Committee I

Committee XI

Urinary Tract Infections

Prof. Khaled Elgamal, MD Professor and head of urology department, Benha University

Prof. Mostafa Khalil, MD Professor of urology, Benha University

Ass. Prof. Shabieb Ahmed, MD Assistant professor of urology, Benha University

Ass. Prof. Rabea Gomaa, MD Assistant professor of urology, Benha University

Dr. Hossam Elawady, MD Lecturer of urology, Ain Shams University

Dr. Hussein Shaher, MD Lecturer of urology, Benha University

Dr. Amany Kasem. MD Lecturer of microbiology, Benha University

Dr. Kareem Nouh, MSC Assistant lecturer of urology, Benha University

Contents
XI.1 List of Abbreviations
  • ABP Acute bacterial prostatitis
  • ABU Asymptomatic bacteriuria
  • AFB Acid fast bacilli
  • AUA American urological association
  • AUC Acute Uncomplicated Cystitis
  • BPS Best Practice statement
  • CAUTI Catheter associated urinary tract infection
  • CBP Chronic bacterial prostatitis
  • CDC The Centers for Disease Control and Prevention
  • CFU colony forming unit
  • CLED cysteine-lactose- electrolyte- deficient media
  • CMV Cytomegalovirus
  • CT Computed tomography
  • cUTI Complicated urinary tract infections
  • EAU European association of urology
  • ESBL extended spectrum beta lactamase
  • FAST-ELISA Falcon assay screening test – enzyme linked immunosorbent assay
  • GCS Glasgow coma scale
  • HPF high power field
  • LUTS Lower urinary tract symptoms
  • MDR Multiple drug resistance
  • ml Milliliter
  • µl Microliter
  • MRSA Methicillin Resistant Staph Aureus
  • NAAT nucleic acid amplification tests
  • NG Neisseria gonorrhoeae
  • NICE National institute for health and care excellence
  • NIDDK National Institute of Diabetes, Digestive and Kidney Diseases
  • NIH National Institutes of Health
  • PCR Polymerase chain reaction
  • PMNL polymorphonuclear leukocytes
  • PNL Percutaneous nephrolithotomy
  • PUT Plain x-ray urinary tract
  • PZQ Praziquentel
  • QSOFA Quick Sequential [Sepsis-related] Organ Failure Assessment
  • RCT Randomized controlled trials
  • SWL Shock wave lithotripsy
  • rUTI Recurrent urinary tract infections
  • TMP-SMX Trimethoprim- sulphamethoxazole
  • TRUS Trans rectal ultrasound
  • TURP Transurethral resection of prostate
  • UTI Urinary tract infection
  • WHO World health organization
  • XGP Xanthogranulomatous pyelonephritis
XI.2 Introduction.
These guidelines provide essential summarized updated information for diagnosis, treatment and prevention of urinary tract Infections with emphasizing on judicious use of antimicrobials based on culture and sensitivity to reduce bacterial resistance which is a serious issue especially with malpractice and misuse of antibiotics in Egypt. Moreover, the recommendations included in these guidelines are not representing absolute mandates but provisional protocols respecting environmental and socioeconomic conditions of Egypt, considering our religious and traditional background.
XI.2.1 Methodology
Our recommendations are the outcome of integrating 3 resource categories:
1. Four guidelines (including their latest updates), namely American Urological Association [AUA], European Urological Association [EUA], Canadian Urological Association [CUA] and National Institute for Health and care excellence [NICE].
2. Good quality relevant international and Egyptian publications.
3. A panel of 7 urologists and a microbiologist working in several Governorates in Egypt dealing with several types of urological infections.
All statements were graded according to 2 parameters:
Strength of clinical practice recommendation, it is expressed as: strong and weak. This reflects the consensus of the authors and guided by other guideline recommendations, it is modified to suit the Egyptian environment.
XI.3 Asymptomatic Bacteriuria (ABU):
XI.3.1 Definition.
Asymptomatic bacteriuria (ABU) is the presence of bacteria in the properly collected urine of a patient that has no symptoms or signs of urinary tract infection. Escherichia coli (Ecoli) is the most common bacteria identified. (1). .

XI.3.2 Incidence:
ABU is more common in females than males because of short wide urethra with easy access of the bacteria from the urethral meatus and perineum to the bladder. (2)

XI.3.3 Recommendations for diagnosis:


o Diagnosis of ABU is made by urine culture is strongly recommended, either properly collected clean-catch specimen or a catheterized specimen is acceptable.
o The combination between urine dipstick for leucocyte esterase and nitrites is recommended.
o Urinalysis with microscopic examination for bacteria is suggested but nonquantitative way to identify bacteriuria.



XI.3.5 Recommendation for Management of UTI

Table XI:1 Recommendation for Management of UTI

Recommendations

Strength rating
1. Do not screen or treat asymptomatic bacteriuria in the following conditions:
o Women without risk factors
o Patients with well-regulated diabetes mellitus; However poorly regulated diabetes is a risk factor for symptomatic UTI and infectious complications and ABU should be treated
o Post-menopausal women;
o Patients with spinal cord injury, dysfunctional and/or reconstructed lower urinary tracts, and indwelling catheter in the urinary tract and/or catheter exchange.
o Elderly institutionalized patients;
o Patients with dysfunctional and/or reconstructed lower urinary tracts;
o Patients with renal transplant. Except in patients who are in the first three months following renal transplantation should be treated as treatment of these patients decrease the risk of symptomatic UTI.
o Patients prior to arthoplasty surgeries;
o Patients with recurrent urinary tract infections. 		Strong
2. Treatment of UTI prior to urologic procedure breaching the mucosa Strong
3. Treatment of UTI in pregnancy Strong
XI.3.5.1 Treatment of ABU is strongly recommended in pregnancy

The incidence of ABU in pregnant Egyptian ladies is 10% and increase with frequent sexual intercourse which increase the probability of transfer of uropathogens into the urethra. Washing the genitalia after urination or defecation from back to front which leads to spread of anal or vaginal flora into the urethra, (4)
The most common organism isolated in ABU during pregnancy is E-coli, followed by klebsiella (5)
Periodic screening each trimester especially at 9-17 gestational weeks by quantitative urine culture is recommended. (4)
Antibiotic treatment of ABU during pregnancy significantly reduced the number of symptomatic UTI, and associated with low rate of low birthweight and low rate of preterm delivery. The treatment duration varies between single dose, short course (2-7 days), long course (8-14 days), and continuous (until delivery). And we recommend short course treatment as it is associated with significant decrease in the rate of low birthweight and preterm deliveries as compared to single dose which is characterized by significant low rate of side effects.
An Egyptian study showed that the most common antibiotic used according to culture and sensitivity are nitrofurantoin, imipenem and amikacin demonstrated 100% sensitivity, followed by ceftriaxone, ceftazidime, sulphamethoxazole-trimethoprim, ciprofloxacin and norfloxacin. (4)

XI.4 Acute uncomplicated cystitis (AUC):

XI.4.1 Definition:

Acute uncomplicated cystitis (AUC) refers to a bladder infection that occurs in women who have normal structure and function of the genitourinary tract. (6)

XI.4.2 Incidence:


o 10% of women experience at least one episode of AUC in a year.
o 60% have at least one episode during their lifetime. (7)
o The peak incidence of infection occurs in young, sexually active women aged 18 to 24 years. (8)
XI.4.3 Causative organisms: .
In Egypt, the most common organisms are eight species, the common organism is E. coli (74%), the next most common is Pseudomonas (13.1%), other organisms include; MRSA (6.1%), Klebsiella (2.2%), enterococcus (1.9%), proteus (1.3%), Acinetobacter and staph. aureus (0.6%). (8)



Table XI:2 Recommendations for diagnosis:

