Urogenital Infections and Inflammations

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

Which antibiotics are used in urology worldwide

 Mete Çek 1
Truls Erik Bjerklund Johansen 2

1 Urology, Trakya University, School of Medicine, Edirne, Turkey
2 Urology Department, Oslo University Hospital, Oslo, Norway


A literature search of meta-analyses and reviews on the use of antibiotics in urology was made, and papers included were reviewed. The use of antibiotics in certain urological conditions and the clinical results obtained are discussed in light of these meta-analyses and reviews. The results of the Global Prevalence of Infections in Urology studies on usage of antibiotics for nosocomially acquired urinary tract infections and for prophylaxis before urological interventions are also reviewed and compared with international guideline recommendations.

Although there are no precise data on the amount of consumption of antibiotics in urology, the papers reviewed shed light on the variety of antimicrobial agents used for urinary tract infections. The raising resistance to antibiotics and a relatively high non-compliance with guidelines recommendations emerge as important issues for consideration.

Summary of recommendations

General consumption of antibiotics is increasing worldwide (36% between 2000 and 2010). The highest increases are for cephalosporins, broad-spectrum penicillins and fluoroquinolones, which are the most frequently used antibiotics in urology. This rise is associated with an increase in resistance rates globally, although variations are observed between countries. Non-compliance with national and international guidelines, high rates of non-prescription antibiotic use in certain regions are main causes of this development. These facts underline a major threat to public health.

1 Introduction

Urinary tract infections are one of the most frequent infections resulting in the use of a remarkable amount and a broad variety of antibiotics worldwide. Although the prescription and consumption of antibiotics worldwide can be traced by various means, data documenting the amount of antibiotics used in urology only is unfortunately not available.

An overall estimation of the use of antibiotics in urological practice requires particular consideration of certain issues. Published studies and surveillance programmes have reported on the general consumption of antibiotics globally and regionally [1], [2], [3]. The use of a certain group of antibiotics for a given time interval, in a specific region or country can also be traced and documented [4], [5], [6]. Increased antibiotic use is reported to be associated with increased antibiotic resistance [7]. However, there is no direct evidence indicating that a specific antibiotic is used for the treatment of a specific urologic condition. The use of different methods to measure the amount of antibiotics prescribed (DDD vs. standard units) complicates estimations of antibiotic use, as well [8]. Of concern, there are areas where consumption is not limited with prescription [8], [9]. We aimed to find out which antibiotics are used more frequently in urology and which doses of these antibiotics were preferred. We also searched for a general trend in the amount of consumption of antibiotics in urology.

2 Methods

Given these two facts – i.e. lack of specific data on the amount of consumption of antibiotics in urology and the obvious relationship between use of antibiotics and development of resistance – there are several sources to retrieve information about the use of antibiotics in urology:

  1. Studies analyzing the development of resistance to antibiotics
  2. Meta-analyses and review articles about antimicrobial treatment of various urological infections
  3. Guidelines for the treatment/prophylaxis of urological infections
  4. Prevalence and surveillance studies on infections in urology

Although these sources give indirect information, they are useful aids for estimating the use of antibiotics in urology, and they were reviewed to retrieve information about the use of antibiotics in urology.

Two separate systematic literature searches were performed to address the first two options mentioned above:

2.1 First systematic literature search

A systematic literature search was performed for publications between January 1990–January 2016 in MEDLINE with the following key words: “Anti-Bacterial Agents”[Mesh] AND “Prescriptions”[Mesh]) OR “Prescription Drug Overuse”[Mesh]) OR “Drug Prescriptions”[Mesh]) AND “Urology”[Mesh]) OR “Urology Department, Hospital”[Mesh])).

This search yielded 36 results. Fourteen of these publications were excluded because they were not in English; three more sources were excluded due to the lack of an abstract. After reviewing the 19 abstracts available, 14 were found to be non-relevant, i.e. not analyzing the usage or consumption of antibiotics. The remaining 5 were included in the evaluation [10], [11], [12], [13], [14].

