan;48(1):51-4. DOI: 10.1038/sc.2009.81
[39] Arnoldo L, Migliavacca R, Regattin L, Raglio A, Pagani L, Nucleo E, Spalla M, Vailati F, Agodi A, Mosca A, Zotti C, Tardivo S, Bianco I, Rulli A, Gualdi P, Panetta P, Pasini C, Pedroni M, Brusaferro S. Prevalence of urinary colonization by extended spectrum-beta-lactamase Enterobacteriaceae among catheterised inpatients in Italian long term care facilities. BMC Infect Dis. 2013 Mar;13:124. DOI: 10.1186/1471-2334-13-124
[40] Brennan BM, Coyle JR, Marchaim D, Pogue JM, Boehme M, Finks J, Malani AN, VerLee KE, Buckley BO, Mollon N, Sundin DR, Washer LL, Kaye KS. Statewide surveillance of carbapenem-resistant enterobacteriaceae in Michigan. Infect Control Hosp Epidemiol. 2014 Apr;35(4):342-9. DOI: 10.1086/675611
[41] Lo E, Nicolle LE, Coffin SE, Gould C, Maragakis LL, Meddings J, Pegues DA, Pettis AM, Saint S, Yokoe DS. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S32-47.
[42] Mody L, Maheshwari S, Galecki A, Kauffman CA, Bradley SF. Indwelling device use and antibiotic resistance in nursing homes: identifying a high-risk group. J Am Geriatr Soc. 2007 Dec;55(12):1921-6. DOI: 10.1111/j.1532-5415.2007.01468.x
[43] Alling B, Brandberg A, Seeberg S, Svanborg A. Effect of consecutive antibacterial therapy on bacteriuria in hospitalized geriatric patients. Scand J Infect Dis. 1975;7(3):201-7.
[44] Warren JW, Anthony WC, Hoopes JM, Muncie HL Jr. Cephalexin for susceptible bacteriuria in afebrile, long-term catheterized patients. JAMA. 1982 Jul;248(4):454-8.
[45] Köves B, Magyar A, Tenke P. Spectrum and antibiotic resistance of catheter-associated urinary tract infections. GMS Infect Dis. 2017;5:Doc06. DOI: 10.3205/id000032

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.

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Truls E. Bjerklund Johansen (Norway),

Florian ME Wagenlehner (Germany),

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John N Krieger (USA),

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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

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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

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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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Iara Linhares

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

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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

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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

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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

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Prof. Dr. Roswitha Siener

University of Bonn
University Stone Centre, Department of Urology

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Sofia Sjöström

Queen Silvia Childrens Hospital, Sahlgrens Academy
Pediatric surgery and urology

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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

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Satoshi Takahashi

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

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Professor Paul Anantharajah Tambyah

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

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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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