Recommendations

Strength rating
1. Diagnose uncomplicated cystitis in women who have no risk factors for complicated urinary tract infections based on: o A focused history of lower urinary tract symptoms (dysuria, frequency and urgency) is strongly recommended.
o The absence of vaginal discharge or irritation. 		Strong
2. Use urine dipstick testing for diagnosis of acute uncomplicated cystitis is suggested Weak
3. Urine cultures is strongly recommended in the following situations:
o Suspected acute pyelonephritis;
o Symptoms that do not resolve or recur within four
o Weeks after the completion of treatment;
o Women who present with atypical symptoms;
o Pregnant women.		 Strong
XI.4.4 Recommendations for management:
Women with uncomplicated cystitis should be treated by antimicrobial therapy with or without symptomatic treatment e.g. ibuprofen. The choice of antimicrobial therapy should be guided by spectrum and susceptibility patterns of the aetiological pathogens, tolerability and adverse reactions, costs, and availability. (10)
According to the previously mentioned principles and available susceptibility patterns in Egypt, an Egyptian study determined the most common uropathogens and their pattern of sensitivity to the commonly used antimicrobials (9)
XI.4.4.1 In mild cases:
We strongly recommend empirical treatment by one of the following antimicrobial therapy:
o • Nitrofurantoin has sensitivity 52.9% (100 mg twice daily for 5 days)
o • Levofloxacin has sensitivity 39.4% (500 mg once /day for 5 days)
o • Ciprofloxacin has sensitivity 35.9% (500mg twice /day for 5 days)
o • Norfloxacin has sensitivity 33% (400 mg twice /day for 5 days)
o • Trimethoprim- sulphamethoxazole (TMP-SMZ) has sensitivity 12.2% (160-800 mg twice daily for 3 days)
E. coli strains showed the least rate of resistance to Nitrofurantoin and the highest rate of resistance to TMP/SMZ. No organism was absolutely resistant to Nitrofurantoin while Klebsiella, Enterococcus, Proteus, Staph. aureus and Acinetobacter were absolutely resistant to TMP/SMZ. (9)
It is strongly recommended to not use Aminopenicillins for empirical therapy because of worldwide high E. coli resistance. But Aminopenicillins in combination with a betalactamase inhibitor such as ampicillin/sulbactam or amoxicillin/clavulanic acid and oral cephalosporins may be suggested in selected cases.
XI.4.4.2 In severe cases:
It is strongly recommended to send a sample of urine for culture and sensitivity and start empirical treatment as before till the result of culture and sensitivity appear. If the symptoms persist, change the antibiotic according the culture and sensitivity, but if the symptoms improved and the result of culture is different from the current antibiotic use, you should not change the antibiotic, because of differences between the in vitro and in vivo effectiveness so an additional course of antibiotics may be unnecessary treatment.
XI.4.5 Recommendations for follow-up:
It is strongly recommended to do urine culture and sensitivity in patients with persistent symptoms or recurrent symptoms within 2weeks post treatment and antimicrobial therapy should be given at least 7 days.
It is recommend not doing urine culture and sensitivity in asymptomatic patients post treatment

XI.5 Recurrent urinary tract infections (rUTIs):

XI.5.1 Definition:
Recurrent UTIs (rUTIs) are recurrences of uncomplicated and/or complicated UTIs, with a frequency of at least three UTIs/year or two UTIs in the last six months. Although rUTIs include both lower tract infection (cystitis) and upper tract infection (pyelonephritis), repeated pyelonephritis should prompt consideration of a complicated etiology. (11)
Recurrent UTIs occur due to bacterial reinfection or bacterial persistence. Persistence involves the same bacteria not being eradicated in the urine 2 weeks after sensitivityadjusted treatment. A reinfection is a recurrence with a different organism, the same organism in more than 2 weeks, or a sterile intervening culture (12)

Table XI:3 Risk factors associated with recurrent UTIs in women:

Young and pre-menopausal women (11)

Post-menopausal and elderly women

Use of spermicide
Sexual intercourse
A new sexual partner
A mother with a history of UTI
History of UTI during childhood
Blood group antigen secretory status 		Urinary incontinence
History of UTI before menopause
Atrophic vaginitis due to oestrogen
deficiency
Cystocele
Increased post-void urine volume
Blood group antigen secretory status


Table XI:4 Host factors that classify a urinary tract infection as complicated

Complication (12)

Examples

Anatomic abnormality Cystocele, diverticulum, fistula
Iatrogenic Indwelling catheter, nosocomial infection, surgery
Voiding dysfunction Vesicoureteric reflux, neurologic disease, pelvic floor dysfunction, high post void residual, incontinence
Urinary tract obstruction Bladder outlet obstruction, ureteral stricture, ureteropelvic junction obstruction
Others Pregnancy, urolithiasis, diabetes or other immunosuppression
XI.5.2 Recommendations for diagnosis:
a. It is strongly recommended to diagnose each UTI episode clinically and is supported by symptoms of dysuria, frequency, urgency, hematuria, back pain, costovertebral tenderness and the absence of vaginal discharge or irritation.
b. Complicated causes of UTI may also be ruled out on history and physical examination. Uroflowmetry and determining post void residual are suggested tests in postmenopausal women to exclude complicated causes of UTI.
c. Culture and sensitivity analysis is strongly recommended when symptomatic and in 2 weeks from sensitivity-adjusted treatment to confirm UTI, guide further treatment and exclude persistence.
d. Further investigations e.g. (pelviabdominal US, PUT, CT abdomen and pelvis with or without contrast or cystoscopy) are not routinely recommended except in atypical cases as in table 2.
XI.5.3 Recommendations for disease management and follow-up:

XI.5.3.1 Avoidance of risk factors:
Behavioral modifications are suggested e.g. reduced fluid intake, habitual and post-coital delayed urination, wiping from front to back after defecation, douching and wearing occlusive underwear.
XI.5.3.2 Non-antimicrobial measures:
1. Hormonal replacement: it is suggested to use vaginal oestrogen cream in postmenopausal women to prevent recurrent UTIs (3C) and we recommend not to use oral oestrogen for fear of cancer.
2. Immunoactive prophylaxis: it is strongly recommended to use OM-89 (Uro-vaxom) as an immunoprophylaxis in females with recurrent UTIs (1C)
3. Prophylaxis with cranberry: it is recommended not to use cranberry as a prophylaxis against recurrent UTIs.
XI.5.3.3 Antimicrobial prophylaxis:
It is strongly recommended to use antimicrobial prophylaxis either continuously for long period (3-6 months) or shortly within 2 hours post coital.

Table XI:5 Antimicrobial prophylaxis

Continuous

Postictal (within 2 hours of coitus)

Trimethoprim/sulfamethoxazole (TMP/SMX) (40 mg/200 mg daily or thrice weekly)
Ciprofloxacin (125 mg daily)
Cephalexin (125 mg to 250 mg daily)
Cefaclor (250 mg daily)
Nitrofurantoin (50 mg–100 mg daily)
Norfloxacin (200 mg daily)
Fosfomycin (3 g every 10 days)
TMP/SMX (40 mg/200 mg to 80 mg/400 mg)
Ciprofloxacin (125 mg)
Cephalexin (250 mg)

Nitrofurantoin (50 mg–100 mg)
Norfloxacin (200 mg)
Ofloxacin (100 mg)


Table XI:6 Recommendations for the diagnostic evaluation and treatment of rUTIs

Recommendation

Strength Rating

1. Diagnose recurrent UTI by urine culture Strong
2. Advise patients on behavioural modifications which might reduce the risk of recurrent UTI. Weak
3. Use immunoactive prophylaxis to reduce recurrent UTI in all age groups. Strong
4. Use continuous or post-coital antimicrobial prophylaxis to prevent recurrent UTI when non-antimicrobial interventions have failed. Counsel patients regarding possible side effects. For patients with good compliance self-administered short term antimicrobial is advised Strong