None of these studies was a meta-analysis or systematic review.

2.2 Second systematic literature search

A second literature search was performed for publications between January 1990–January 2016 in MEDLINE with the following key words: ("Anti-Bacterial Agents"[Mesh]) AND "Urinary Tract Infections"[Mesh] with a filter to include only meta-analyses.

This search yielded 38 results. Six of them were not in English and were excluded. Three papers were not about urological interventions, 9 were on pediatric patients and 6 studies evaluated the efficacy of single agents. Two other studies were found irrelevant to the search topic. After excluding these studies the remaining 12 meta-analyses and reviews were included and the data obtained from each study were discussed in the relevant sections of our review [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26].

Major guidelines for the treatment of urological infections were also reviewed to address the third option [27], [28]. Results obtained from the Global Prevalence study on Infections in Urology (2003–2014) were also reviewed. These studies were already retrieved during the first search [10], [12], [13]. A recently published report on adherence to the EAU Guidelines on the use of prophylactic antibiotics and a surveillance study which included patients from nine European countries and Brazil were also included [29], [30].

Data on the use of antibiotics could be extracted only for certain clinical conditions. These conditions and antibiotics used are listed and analysed below.

3 Results

Data on the use of antibiotics worldwide suggest a general trend towards an increase in time, favouring some groups of antibiotics over others. Van Boeckel et al. reviewed the consumption of antibiotics in 71 countries between 2000 and 2010 by analysing national sales data [8]. Their search of PubMed for articles up to 2014 using the search terms “antibiotic”, “utilization”, and “global” or “countries” revealed only one review published in 1987. However, their review on 16 groups of antibiotics revealed that utilisation of antibiotics increased by 36% between 2000 and 2010. The highest increases in this period were for cephalosporins, broad-spectrum penicillins and fluoroquinolones. They found out that India, China, and the USA were the three largest consumers of antibiotics. These authors noticed that antibiotic consumption was stable or moderately increasing in this period in high-income countries while the increase was substantial in developing countries. Rates of antibiotic use per person were higher in the USA compared to most European countries. Another finding was that there were different trends for different classes of antibiotics, across countries. The use of glycopeptides, carbapenems, polymixins, and monobactams increased in many countries while increases in the consumption of cephalosporins and fluoroquinolones were observed mostly in middle-income countries (India and China). Unfortunately, the data van Boeckel et al. analysed covers only pharmaceutical sales distribution channels, which don’t reflect the whole market activity in some countries. True consumption could only be estimated in this situation. Moreover, this type of data doesn’t yield information about the indications for antibiotic use. Non-prescription use of antibiotics, which may amount to 19–100% of antimicrobial use outside of northern Europe and North America [9], further complicates these estimations.

3.1 Asymptomatic bacteriuria during pregnancy

Widmer et al. searched the Cochrane Pregnancy and Childbirth Group's Trials Register and reference lists of identified articles for randomized and quasi-randomized trials comparing antimicrobial therapeutic regimens that differed in duration [particularly comparing single dose with short course (three to seven days) regimens] in pregnant women diagnosed with asymptomatic bacteriuria [15]. Their review included 13 studies, involving 1,622 women. The antimicrobial agents used were fosfomycin trometamol, amoxicillin and nitrofurantoin.

3.2 Antibiotics for prophylaxis

Garcia-Perdomo et al. reviewed PubMed, CENTRAL and EMBASE to estimate the efficacy of antibiotic prophylaxis to prevent UTI in patients undergoing cystoscopy [16]. Their search ended up with seven randomized controlled trials with a total of 3,038 patients. The antibiotics used were ceftriaxone 1 g (2,284 pts), levofloxacin 500 mg (276 pts), cefoperazone 1 g (200 pts), gentamicin 120 mg (161 pts), norfloxacin 400 mg (126 pts), fosfomycin trometamol 3 g (60 pts) and sparfloxacin (47 pts). The authors concluded that prophylaxis couldn’t be recommended for cystoscopy. However, GPIU Studies revealed that prophylactic antibiotics are used in 46.3% of patients undergoing cystoscopy; with ciprofloxacin, 2nd generation cephalosporins and cefotaxime in the order of preference [10].

