Urological infections, or urinary tract infections (UTIs) are one of the most frequently occurring infections worldwide. While 50% to 60% of adult women have experienced a UTI at least once in their lifetime, urinary tract obstruction caused by enlarged prostate is the main cause of UTI in men older than 50 years.¹ These data might be lower than actual infection rates since it is not mandatory to report UTIs.² Evidently, UTIs present a significant healthcare and financial burden worldwide, and the rise of antimicrobial resistance further complicates their treatment.²

Aiming to address this public healthcare concern, the European Association of Urology (EAU) compiled a set of clinical guidelines to aid clinicians and healthcare professionals with evidence-based recommendations for treatment and prevention of UTIs.^3,4 The EAU has also provided separate guidelines for paediatric UTIs and for urological infections in patients with neurological urinary tract dysfunction.^5,6 This article shares updates from the guidelines.

Main changes made in the 2020 guidelines are as follows⁴:

• Fluoroquinolones should not be used for uncomplicated cystitis due to their disabling and potentially long-lasting side effects. This measure is legally enforced in all EU countries. Fluoroquinolones should only be used for uncomplicated cystitis when other standard antibacterial agents are deemed inappropriate.
• Last-line antimicrobial alternatives are now included in the list of suggested regimens for empirical parenteral antimicrobial therapy in uncomplicated pyelonephritis. New last-line alternatives include ceftolozane/tazobactam 1.5 g (TID)* and cefiderocol 2 g (TID).
• For the treatment of urethritis:
• • Treatment should be delayed until nucleic acid amplification test (NAAT) results to diagnose chlamydial and gonococcal infections are available to guide treatment in patients with mild symptoms.

• • For patients with a positive NAAT test, urethral swab culture should be performed prior to treatment initiation to determine antibiotic susceptibility.

• • Sexual partners of patients should be treated, while maintaining patients’ confidentiality.
• Recommendations for antimicrobial therapy of persistent non-gonococcal urethritis were also included in this update.

• • First-line doxycycline should be followed by oral azithromycin (500 mg on day 1, then 250 mg for 4 days) + metronidazole (400 mg, BID*, for 5 days).

• • First-line azithromycin should be followed by oral moxifloxacin (400 mg, QD*, for 7–14 days) + metronidazole (400 mg, BID*, for 5 days).

The EAU emphasises that these recommendations are made based on the best evidence available to experts and are not meant to be a legal mandate (unless otherwise stated). These recommendations do not replace clinical expertise when making treatment decisions for individual patients, but rather aim to help focus decisions.⁴ Treatment should be individualised, taking personal values and preferences/circumstances of patients into account.⁴

* TID, three times daily; BID, twice daily; QD, once daily.

References:

1. Medina M, Castillo-Pino E. Ther Adv Urol 2019;11:3-7.
2. Ozturk R, Murt A. World J Urol 2020;38:2669-2679.
3. European Association of Urology. EAU Guidelines on Urological Infections, 2019. Available at: https://uroweb.org/guideline/urological-infections/. Accessed 4 Mar 2021.
4. European Association of Urology. EAU Guidelines on Urological Infections, 2020. Available at: https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-Urological-infections-2019.pdf. Accessed 4 Mar 2021.
5. Blok B, et al. EAU Guidelines on Neuro-urology. Presented at: EAU Congress Amsterdam 2020; 17–21 July 2020; Amsterdam, Netherlands
6. Stein R, et al. Eur Urol 2015;67:546-558.