XI.6 Uncomplicated pyelonephritis
Uncomplicated pyelonephritis is defined as pyelonephritis with no known relevant urological abnormalities or comorbidities. (11)
XI.6.1 Recommendations for diagnosis and management:
• Urinalysis is strongly recommended including the assessment of white and red blood cells and nitrite, for routine diagnosis
• It is strongly recommended to perform urine culture and antimicrobial susceptibility testing in patients with pyelonephritis
• Imaging of the urinary tract (US) is strongly recommended to exclude urgent urological disorders
• It is strongly recommended to treat patients who will be managed as outpatients by single-drug oral therapy with a fluoroquinolone or cephalosporines.
• It is strongly recommended for patients requiring hospitalization should be treated initially with an intravenous antimicrobial regimen e.g. a fluoroquinolone, an aminoglycoside (with or without ampicillin), or an extended-spectrum cephalosporin.
• Carbapenem is stongly recommended only in patients with early culture results indicating the presence of multi-drug resistance organisms. (13)

Table XI:7 Treatment Regimens for empirical oral antimicrobial therapy in Uncomplicated Pyelonephritis

Antimicrobial

Daily dose

Duration of Therapy

Ciprofloxacin 500-750 mg b.i.d 7 days
Levofloxacin 500-750 mg q.d 5-7 days
Cefexime 400mg dq 5-10 days
b.i.d = twice daily; q.d = every day.

Table XI:8 Table 11:9: Treatment Regimens for empirical parentral antimicrobial therapy in Uncomplicated Pyelonephritis

Antimicrobial

Daily dose

Duration of Therapy

Ampicillin and gentamicin or Ampicillin and Amikacin 1 gm and 5mg/kg or 15mg/kg qd 7-14 days
Levofloxacin 500 mg q.d 7-14 days
Ciprofloxacin 400 mg bid 7-14 days
Ceftriaxone 1-2 gmqd 7-14 days
Imipenem 0.5 g t.i.d 7-14 days
Meropenem 1 g t.i.d 7-14 days
b.i.d = twice daily; t.i.d = three times daily; q.d = every day.

• The antimicrobial agents should be modified according to local resistance patterns and drug susceptibility results (14)
• The higher rate of sensitivity among uropathogen was towards amikacin (77.55%), imipenem (76.53%), nitrofurantoin (75.5%) and gentamicin (71.43%). So, these antimicrobial agents should be used. (13)
• When Extended Spectrum β-Lactamase Producing Escherichia coli and Klebsiella pneumonia were suspected imipenem and fosfomycin should be considered. (14)
• It is strongly recommended to repeat urine analysis on the fifth to the seventh day of therapy and 10 to 14 days after discontinuing antimicrobial therapy to ensure that the urinary tract remains free of infections.

c

XI.7 Complicated UTIs (cUTI):

A complicated UTI (cUTI) occurs in an individual with predisposing factors (e.g. diabetes or immunosuppression) or specific anatomical or functional abnormalities related to the urinary tract (e.g. obstruction, incomplete voiding due to detrusor muscle dysfunction), pregnancy or recent instrumentations are believed to result in an infection that will be more difficult to eradicate than an uncomplicated infection (11).
XI.7.1 Recommendations for diagnosis and management:

• Urinalysis is strongly recommended including the assessment of white and red blood cells and nitrite, for routine diagnosis
• Performing urine culture and antimicrobial susceptibility testing is also strongly recommended in patients with complicated UTI
• Imaging of the urinary tract with US to exclude urgent urological disorders is strongly recommended. Additional investigations, such as an unenhanced helical computed tomography (CT) are strongly recommended if the patient remains febrile after 72 hours of treatment. For diagnosis of complicating factors in pregnant women, US or magnetic resonance imaging (MRI) is strongly recommended to avoid radiation risk to the foetus.
• It is strongly recommended appropriate management of the urological abnormality or the underlying complicating factor.
• Patients with UTI with systemic symptoms requiring hospitalization strongly recommended to be initially treated with an intravenous antimicrobial regimen, such as an aminoglycoside with or without amoxicillin, or a second or third generation cephalosporin.
• Do not use ciprofloxacin and other fluoroquinolones for the empirical treatment of complicated UTI in patients from the urology department or when patients have used fluoroquinolones in the last six months.
• Treatment for seven to fourteen days is strongly recommended, but the duration should be closely related to the treatment of the underlying abnormality.
• The choice between these agents should be based on local resistance data, and the regimen should be tailored on the basis of susceptibility results. These recommendations are not only suitable for pyelonephritis but for all other cUTIs.
XI.8 Special Types of Renal Infections:
XI.8.1 Renal abscess:
They can rupture into the urinary tract or penetrate through the renal capsule to become a perinephric abscess. (15) Use of IV combined antibiotics and careful observation of a small abscess less than 3 cm or even 5 cm in a clinically stable patient is strongly recommended. Percutaneous drainage, however, remains the first line procedure of choice for most renal abscesses greater than 5 cm in diameter or open surgical drainage if percutaneous failed.
XI.8.2 Perinephric abscess:
The clinical symptoms are chills, fever, back or abdominal pain, CVA tenderness, flank mass and redness (15) Broad spectrum antimicobrial agents are strongly recommended to be started immediately upon diagnosis of perinephric abscess. For larger collections or those not responsive to initial antibiotic therapy, intervention is the next step in treatment. Surgical drainage or nephrectomy if the kidney is nonfunctioning or severely infected, was the classic treatment for perinephric abscesses. However, with the advent of the field of interventional radiology and improvements in percutaneous drainage techniques, renal ultrasonography and CT- or ultrasound-guided percutaneous aspiration and drainage of perirenal collections is now a good option for therapy.
XI.8.3 Emphysematous pyelonephritis:
This is caused by gas-forming E. coli, K. pneumoniae, E. cloacae fermenting glucose. The contralateral kidney is often also affected. (15) Emphysematous pyelonephritis is a surgical emergency. Most patients are septic, and fluid resuscitation and broad-spectrum antimicrobial therapy are strongly recommended. If the kidney is functioning, medical therapy can be considered. If a kidney is obstructed, catheter drainage is strongly recommended. If the affected kidney is nonfunctioning and not obstructed, nephrectomy should be performed because medical treatment alone is usually lethal. Nephrectomy is recommended for patients who do not improve after a few days of therapy.
XI.8.4 Xanthogranulomatous pyelonephritis (XGP):
This is characterized by a chronic purulent, fatty inflammation of the renal parenchyma, the pelvis and the hilar tissue. (15) The primary obstacle to the correct treatment of XGP is incorrect diagnosis. Broad-spectrum antimicrobial therapy is strongly recommended to stabilize the patient preoperatively, and, occasionally, long-term antimicrobial therapy will eradicate the infection and restore renal function. Because the renal abnormality may be diagnosed preoperatively as a renal tumor and/ or is diffuse, nephrectomy is usually performed. If localized XGP is diagnosed preoperatively or at exploration, it is amenable to partial nephrectomy.