Roberts et al. performed a meta-analysis of studies on the baseline prevalence of antimicrobial resistance among patients undergoing prostate biopsy by using Cochrane, MEDLINE, EMBASE and CINAHL databases [17]. In the nine studies which were included and where antibiotic prophylaxes were detailed, ciprofloxacin 1000 mg oral, ciprofloxacin 500 mg oral plus amoxicillin/clavulanate IV plus AMK, ceftriaxone, gentamicin, trimethoprim/sulfamethoxazole, meropenem, levofloxacin were the preferred antibiotics. Ciprofloxacin was found to be the most frequently used antibiotic (36%), followed by nitrofurantoin (31%) in the GPIU Study [10].

Green et al. searched CENTRAL, PUBMED, LILACS and relevant conference abstracts for randomized controlled trials on prophylaxis in renal transplant patients and performed a meta-analysis [18]. Their meta-analysis included 545 patients from six trials. While they concluded that prophylaxis reduced bacteriuria and sepsis in this specific patient group, the antibiotics used were TMP/SMX 160/800 mg (X1 or X2), ciprofloxacin 250 mg (X1), ampicillin 250 mg (X1), cephalexin 250 mg. (X1). The duration of the antibiotic regimen varied between one month and 8.5 months (average; maximum period not mentioned).

Latthe and co-workers searched Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, TRIP LILACS, and the National Library for Health for randomized controlled trials on prophylactic antibiotic in patients undergoing urodynamics [19]. They identified eight randomized controlled trials with 995 patients. Although the studies were reportedly of low quality and methods were poorly described, they concluded that prophylaxis reduced the risk of significant bacteriuria after urodynamic studies. The antibiotics preferred in the reviewed trials were: trimethoprim, nitrofurantoin, augmentin, ciprofloxacin, norfloxacin, and cinoxacin. All were used as a single dose per day for periods varying between one and five days.

3.3 Uncomplicated UTI

Knottnerus et al. performed a network meta-analysis of randomized trials on the effectiveness of antibiotics for uncomplicated UTI [20]. They identified twelve studies comparing different antibiotics with different treatment regimes. The antibiotics and the regimens included in these studies are summarized in Table 1. The authors reported a higher efficacy for ciprofloxacin and gatifloxacin treatment in patients with uncomplicated UTI.

Table 1: Studies on antibiotics for uncomplicated UTI (adapted from Knottnerus et al. [20])
Randomized trials First author (year) (N) patients
Ciprofloxacin 250 mg b.i.d. or TMX 160/800 mg or Norfloxacin 400 mg b.i.d. (285 pts) Arredondo-Garcia (2004) 285 pts
Pivmecillinam 400 mg t.i.d. or Sulfamethiazole 1 g b.i.d. Bjerrum (2009) 175 pts
Prulifloxacin 600 mg s.d. or Pefloxacin 2X 400 mg s.d. Cervigni (2003) 231 pts
Nitrofurantoin 100 mg q.i.d. or placebo Christiaens (2002) 78 pts
Pivmecillinam 200 mg b.d. or Pivmecillinam 200 mg t.i.d. or Pivmecillinam 400 mg b.d. or placebo Ferry (2007) 1,143 pts
TMX 160/800 mg or nitrofurantoin 100 mg b.d. Gupta (2007) 308 pts
Amoxicillin/Clavulanate 500/125 mg b.d. or Ciprofloxacin 250 mg b.d. Hooton (2005) 322 pts
Gatifloxacin 400 mg s.d. or Gatifloxacin 200 mg s.d. or Ciprofloxacin 250 mg b.d. Naber (2004) 1,102 pts
Pivmecillinam 400 mg b.d. or Norfloxacin 400 mg b.i.d. Nicolle (2002) 901 pts
Ciprofloxacin 500 mg qid or Trimethoprim/Sulfamethoxazole 160/800 mg Park (2007) 65 pts
Gatifloxacin 400 mg s.d. or Gatifloxacin 200 mg s.d. or Ciprofloxacin 10 mg b.d. Richard (2002) 673 pts
Fosfomycin 3 g s.d. or Nitrofurantoin 50 mg q.i.d. Van Pienbroek (1993) 231 pts