XI.9 Catheter Associated Urinary Tract Infection

Catheter-associated UTI refers to presence of symptoms or signs compatible with UTI in a person whose urinary tract is currently catheterized within the past 48 hours with no other identified source of infection.(11,16) The most common isolated organisms among Egyptian patients in cross sectional prospective study in medical words and intensive care unit's patients ;Candida yeasts (18%) ,E.coli (3%) ,Pseudomonas (1%), Isolated MDR organisms consisted about 10% of the total isolated organisms and the most common isolated MDR organism is Vancomycin resistant enterococci (50%)and no organism isolated in 70.5%.(17).
XI.9.1 Recommendations for Diagnosis:
o It is strongly recommended to do routine urinary culture only in symptomatic patients, take the sample from the catheter using an aseptic technique, if the catheter has been removed obtain a midstream urine sample.
o It is strongly recommended not to use pyuria as indicator for catheter associated UTI, the longer the catheter in place, the most likely bacteria will be found. After one month nearly all patients have bacteriuria.
o It is strongly recommended not to use the presence or absence of odorous or cloudy urine alone differentiates CA-UTI from CA- asymptomatic bacteriuria.
XI.9.2 Recommendations for Management:

o It is strongly recommended to treat symptomatic catheter CA-UTI according to recommendations for complicated UTI.
o When prescribing an antibiotic for catheter-associated UTI, take account of local antimicrobial resistance.
o Give oral antibiotics as a first line if the person can take oral medications, and the severity of their condition does not require intravenous antibiotics.
o Choice of intravenous antibiotics (if vomiting, unable to take oral antibiotics or severely unwell). Antibiotics may be combined if susceptibility of sepsis is a concern.
o It is strongly recommended to consider removing or, changing the catheter as soon as possible in people with a catheter-associated UTI if it has been in place for more than 7 days. Do not allow catheter removal or change to delay antibiotic treatment.
o It is strongly recommended not to treat CA-UTI asymptomatic bacteriuria in general except:
o Prior to traumatic urinary tract intervention
o Pregnant woman as of increase risk of pyelonephritis and preterm labor.
XI.9.3 Recommendations for Prevention and Self– care:
o It is strongly recommended not to routinely offer antibiotic prophylaxis to prevent catheter-associated UTIs in people with a short-term or a long-term (indwelling or intermittent) catheter.
o It is strongly recommended to give advice about seeking medical help if symptoms of an acute UTI develop.
o It is strongly recommended to use paracetamol for pain associated with CAUTI.
o It is recommended to advise people with CA-UTI about drinking enough fluids to avoid dehydration.

Table XI:10 Recommendations for the diagnostic evaluation of uncomplicated pyelonephritis

Recommendations

Strength Rating

1. Perform urinalysis (e.g. using a dipstick method), including the assessment of white and red blood cells and nitrite, for routine diagnosis Strong
2. Perform urine culture and antimicrobial susceptibility testing in patients with pyelonephritis Strong
3. Perform imaging of the urinary tract to exclude urgent urological disorders. Strong
4. Treat patients with uncomplicated pyelonephritis not requiring hospitalization with short course fluoroquinolones as first line treatment. Strong
5. Treat patients with uncomplicated pyelonephritis requiring hospitalization with an intravenous antimicrobial regimen initially. Strong
6. Switch patients initially treated with parenteral therapy, who improve clinically and can tolerate oral fluids, to oral antimicrobial therapy. Strong
7. Do not use nitrofurantoin, oral fosfomycin, and pivmecillinam to treat uncomplicated pyelonephritis. Strong


Table XI:11 Recommendations for diagnostic evaluation of CA-UTI

Recommendations

Strength Rating

1. Do not use prophylactic antimicrobials to prevent catheter-associated UTIs. Strong
2. Do not apply topical antiseptics or antimicrobials to the catheter, urethra or meatus. Strong
3. Do not carry out routine urine culture in asymptomatic catheterised patients. Strong
4. Do not use pyuria as sole indicator for catheter-associated (CA-UTI). Strong
5. Do not use the presence or absence of odorous or cloudy urine alone to differentiate catheter-associated asymptomatic bacteriuria from CA-UTI. Strong
6. Do not treat catheter-associated asymptomatic bacteriuria in general. Strong
7. Treat symptomatic CA-UTI according to the recommendations for complicated UTI. Strong
8. Take a urine culture prior to initiating antimicrobial therapy in catheterised patients. Strong
9. Replace or remove the indwelling catheter before starting antimicrobial therapy. Strong
10. Treat catheter-associated asymptomatic bacteriuria prior to traumatic urinary tract interventions (e.g. transurethral resection of the prostate). Strong


XI.10 Urosepsis

Sepsis in urology remains a severe situation with a considerable mortality rate. Early recognition of the symptoms may decrease the mortality by timely treatment of urinary tract disorders, e.g. obstruction, or urolithiasis, although the rate of sepsis due to Grampositive and fungal organisms has increased, Gram-negative bacteria remain predominant in urosepsis (11, 18, 19)

Table XI:12 Definition and criteria of sepsis and septic shock

Disorder

Definition (20,21,22)

Sepsis Life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical application, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more. For rapid identification, a quick SOFA (qSOFA) score was developed: respiratory rate of 22/min or greater, any altered mentation" instead of requiring a GCS < 15, or systolic blood pressure of 100 mmHg or less. The score ranges from 0 to 3 points. The presence of 2 or more qSOFA points near the onset of infection was associated with a greater risk of death or prolonged intensive care unit.
Septic shock Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.

XI.10.1 Recommendations for diagnosis:

o It is strongly recommended to perform the quick SOFA score to identify patients with potential sepsis.
o It is strongly recommended to take a urine culture and two sets of blood cultures before starting antimicrobial treatment.
o It is suggested using biomarkers for diagnosis however; urosepsis cannot be diagnosed from biomarkers alone.
o Procalciton in monitoring may be useful in patients likely to develop sepsis and to differentiate from a severe inflammatory status not due to bacterial infection,
o Serum lactate is a marker of organ dysfunction and is associated with mortality in sepsis.
XI.10.2 Recommendations for treatment of urosepsis:
o It is strongly recommended that urosepsis treatment requires a combination of appropriate antimicrobial therapy, source control (obstruction of the urinary tract) and adequate life-support care.
o In such a situation, it is suggested that urologists collaborate with intensive care and infectious disease specialists for the best management of the patient
XI.10.2.1 Antimicrobial therapy:
o It is strongly recommended to administer parenteral high dose broad spectrum antimicrobials within the first hour after clinical assumption of sepsis.
o It is strongly recommended to provide broad antimicrobial coverage against all likely causative pathogens and should be adapted on the basis of culture results, once available.
o It is strongly recommended to use high dosage of the antimicrobial substances in patients with sepsis syndrome with appropriate adjustment for renal function.

Table XI:13 Suggested regimens for antimicrobial therapy for urosepsis.

Antimicrobials

Daily dose

Duration of therapy (11)

Cefotaxime 2 g t.i.d 7-10 days
Ceftazidime 1-2 g t.i.d 7-10 days
Ceftriaxone 1-2 g q.d 7-10 days
Cefepime 2 g b.i.d 7-10 days
Piperacillin/tazobactam 4.5 g t.i.d 7-10 days
Ceftolozane/tazobactam 1.5 g t.i.d 7-10 days
Ceftazidime/avibactam 2.5 g t.i. d 7-10 days
Gentamicin* 5 mg/kg q.d 7-10 days
Amikacin* 15mg/kg q.d 7-10 days
Ertapenem 1 g q.d 7-10 days
Imipenem/cilastatin 0.5 g t.i.d 7-10 days
Meropenem 1 g t.i.d 7-10 days
b.i.d = twice daily; t.i.d = three times daily; q.d = every day.

XI.10.2.2 Source control:
o It is strongly recommended to initiate as soon as possible source control including removal of foreign bodies, decompression of obstruction and drainage of abscesses in the urinary tract.
o It is recommended to use of least-invasive methods to release urinary tract obstruction until the patient is stabilized
o It is strongly recommended to urgently decompress the collecting system in case of sepsis with obstructing stones, using percutaneous drainage or ureteral stenting.
o It is strongly recommended to collect (again) urine for antibiogram test following decompression
o It is strongly recommended to delay definitive treatment of the stone until sepsis is resolved.
XI.10.2.3 Adjunctive measures:
o It is strongly recommended to provide immediate adequate life-support measures including fluid therapy with crystalloids, or albumin, if crystalloids are not adequately increasing blood pressure: as vasopressors norepinephrine, should be used primarily, dobutamine in myocardial dysfunction.
o It is strongly recommended to give hydrocortisone only if fluid and vasopressors do not achieve a mean arterial pressure of ≥ 65 mmHg.
o It is strongly recommended to give blood products target a hemoglobin level of 7-9 g/dL.
o It is strongly recommended to apply mechanical ventilation with a tidal volume 6 mL/kg and plateau pressure ≤ 30 cm H2O and a high positive endexpiratory pressure.
o It is strongly recommended to use sedation minimally; neuromuscular blocking agents should be avoided o It is strongly recommended that glucose levels to be targeted at ≤ 180 mg/dL.
o It is strongly recommended to use low-molecular weight heparin subcutaneously for deep vein thrombosis prevention.
o It is strongly recommended to use proton pump inhibitors for stress ulcer prophylaxis in patients at risk.
o It is strongly recommended to start parenteral nutrition early (< 48 hours).
XI.10.3 Recommendations for management of urosepsis:
o It is recommended to reduce hospital stay as possible.
o It is recommended to remove indwelling urinary catheters early.
o It is recommended to avoid unnecessary urethral catheterization, correct use of closed catheter systems, and to pay attention to simple daily aseptic techniques to avoid cross-infection.
o It is recommended to routine use of disposable gloves. Frequent hand disinfection and infectious disease control measures to prevent crossinfections.

Table XI:14 Recommendations for the diagnosis and treatment of urosepsis

Recommendation

Strength Rating

1. Take urine and blood cultures before starting antimicrobial treatment. Strong
2. Administer parenteral high dose broad spectrum antimicrobials within the first hour after clinical assumption of sepsis, and then shift according to culture results. Strong
3. Initiate source control including removal of foreign bodies, decompression of obstruction and drainage of abscesses in the urinary tract. Strong
4. Provide immediate adequate life-support measures. Strong

XI.11 Urethritis:

Urethritis is the most common genitourinary syndrome in sexually active men. Urethritis is associated with several etiological agents including Neisseria gonorrhoeae (NG), Chlamydia trachomatis, and Mycoplasma genitalium and causes a wide variety of symptoms, which include discharge, dysuria, localized pruritus, and penile tingling. (23)
XI.11.1 Recommendation for diagnosis:
o Detailed history taking including age, sexual activities, and presence of urethral discharge is strongly recommended.
o It is strongly recommended to do urine analysis (first voided urine) and leukocyte esterase testing five or more polymorphonuclear leukocytes (PMNL) per high power field (HPF) is diagnostic of urethritis.
o It is recommended to do Gram or methylene-blue stain of urethral secretions, to diagnose gonococcal urethritis.
o Nucleic acid amplification tests are suggested (NAAT) especially in cases of urethritis with negative Gram stain test as it is more sensitive and specific in diagnosis of chlamydial and gonococcal infections.
o Urethral swab culture is suggested before initiation of treatment, in patients with a positive NAAT for gonorrhea to assess the antimicrobial resistance profile of the infective strain.
o Urethral swab culture for N. gonorrhoeae and C. trachomatis is recommended in treatment failure or persistence of symptoms more than 4 weeks of treatment.
XI.11.2 Recommendation for disease management:
o It is strongly recommended to assess all sexual partners at risk with maintaining patient confidentiality. Empirical treatment is strongly recommended following diagnosis especially in severe cases even before Gram stain test result.
XI.11.3 Gonococcal urethritis:
o Combination treatment using two antimicrobials with different mechanisms of action is strongly recommended to improve treatment efficacy o It is strongly recommended to start with Ceftriaxone 1 g intramuscularly or intravenously with azithromycin 1 g single oral dose as first-line treatment
XI.11.4 Non-gonococcal urethritis:
o Oral doxycycline 100 mg twice daily for seven days as first-line treatment is strongly recommended.
o It is also recommended, single dose oral azithromycin 500 mg day one and 250 mg day’s two to four.
o Fluoroquinolones, such as ofloxacin or levofloxacin is recommended as second-line treatment only in selected cases when the use of other agents is not possible, such as hypersensitivity to avoid bacterial resistance to quinolones.
o Oral metronidazole or tinidazole 2 g single dose as first-line treatment for urethritis caused by T. vaginalis is strongly recommended.
o It is strongly recommended to instruct Patients to abstain from sexual intercourse for seven days after therapy is initiated, provided their symptoms have resolved and their sexual partners have been adequately treated.

Table XI:15 Suggested regimens for antimicrobial therapy for urethritis

Pathogen

Antimicrobial

Dosage&Duration of therapy

Alternative regimen (24):

Gonococcal Infection Cefriaxone Azithromycin 1g i.m or i.v, SD 1g p.o., SD Cefriaxone 400 mg p.o., SD pluse Azithromycin 19 p.o., SD In case of cephalosporin allergy: Genatamicin 240 mg i.m SD plus Azithromycin 2 g p.o., SD Genatamicin 320 mg p.o., SD plus Azithromycin 2 g p.o., SD Spectinomycin 2g i.m., SD Fosfomycin trometamol 3g p.o., on days 1, 3 and 5 In case of azithromycin allergy in combination with ceftriaxone or cefixime: Doxycycline 100 mg b.i.d. p.o., 7 days
Nongonococcal Infection (non Cefriaxone Azithromycin 100 mg b.i.d, p.o., 7-10 days Azithromycin 500 mg p.o., day1 250 mg p.o., 4 days
Mycoplasma genitalium Azithromycin 500 mg p.o., day1 250 mg p.o., 4 days In case of macrolide resistance: Moxifloxacin 400 mg q.d., 7-14 days
Ureaplasma Urealyticum Doxycycline 100 mg b.i.d, p.o., for 7 days Azithromycin 1.0 - 1.5g p.o..SD
Trichomonas vaginalis Metronidazole Tinidazole 2 g p.o., SD 2 g p.o., SD Metronidazole 500 mg p.o., b.i.d., 7 days
Persistent non-gonococcal urethritis
After firstline doxycycline Azithromycin Plus Metronidazole 500 mg p.o., day1 250 mg p.o., 4 days 400 mg p.o., b.i.d., 5 days If macrolide resistant M. genitalium is detected moxifioxacin should be substituted for azithromycin
After firstline azithromycin Moxifoxacin Plus Metronidazole 400 mg q.d., 7-14 days 400 mg p.o., b.i.d., 5 days


XI.12 Bacterial Prostatitis:



Table XI:16 Classification of prostatitis and CPPS according to NIDDK/NIH

Type (24):

Name and description

I Acute bacterial prostatitis (ABP)
II Chronic bacterial prostatitis (CBP)
III Chronic non-bacterial prostatitis – CPPS
IIIA Inflammatory CPPS (white cells in semen/EPS/VB3)
IIIB Non-Inflammatory CPPS (no white cells in semen/EPS/VB3)
IV Asymptomatic inflammatory prostatitis (histological prostatitis)

CPPS = chronic pelvic pain syndrome; EPS=expressed prostatic secretion;
VB3 = voided bladder urine specimen 3 (urine following prostatic massage)
XI.12.1 Acute Bacterial Prostatitis (ABP):
XI.12.1.1 Recommendation for diagnosis:

o Detailed history taking is strongly recommended as ABP usually presents abruptly with fever and voiding symptoms and distressing poorly localized pain (25). It is often associated with malaise and fever.
o Mid-stream urine analysis, testing for nitrite and leukocytes is strongly recommended.
o Mid-stream urine culture and sensitivity for proper antimicrobial treatment is recommended.
o Prostatic massage is not recommended in acute bacterial prostatitis (ABP) as it can induce bacteremia and sepsis.
o Transrectal ultrasound is recommended if prostatic abscess is highly suggested.
o PSA testing is not recommended for patients with ABP as it has no clinical or practical significance.
XI.12.1.2 Recommendation for management:

o Empirical high doses bactericidal antimicrobials, such as broad spectrum penicillins, a third-generation cephalosporin or fluoroquinolones are strongly recommended. (26)
o It is strongly recommended to continue oral treatment after improvement of general condition for two to four weeks.
o In case of prostatic abscess, both surgical drainage or conservative treatment according to abscess size and general condition is recommended

Table XI:17 Recommendations for the diagnosis and treatment of bacterial prostatitis