Katchman et al. performed a meta-analysis to compare the efficacy and safety of short-term (3 days) antibiotic treatment of uncomplicated cystitis in adult non-pregnant women with longer (5 days or longer) treatment [21]. They searched The Cochrane Library, the Cochrane Renal Group's Register of trials, EMBASE, and MEDLINE for randomized controlled trials comparing two different regimes. Thirty-two trials and 9,605 patients met the inclusion criteria. They concluded that antibiotic therapy for 3 days is similar to prolonged therapy in achieving symptomatic cure for cystitis, while the prolonged treatment is more effective in obtaining bacteriological cure.

Leibovici et al. reviewed 25 trials with 2,397 patients, comparing single dose treatment with conventional treatment of UTI [22]. Amoxicillin, TMP/SMX, and various oral cephalosporins were used in these trials. The authors concluded that single dose treatment of UTI is less effective than conventional treatment.

The ARESC Study evaluated the resistance rates of microorganisms to antimicrobials in 4,264 female patients with cystitis [30]. The authors reported that fosfomycin, mecillinam, and nitrofurantoin have preserved their in vitro activity in all countries investigated. However, the prescription rates of these antibiotics were not reported in this study.

3.4 Complicated UTI

Bai et al. searched the PubMed, EMBASE, and the Cochrane Library for published randomized controlled trials (RCTs) that compared the efficacy and safety of ertapenem with ceftriaxone for the treatment of complicated infections including complicated urinary tract infections (cUTIs) [23]. Eight RCTs, involving 2,883 patients, were included in this meta-analysis which concluded that Ertapenem is as efficient and safe as Ceftriaxone for the treatment of complicated UTI.

Singh et al. selected three antimicrobial drugs (doripenem, levofloxacin, and imipenem-cilastatin) for their meta-analysis on antimicrobial treatment in complicated UTI [24]. The estimated eradication rates were comparable (81%, 79%, and 80.5% consecutively).

Eliakim-Raz et al. reviewed all randomized controlled trials comparing treatment periods of ≤7 days and >7 days in acute pyelonephritis and septic UTI [25]. In the eight trials they included in their meta-analysis, the antibiotics used were ciprofloxacin (626 pts), levofloxacin (1,420 pts), ceftriaxone + cefixime (304 pts), fleroxacin (54 pts), pivampicillin/pivmecillinam (77 pts) and ampicillin (42 pts).

Pohl searched the Cochrane Renal Group's specialized register, the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE to assess whether the mode of administration of antibiotic therapy for severe UTI has an effect on cure rate, re-infection rate and kidney scarring [26]. No restriction of age and sex was applied in this search. Fifteen RCTs (1,743 pts) were included. Pohl concluded that there is no evidence suggesting that oral antibiotic therapy is less effective for treatment of severe UTI than parenteral or initial parenteral therapy.

3.5 Management of Chlamydia Trachomatis infections

Dale et al. conducted a survey for their audit on the management of Chlamydia infections in 31 Genitourinary Medicine Clinics in the UK [14]. They reported that antibiotic prescription for these infections were largely in accordance with the UK National Guidelines, the guidelines, which are Doxycycline 100 mg b.d. for 7 days or Azithromycin 1 g orally in a single dose.