Recommendations

Strength Rating

1. Do not perform prostatic massage in acute bacterial prostatitis (ABP). Strong
2. Take a mid-stream urine culture in patients with ABP symptoms to guide diagnosis and tailor antibiotic treatment. Weak
3. Treat acute bacterial prostatitis according to the recommendations for complicated UTI. Strong

XI.12.2 Chronic Bacterial Prostatitis:
Chronic bacterial prostatitis is defined by symptoms (pain or/ and LUTS) that persist for at least three months. (27)
XI.12.2.1 Recommendations for diagnosis:

o Detailed history taking is strongly recommended including the character, site and duration of symptoms, Prostatitis symptom questionnaires have a weak clinical importance.
o Detailed history of sexual activities, marital status and age of marriage is recommended as the delayed marriage and absence of sexual activities due to religious and traditional conditions are important causes of prostatic congestion and chronic prostatitis in Egypt.
o The Meares and Stamey 2- or 4-glass test is strongly recommended in patients with CBP.
o Prostatic biopsy is not recommended to avoid sepsis in case of untreated chronic bacterial prostatitis.
o Transrectal ultrasound is suggested in selected cases to rule out chronic prostatic abscess and prostatic calcification.
o Semen culture is suggested as a part of evaluation of chronic bacterial prostatitis
o PSA testing is not recommended for patients with CBP as it has no clinical or practical significance.
XI.12.2.2 Recommendations for management:
o Fluoroquinolone (e.g. ciprofloxacin, levofloxacin) is strongly recommended as a first-line treatment for CBP. o Tetracycline or macrolides is strongly recommended if intracellular bacteria have been identified as the causative agent of CBP. o Metronidazole is strongly recommended in patients with Trichomonas vaginalis CBP.
Table XI:18 Suggested regimens for antimicrobial therapy for chronic bacterial prostatitis

Antimicrobial (24):

Daily dose

Duration of therapy

Comment
Floroquinolone Optimal oral daily dose 4-6 week
Doxycycline 100 mg b.i.d. 10 days Only for C. trachomatis or mycoplasma infection
Azithromycin 500 mg once daily 3 weeks Only for C. trachomatis infection
Metronidazole 500 mg t.i.d. 14 days Only for T. vaginalis infection
b.i.d = twice daily; t.i.d = three times daily.

XI.13 Acute Infective Epididymitis

XI.13.1 Recommendations for the diagnosis and treatment of acute infective epididymitis

• It is strongly recommended to obtain first voided urine and mid-stream urine for pathogen identification by culture and nucleic acid amplification test.
• It is strongly recommended to initially prescribe a single antibiotic or a combination of two antibiotics active against Chlamydia trachomatis and Enterobacteriaceae in young sexually active men; in older men without sexual risk factors only Enterobacteriaceae have to be considered.
• It is strongly recommended that if gonorrhoeal infection is likely to give single dose ceftriaxone 500 mg intramuscularly in addition to a course of an antibiotic active against Chlamydia trachomatis.
• It is strongly recommended to follow national policies on reporting and tracing/treatment of contacts for sexually transmitted infections.
• Torsion of the spermatic cord (testicular torsion) is the most important differential diagnosis in boys and young men. (28)
• The predominant pathogens isolated are C. trachomatis, Enterobacteriaceae (typically E. coli) and N gonorrhoeae. (28)
• If tuberculous epididymitis is suspected, three sequential early morning urine samples should be cultured for acid-fast bacilli (AFB) and sent for screening by NAAT for M. tuberculosis DNA (28)
XI.13.2 Empiric antibiotic regimens for acute infective epididymitis
XI.13.2.1 For men with acute epididymitis at low risk of gonorrhoea
A single agent or combination of two agents of sufficient dose and duration to eradicate C. trachomatis and Enterobacteriaceae should be used (28). Appropriate options are:
A. fluoroquinolone active against C. trachomatis orally once daily for ten to fourteen days* OR
B. Doxycycline 200 mg initial dose by mouth and then 100 mg twice daily for ten to fourteen days plus an antibiotic active against Enterobacteriaceae for ten to fourteen days
XI.13.2.2 For men with likely gonorrhoeal acute epididymitis
A combination regimen active against Gonococcus and C. trachomatis must be used such as:
Ceftriaxone 500 mg intramuscularly single dose plus Doxycycline 200 mg initial dose by mouth and then 100 mg twice daily for ten to fourteen days
XI.13.2.3 For non-sexually active men with acute epididymitis
A single agent of sufficient dose and duration to eradicate Enterobacteriaceae should be used. Appropriate option is a fluoroquinolone by mouth once daily for ten to fourteen days. Table XI:19 Surgical exploration may be required to drain abscesses or debride tissue

Recommendation

Strength Rating
1.Obtain mid-stream urine and first voided urine for pathogen identification by culture. Strong
2.Initially prescribe a single antibiotic or a combination of two antibiotics active against Chlamydia trachomatis and Enterobacteriaceae in young sexually active men; in older men without sexual risk factors only Enterobacteriaceae have to be considered Strong
3.If gonorrhoeal infection is likely give single dose ceftriaxone 500 mg intramuscularly in addition to a course of an antibiotic active against C. trachomatis. Strong
4. Adjust antibiotic agent when pathogen has been identified and adjust duration according to clinical response. Strong

XI.14 Fournier’s gangrene

Fournier’s gangrene is an aggressive and fulminant infection affecting soft tissue of external genitalia and perineum with high mortality rate 21.6 % (29).
Typically, there is painful swelling of the scrotum or perineum with sepsis (28).
Patient risk factors for occurrence and mortality include immune compromise, most commonly diabetes or malnutrition, recent urethral or perineal surgery, and high body mass index (BMI). (28)
Examination shows small necrotic areas of skin with surrounding erythema and oedema. Crepitus on palpation and a foul-smelling exudate occurs with more advanced disease (28)
XI.14.1 Recommendations for the disease management of Fournier’s Gangrene
• It is strongly recommended to start treatment for Fournier’s gangrene with broadspectrum antibiotics on presentation, with subsequent refinement according to culture and clinical response.
• It is strongly recommended to commence repeated surgical debridement for Fournier’s gangrene within 24 hours of presentation.
• It is suggested to perform primary or secondary wound closure for scrotal defects ≤ 50% with the use of flaps or skin grafts for defects involving > 50% of the scrotum or with extension outside the scrotum.
Table XI:20 Suggested regimens for antimicrobial therapy for Fournier’s Gangrene of mixed microbiological aetiology

Antimicrobial (28)

Daily dose

Piperacillin-tazobactam plus
Vancomycin 		3.37 g every 6-8 h IV
15 mg/kg every 12 h
Imipenem-cilastain 1 g every 6-8 h IV
Meropenem 1 g every 8 h IV
Eryapenem 1 g once daily
Eryapenem 1 g once daily
Cefotaxime plus
Metronidazole
Clindamycin		 2 g every 6 h IV
500 mg every 6 h IV
600-900 mg every 8 h IV


Table XI:20 Suggested regimens for antimicrobial therapy for Fournier’s Gangrene of mixed microbiological aetiology