3.6 Global Prevalence studies in Infections in Urology (GPIU) and the EAU Guidelines

Probably the best available data on antibiotic use in urology clinics can be retrieved from Global Prevalence studies on Infections in Urology (GPIU), reported by Bjerklund-Johansen et al. The first two publications reported the prevalence, microorganisms and resistance of microorganisms in nosocomially acquired urinary tract infections (NAUTI) [5], [6], [12], [13]. The first two years of this study (PEP and PEAP) included 4,706 of the 6,033 hospitalized patients on study days; 2,617 were receiving antibiotics (56%); 26% of the antibiotic use was for a microbiologically proven UTI, 21% for a clinically suspected, but not microbiologically proven UTI, 7% for other infections, and 46% for prophylaxis [12], [13]. Among 686 of the 727 patients with NAUTI the largest group was asymptomatic bacteriuria (29%) followed by cystitis (26%), pyelonephritis (21%), and urosepsis (12%). The most commonly used antibiotics for the treatment of these infections were fluoroquinolones (in 35% of cases), cephalosporins (in 27% of cases). Sixteen percent of the patients received penicillins, mostly aminopenicillins with beta-lactamase inhibitor. Aminoglycosides (in 15% of patients) and co-trimoxazol in 8% followed these antibiotics. Trimethoprim alone was given in less than 1% of cases. Other antibiotics given were imipenem (6%), vancomycin (2%), antifungal drugs (2%), and tetracyclines (2%). Important findings of these studies are regional differences in terms of pathogen spectrum, susceptibility patterns, as well as the differences in prophylactic regimens.

Antibiotics used for prophylaxis in urology departments were analyzed by Çek et al. [10]. The authors reported data on 13,723 patients enrolled in the GPIU studies between 2005 and 2010. Of these patients, 8,178 received antibiotics on the study days; 3,898 (47.7%) for prophylaxis. The three most frequently used prophylactic antibiotics for various specific conditions are listed in table 2 together with major guideline recommendations for these conditions. Non-adherence with EAU guidelines in the application of prophylaxis in procedures like cystoscopy, URS, TUR-BT, and clean operations are evident in this table. Variation in antimicrobial prophylaxis in urological practice is recently reported by Mossanen et al. [31]. The authors reported a wide variance of compliance rates with AUA Best Practice Statement, between 0.6% for radical cystectomy and 97% for shock wave lithotripsy. Cai et al. compared the data for 3,529 urologic procedures performed after implementation of a protocol for antibiotic prophylaxis according to the EAU Guidelines, with data for 2,619 procedures performed before the implementation of this protocol. They showed that adherence to EAU guidelines on antibiotic prophylaxis reduced antibiotic usage without increasing post-operative infection rate and lowered the prevalence of resistant uropathogens [29].