Recommendations

Strength Rating

1. Start treatment for Fourniers gangrene with broad-spectrum antibiotics on presentation, with subsequent refinement according to culture and clinical response Strong
2. Commence repeated surgical debridement for Fournier’s gangrene within 24 hours of presentation. Strong
XI.14.2 Antibiotic prophylaxis in urologic surgery
XI.14.2.1 Antibiotic prophylaxis
Antibiotic prophylaxis entails the treatment with antimicrobial agent(s) before or shortly after (for limited time) certain surgical procedure to prevent local surgical site infection or systemic postprocedural infection. The 2019 Best Practice statement (BPS) from the American urological association (AUA) education and research recommended perioperative antibiotic for any urological procedures that will break the normal tissue barrier, and antibiotic should be administrated within 60 minutes of the procedure. (30,31)
XI.14.2.2 Ability of the host to respond to bacteruria or bacteremia
Ability of the host to respond to bacteruria or bacteremia is affected by many factors that increased risk of infection as:
Advanced age, and poor nutritional status
Anatomic anomalies and smoking
Chronic corticosteroid use and, immunodeficiency
Chronic indwelling hardware and Infected endogenous/exogenous material
Distant coexistent infection/Prolonged hospitalization (32)
XI.14.2.3 Timing and dose of prophylactic antibiotic:
Infusion of the first dose should begin within 60 minutes of the surgical incision (with the exception of 120 minutes for intravenous fluoroquinolones and vancomycin). As with timing, correct dosing is equally important. Some drugs should be adjusted to the patient’s body weight (or corrected dosing weight) or body mass index. Additional doses are required intraoperatively if the procedure extends beyond two half-lives of the initial dose (30,33,34)
XI.14.2.4 Asymptomatic bacteriuria and prophylactic antibiotic
Generally, asymptomatic bacteriuria is not considered as risk factor indicating antibiotic prophylaxis, in diagnostic and therapeutic procedures not entering the urinary tract. It is a definite risk factor if the procedures entering the urinary tract and breaching the mucosa, especially in endoscopic urologic surgery, so it is recommended to do urine culture before such procedures and preoperative antibiotic is given accordingly. (35)
Antimicrobial prophylaxis in different urologic procedures
1. Urodynamic study and cystography:(Prophylaxis is indicated if risk factors) Antimicrobial prophylaxis is not recommended before cystography and urodynamic study (30,36). Our panel recommend prophylactic antibiotic in case of bacteruria (Fluoroquinolone, or trimethoprim sulfamethoxazole)
2. Urethral Catheterization and removal:(Prophylaxis is indicated if risk factors) Prophylactic antimicrobials are not recommended for patients with risk factors for infection antibiotic prophylaxes with an oral agent such as TMP-SMX should decrease the risk of postprocedural infection (30,37).
3. Shock-Wave Lithotripsy (Prophylaxis is indicated if risk factors) Antimicrobial prophylaxis is not recommended before shock-wave lithotripsy Antimicrobial prophylaxis is recommended if there is recent documented UTI or infected stone is present. (Fluoroquinolone, or trimethoprim sulfamethoxazole) (38,39).
4. TRUS guided prostatic biopsy (Prophylaxis indicated in all patients) Antimicrobial prophylaxis is moderately recommended before TRUS prostatic biopsy, in the form of fluoroquinolone that should be given orally the day of the procedure and two days after (40).
5. Simple Cystoscopy (Without Manipulation) (Prophylaxis is indicated if risk factors) Antimicrobial prophylaxis is not necessary for the majority of either flexible or rigid diagnostic urethracystoscopy with absence of any manipulations and in good surgical sterile condition (35).
6. Transurethral Resection of the Prostate and Bladder (Cystourethroscopy With Manipulation): (Prophylaxis indicated in all patients) Large numbers of RCTs showed that antimicrobial prophylaxis reduce the rate of infectious complications after TURP (41). It is strongly recommended to give either fluoroquinolone or 3rdgeneration cephalosporin before the procedure.
7. Ureteroscopy: (Prophylaxis indicated in all patients) The rate of bacteruria is up to 30 % after ureteroscopt if done without prophylactic antibiotic, with febrile UTI in 4-25% of cases. It is strongly recommended to give fluoroquinolone, trimethoprim sulfamethoxazoleor 3rd generation cephalosporin before ureteroscopy(35)
8. Percutaneous Renal Surgery (Prophylaxis indicated in all patients) Antibiotic prophylaxis in the form of fluoroquinolone, aminoglycosides or 3rd generation cephalosporin is strongly recommended before surgery (42). In a recent randomized Egyptian study, the use of single dose of ciprofloxacin infusion before PNL showed higher efficacy than 3rd generation cephalosporin in protection against postoperative febrile UTI (43).
9. Open or laparoscopic surgery without entering the urinary tract (Prophylaxis indicated in all patients) Antibiotic prophylaxis in the form of first, 2 nd, or 3rd generation cephalosporin is strongly recommended before surgery, especially if there is risk factors (44)
10. Open or laparoscopic surgery entering the urinary tract (Prophylaxis indicated in all patients) It is strongly recommended to give antibiotic prophylaxis in the form of fluoroquinolone, aminoglycosides or 3rd generation cephalosporin before such procedure, as the expected rate of febrile UTI is 5% to 10% without prophylaxis (42).
11. Open or laparoscopic surgery involving implanted prosthesis (Prophylaxis indicated in all patients) It is strongly recommended to give aminoglycosides plus 1st or 2nd generation cephalosporin or vancomycin before penile prosthesis surgery (30)

XI.15 Urinary Schistosomiasis

Schistosomiasis is a chronic parasitic disease affecting about 207 million individuals worldwide. It is still a major health problem in many tropical and subtropical countries, as well as for travelers from developed countries (46).
XI.15.1 Prevalence:
In Egypt, between 1989 and 1996, about 2.5 million schistosomiasis cases were diagnosed and treated, mentioning that the prevalence of schistosomiasis was close to 40% in 1983 at the national level. The Ministry of Health and Population in Egypt has announced the start of a campaign to confirm the final elimination of schistosomiasis by 2020, and the ministry has achieved success in reducing the prevalence of schistosomiasis to about 0.2% by the end of 2016. (47)
XI.15.2 Recommendations for diagnosis
Clinical picture is not specific for the disease, especially in endemic areas like Egypt. o Acute schistosomiasis has either non-specific symptoms or passed silent and so all persons exposed to potentially infested water are considered infected and strongly recommended to start laboratory diagnostic procedure and treatment. (48) o Chronic schistosomiasis: Chronic active stage characterized by increased eggs in the urotheliumand irritative LUTS and hematuria. Urinary tract obstruction due to vesical sclerosis or ureteral stenosis, renal insufficiency, and genital lesions are seen at a later stage of the infection. Urethralgia is also a typical symptom in the late ulcerative stage. (49)
Investigations:
XI.15.2.1 Urine analysis:
It is the gold standard and strongly recommended when infection is suspected. Urine should be collected between 9 AM and 3 PM. Degree of infection is according to the egg count (number of eggs / 10ml of urine)
Light infection < 100,
Moderate infection (100-400)
Sever infection > 400(50)
XI.15.2.2 Serologic tests:
It is strongly recommended when the diagnosis of urinary schistosomiasis is suspected and urine is negative for eggs. (1C)
o FAST-ELISA followed by Western blot analysis. Patients become antibody positive after 4-6 months from infection The assays are more than 90% sensitive and specific, but did not distinguish between active and chronic infection
o PCR for antigen detection: Detection of circulating anodic antigen (CAA) and circulating cathodicschistosome antigens (CCA) in serum and urine are specific foe active infection and quantitative measurements useful for determining infection severity (51)
XI.15.2.3 Radiological investigations:
Ultrasonography on the abdomen and pelvis: is strongly recommended as ascreening tool for upper urinary tract obstruction in all patients diagnosed or suspected to have the diseases (50,52). Intravenous urography or CT urography: is strongly recommended for all patients proved to have positive findings in ultrasound.
o Detect calcifications in the urinary bladder wall and intramural ureteral wall calcifications in plain films
o Ureter stenosis with hydronephrosis
o Filling defects in the bladder and ureters (polyps or tumor)
o Large post voiding residual urine due to bladder neck contracture.
o Combining intravenous urography with fluoroscopy can differentiate between tonic and atonic ureters and identify nonstenotic immobile ureters (50,52)
XI.15.2.4 Voiding cystography:
Recommended when vesico-ureteral reflux is suspected as it occurs in 25% of the affected ureters (50,52).
XI.15.3 Recommendations for treatment:
XI.15.3.1 Medical treatment