Table 2: Adapted from Çek et al. [10] and AUA [28]
  EAU Guidelines AUA Best Practice AP in GPIU Studies 2005-2010 First three antibiotics for routine AP
Procedure Routine AP Recommended antibiotic Prophylaxis indicated Antimicrobials of choice In high risk only Routinely Not routinely  
Diagnostic procedures
Cystoscopy No TMP±SMX If risk factors Fluoroquinolone 20% 46% 34% Ciprofloxacin
2G cephalosporins TMP±SMX 2G cephalosporins
URS No TMP±SMX All Fluoroquinolone 14.4% 77% 8.7% Ciprofloxacin 
2G cephalosporins  TMP-SMX 2G cephalosporins 
TRUS biopsy All patients Fluoroquinolones All Fluoroquinolone 5.1% 90.% 4.1% Ciprofloxacin 
TMP±SMX cephalosporin 1G/2G/3G. Nitrofurantoin
Metronidazole   TMP-SMX
Endoscopic surgery
URS for un-
complicated stone treatment
No TMP±SMX All Fluoroquinolone 11.3% 84.4% 4.3% Cefotaxim
2G or 3G cephalosporins TMP-SMX Ciprofloxacin
  2G cephalosporins
TURP All patients TMP± SMX All (cystourethroscopy with manipulation) Fluoroquinolone 13% 81.2% 5.9% Ciprofloxacin
2G or 3G cephalosporins TMP-SMX 2G cephalosporins
TURBT No TMP±SMX All (cystourethroscopy with manipulation) Fluoroquinolone 11.7% 74.1% 14.1% Ciprofloxacin 
2G or 3G cephalosporins TMP-SMX Cefotaxime
  2G cephalosporins
PCNL/ URS for impacted or proximal stone All patients TMP  All 1G/2G cephalosporin 11.5% 82.3% 6.2% Cefotaxime
 SMX Aminiglycoside (Aztreonem)+
Metronidazole or Clindamycin
2G cephalosporins
2G or 3G cephalosporins   Ciprofloxacin
Open or laparoscopic surgery according to contamination status
Clean No   If risk factors 1st G cephalosporin 9.4% 62.8% 27.8% Cefotaxime
2G cephalosporins
Clean-contaminated  Recommended TMP    1G/2G cephalosporin 7.2% 87.3% 5.5% Cefotaxime
 SMX Aminoglycoside (Aztreonem)+
Metronidazole or Clindamycin
2G cephalosporins
2G or 3G cephalosporins   Ciprofloxacin
Contaminated All patients 2G or 3G cephalosporins    1G/2G cephalosporin 3.1% 96.9% 0 Cefotaxime
Metronidazole Aminoglycoside (Aztreonem)+
Metronidazole or Clindamycin
2G cephalosporins

As Bell et al. pointed out 90% of antibiotics in Europe are used for non-hospitalized patients; however, data on the use of antimicrobials and resistance patterns are overwhelmingly about hospitalized patients [7]. This gap will hopefully be filled by future studies in this area.

4 Further research

There are various reasons for the overuse of antimicrobials. One of the reasons is non-compliance with guidelines. Hulscher and co-workers reviewed antibiotic prescribing in hospitals from a social and behavioral point of view [32]. They discussed the determinants that influence the use of antibiotics in hospitals, in an attempt to improve strategies for better prescription policies. Further research should definitely concentrate on factors influencing prescription habits and aim to increase compliance with guidelines for the use of antimicrobials in urology.

5 Conclusions

Antibiotic consumption is increasing globally. Although there is no direct evidence for the share of prescriptions in urology, increasing resistance rates confirm that more antibiotics are used in urology, too.

Reports on the use of antibiotics in urology are generally from secondary and tertiary centers. This may be regarded as a bias while assessing the amount and variety of antibiotics used in urological infections. The influence of non-prescription use of antibiotics in certain geographical areas cannot be assessed.

Compliance with guidelines is rather low, although adherence with guidelines has been shown to result in lower prevalence of resistant microorganisms, as well as diminishing treatment costs.

5.1 Treatment of asymptomatic bacteriuria

The most preferred antibiotics are fosfomycin, amoxycilin, and nitrofurantoin.

5.2 Prophylaxis

Various investigations have evaluated the value of prophylaxis in cystoscopy using fluoroquinolones, cephalosporins, Fosfomycin, etc. However, prophylaxis for diagnostic cystoscopy is not recommended by EAU and AUA.

Ciprofloxacin is the most frequently used antibiotic for prophylaxis before TRUS-Bx of the prostate. This finding is supported by the data of GPIU studies (ciprofloxacin in 36% of patients, followed by nitrofurantoin in 31%) [3].

Renal transplantation is probably the single procedure, which is associated with the longest application of antibiotic prophylaxis (TMP/SMX, Ciprofloxacin and Ampicillin), extending up to 8.5 months [11].

5.3 Uncomplicated UTI

Various antibiotics and various regimens have been evaluated (see table 1). Single dose treatment with amoxicillin and trimethoprim-sulfamethoxazol seems to be inferior to longer regimens of 3–7 days.

5.4 Complicated UTI

Carbapenems (ertapenem) are shown to be as efficient and as safe as ceftriaxone. No route of administration (oral vs. parenteral) has been shown to be superior.


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[27] Grabe M, Bartoletti R, Bjerklund Johansen TE, Cai T, Cek M, Köves B, Naber KG, Pickard RS, Tenke P, Wagenlehner F, Wullt B. Guidelines on Urological Infections. Arnhem: European Association of Urology; 2015. Available from: http://uroweb.org/wp-content/uploads/EAU-Guidelines-Urological-Infections-v2.pdf
[28] American Urological Association Education and Research, editor. Best Practice Policy Statement on Urologic Surgery Antimicrobial Prophylaxis. Linthicum: American Urological Association; 2008. Available from: www.auanet.org/documents//education/clinical-guidance/Antimicrobial-Prophylaxis.pdf
[29] Cai T, Verze P, Brugnolli A, Tiscione D, Luciani LG, Eccher C, Lanzafame P, Malossini G, Wagenlehner FM, Mirone V, Bjerklund Johansen TE, Pickard R, Bartoletti R. Adherence to European Association of Urology Guidelines on Prophylactic Antibiotics: An Important Step in Antimicrobial Stewardship. Eur Urol. 2016 Feb;69(2):276-83. DOI: 10.1016/j.eururo.2015.05.010
[30] Naber KG, Schito G, Botto H, Palou J, Mazzei T. Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): implications for empiric therapy. Eur Urol. 2008 Nov;54(5):1164-75. DOI: 10.1016/j.eururo.2008.05.010
[31] Mossanen M, Calvert JK, Holt SK, James AC, Wright JL, Harper JD, Krieger JN, Gore JL. Overuse of antimicrobial prophylaxis in community practice urology. J Urol. 2015 Feb;193(2):543-7. DOI: 10.1016/j.juro.2014.08.107
[32] Hulscher ME, Grol RP, van der Meer JW. Antibiotic prescribing in hospitals: a social and behavioural scientific approach. Lancet Infect Dis. 2010 Mar;10(3):167-75. DOI: 10.1016/S1473-3099(10)70027-X

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.


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


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.


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.


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


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].”


[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


Daniel Shoskes MD, PhD

Cleveland Clinic Glickman Urological and Kidney Institute


Yong-Hyun Cho MD, PhD

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


Tetsuro Matsumoto MD, PhD

University of Occupational and Environmental Health Department of Urology


Florian M. E. Wagenlehner MD, PhD

Justus-Liebig University of Giessen Clinic of Urology and Andrology


Truls Erik Bjerklund Johansen MD, PhD

Oslo University Hospital Urology Department


Kurt G. Naber MD, PhD

Technical University of Munich


Punit Bansal MD, PhD

R G Stone and Super Specialty Hospital
Department of Urology


Riccardo Bartoletti

University of Pisa
Department of Translational Research and New Technologies


Truls Erik Bjerklund Johansen MD, PhD

Oslo University Hospital
Urology Department


PD Dr. med. Gernot Bonkat

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


Prof. Tommaso Cai MD

Santa Chiara Regional Hospital
Dept. of Urology


Dr Leyland Chuang

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


Prof. Milan Cizman

University Medical Centre
Department of Infectious Diseases


Alison Crawford MSc

Queen's University
Department of Psychology


Pfofessor Svetlana Dubrovina MD, PhD

Rostov Medical State University
Obstetrics and Gynaecology


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

Singapore General Hospital
Department of Urology


Philip Hanno

University of Pennsylvania


Ass prof MD Gundela Holmdahl

Queen Silvia Childrens Hospital, Sahlgrens Academy
Pediatric surgery and urology


Udo B. Hoyme

HELIOS Hospital Erfurt Ltd.
Department of Gynecology and Obstetrics


David Hunstad

Washington University School of Medicine
Pediatrics / Molecular Microbiology


Gitte M. Hvistendahl

Aarhus University Hospital


Prof. Michael KOGAN M.D., PhD

Rostov State Medical University
Department of Urology


Dr Akihiro Kanematsu

Hyogo College of Medicine
Department of Urology


Frieder Keller

University Hospital Ulm
Department Internal Medicine 1, Nephrology


Professor Katarzyna Kilis-Pstrusinska PhD, MD

Wroclaw Medical University
Department of Pediatric Nephrology


MD, PhD Tae-Hyoung Kim

Chung-Ang University


John N. Krieger MD, PhD

University of Washington
Section of Urology


Prof Ekaterina Kulchavenya

Novosibirsk Research TB Institute, Novosibirsk State Medical University


Dr Christina Kåbjörn Gustafsson

Ryhov Hospital Jönköping


Dr. Bela Köves

South Pest Teaching Hospital
Department of Urology


Dr. med. Giuseppe Magistro

Ludwig-Maximilians-University of Munich
Department of Urology


Vittorio Magri

Urologic Clinic


András Magyar

South-Pest Hospital
Department of Urology


Professor Emeritus Brian Morris

University of Sydney
School of Medical Sciences


Baerbel Muendner-Hensen

ICA-Deutschland e.V.


Stephen F. Murphy

Feinberg School of Medicine, Northwestern University
Department of Urology


Kurt G. Naber MD, PhD

Technical University of Munich


Prof. Yulia Naboka

Rostov State Medical University
Department of Microbiology


Dr. J. Curtis Nickel MD

Queen's University
Department of Urology


Professor Ralph Peeker MD PhD

University of Gothenburg
Department of Urology


Tamara Perepanova

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


Prof. Gianpaolo Perletti M. Clin. Pharmacol.

University of Insubria
Department of Biotechnology and Life Sciences


Felice Petraglia

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


Michel Pontari

Temple University School of Medicine
Department of Urology


Dr. Jörgen Quaghebeur PhD. Med. Sci.

University Hospital Antwerp and University Antwerp
Department of Urology


Yazan F. Rawashdeh

Aarhus University Hospital
Paediatric Urology Section, Department of Urology


Professor Claus Riedl MD



Matthew Roberts

The University of Queensland
Faculty of Medicine


PD Dr. med Guido Schmiemann MPH

Institut für Public Health und Pflegeforschung, Universität Bremen
Abteilung Versorgungsforschung


Caroline Schneeberger MD PhD

Academic Medical Center (AMC)


Prof. Dr. med. Peter Schneede

Klinikum Memmingen
Department of Urology


Aaron C. Shoskes

Des Moines University Medical College of Ostheopathic Medicine


Daniel Shoskes MD, PhD

Cleveland Clinic
Glickman Urological and Kidney Institute


Prof. Dr. Roswitha Siener

University of Bonn
University Stone Centre, Department of Urology


Sofia Sjöström

Queen Silvia Childrens Hospital, Sahlgrens Academy
Pediatric surgery and urology


Mathew Sorensen

University of Washington School of Medicine
Department of Urology


Prof. Dr. Dr. Walter Ludwig Strohmaier FEBU

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


Satoshi Takahashi

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


Professor Paul Anantharajah Tambyah

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


Peter Tenke

Jahn Ferenc South Pest Teaching Hospital
Department of Urology


Praveen Thumbikat

Department of Urology


Dr. Jose Tiran Saucedo

IMIGO / Universidad de Monterrey
Obstetrics and Gynaecology


Dominic Tran-Nguyen

Des Moines University


Dean Tripp

Queen's University
Psychology, Anesthesia & Urology



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


Florian M. E. Wagenlehner MD, PhD

Justus-Liebig University of Giessen
Clinic of Urology and Andrology


Assoc. Prof. Christian Wejse

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


Prof. Dr. Mete Çek

Trakya University, School of Medicine