o Praziquantel is the recommended oral treatment now
o It is currently recommended by the WHO and has replaced metrifonate and oxamniquine as a main drug of treatment.
o Dose: Two 20-mg/kg oral doses of PZQ are given on the same day, 6 to 8 hours apart (or alternatively, one 40-mg/kg dose)
o The drug has lower effect against schistosomulae than adult worms, so another course should be repeated after several weeks to ensure eradication of infection. (52)
XI.15.3.2 Cystoscopy:
It is highly recommended if LUTS is persisting after adequate medical treatment or radiological findings of bladder lesions.
o Bladder proliferative inflammatory lesions are resected for histopathology.
o Sandy patches are biopsied
o Ulcer are multiple biopsied and coagulated or resected
o Tumor should be resected deeply.
o Bladder neck contracture is incised or resected especially if augmentation cystoplasty is encountered to ensure low pressure augmented bladder (50).
XI.15.3.3 Surgical intervention:
It is recommended according to the long-term sequelae of the disease. XI.15.3.3.1 Stenotic lower end ureter:
o Minimal invasive procedures like endodilatation or incision usually fail unless the lesion is minimal
o Uterteral re-implantation has high failure rate as the lower end of the ureter has to be excised more proximally and the bladder is not healthy for mobilization or Boar flap technique
o Ileal replacement: although it is more complicated technique, it is recommended in such situation with high success rate. (50) XI.15.3.3.2 Contracted bladder:
o Many surgical procedures like, bladder denervation, urinary diversion, ileacystoplasty, or hydrodistension according to the bladder and patient conditions.
o Partial cystectomy indicated for chronic deep bladder ulcer that does not respond to endoscopic surgery. (52)
XI.15.4 Effect of control of schistosomiasis in Egypt on the pattern of cancer bladder:
In a study in the national cancer institute of Egypt between 1970 and 2007, there is reduction in the proportion of patient with cancer bladder from 27.6% to 11.7%, reduction in the percent of presence of schistosomal ova in the pathological specimen from 82.4% to 55.3%, increase in the age of presentation from 47.7 to 60.5, decrease in the male to female ratio from 5.4 to 3.3 and decrease in proportion of squamous carcinoma from 75.9% to 33%. Another study showed that in 2005there is 6-fold increases in the risk of urethalial carcinoma of the bladder versus squamous carcinoma in comparison to 1980 (54)
XI.15.5 Urinary tract infection: Causes, Culture, Susceptibility test and Antibiotic resistance
XI.15.5.1 Urine culture: (technique and interpretations)
XI.15.5.1.1 Specimen collection o It is the responsibility of the laboratory to provide the physician with sterile, wide-mouthed, glass or plastic jars, other suitable receptacles. o The laboratory must insist on a clean-catch midstream urine specimen, particularly in females and children. Since urine itself is a good culture medium, all specimens should be processed by the laboratory within 2 hours of collection, or be kept refrigerated at 4°C until delivery to the laboratory and processed no longer than 18 hours after collection. o Whenever possible, urine specimens for culture should be collected in the morning. It is advisable to ask the patient the night before to refrain from urinating until the specimen is to be collected. o Urine specimens may have to be collected by a surgical procedure, e.g. suprapubic aspiration, cystoscopy, or catheterization. (55)
XI.15.5.2 A female or male outpatient should:

1. Wash her hands thoroughly with soap and water and dry them with a Clean towel.
2. Spread the labia, and cleanse the vulva and labia (or wash the glans) thoroughly using sterile cotton gauze pads and warm soapy water, disinfectants should not be used.
3. Rinse the vulva and labia (or the glans) thoroughly with warm water and dry with a sterile gauze pad. During the entire process the patient should keep the labia separated and should not touch the cleansed area with the fingers.
4. Pass a small amount of urine. The patient should collect most of the remaining urine in a sterile container, closing the lid as soon as the urine has been collected. This is a midstream urine specimen.
5. Hand the closed container to the nursing personnel for prompt delivery to the laboratory.
XI.15.5.3 Culture and interpretation
All urine specimens brought to the microbiology laboratory should be examined at once, or placed in a refrigerator at 4°C until they can be examined. XI.15.5.3.1 The examination procedure includes the following steps: 1. Examination of a Gram-stained smear. 2. A screening test for significant bacteriuria. 3. A definitive culture for urine specimens found to be positive in the screening test, and for all specimens obtained by cystoscopy, suprapubic bladder puncture, or catheterization. 4. Susceptibility tests on clinically significant bacterial isolates. XI.15.5.3.2 Preparation and examination of a Gram-stained smear is a necessary part of the laboratory process: 1. One or more bacterial cells per oil-immersion field usually imply that there are 100,000 or more bacteria per milliliter in the specimen.
2. The presence of one or more leukocytes per oil-immersion field is a further indication of UTI.
3. Non-infected urine samples will usually show few or no bacteria or leukocytes in the entire preparation.
N.B: In specimens from females, the presence of many squamous epithelial cells, with or without a mixture of bacteria, is strong presumptive evidence that the specimen is contaminated with vaginal flora and a repeat specimen is necessary, regardless of the number of bacteria per oil-immersion field. XI.15.5.3.3 Screening method:
1. The absence of leukocytes and bacteria in a Gram-stained smear of a clean- catch urine sample prepared as described above is good evidence that the urine is not infected and does not need to be cultured
2. The strip is dipped into the urine specimen as instructed in the package literature. Any pink color is a positive reaction indicating the presence of leukocyte esterase and/or bacteria in excess of 100,000 per ml.
3. Urine samples that are positive in the screening test should be cultured as soon as possible to prevent possible overgrowth by non-significant bacteria.
4. If the strip does not develop a pink color it is interpreted as a negative screening test, is so reported, and no culture is indicated. N.B: The test strip may not be sensitive enough to detect bacterial counts of less than 100,000 per ml of urine. XI.15.5.3.4 Quantitative culture and presumptive identification by Calibrated loop technique: The recommended procedure uses a calibrated plastic or metal loop to transfer 1µl of urine to the culture medium (MacConkey agar with crystal violet and non-selective blood agar, they can also be replaced by another non-selective medium (e.g. CLED agar). XI.15.5.3.5 Interpretation of quantitative urine culture results For many years, only the presence of at least 100,000 colony-forming units (CFU) per ml in a clean-catch midstream urine specimen was considered clinically relevant for a diagnosis of urinary tract infection. This assumption has been challenged; some experts feel that 10,000 CFU or even fewer may indicate infection. Others believe that the presence of polymorph nuclear leukocytes plays an important role in the pathology and clinical manifestations of UTI. It is not possible to define precisely the minimum number of bacteria per milliliter of urine that is definitely associated with UTI. General recommendations for reporting are given below.
Category 1:(Fewer than 10,000 CFU per ml.) Report as probable absence of UTI. (Exceptions: if fewer than 10,000 CFU per ml are present in urine taken directly from the bladder by suprapubic puncture or cystoscopy, in; symptomatic women, or in the presence of leukocytura, report the identification and the result of the susceptibility test.
Category 2: (10,000 – 100,000 CFU per ml.)
o If the patient is asymptomatic, request a second urine specimen and repeat the count.
o If the patient has symptoms of UTI, precede with both identification and susceptibility tests if one or two different colony types of bacteria are present. Bacterial counts in this range strongly suggest UTI in symptomatic patients, or in the presence of leukocyturia.
o If the count, the quality of the urine specimen, or the significance of the patient’s symptoms is in doubt, a second urine specimen should be obtained for retesting. Report the number of CFU.
Category 3: (More than 100,000 CFU per ml.)
Report the count to the physician and proceed with identification and susceptibility tests if one or two different colony types of bacteria are present. These bacterial counts are strongly suggestive of UTI in all patients, including asymptomatic females.
If more than two species of bacteria are present in urine samples in categories 2 and 3, report as “Probably contaminated; please submit a fresh, clean-catch specimen”. XI.15.5.3.6 Susceptibility tests: Susceptibility tests should only be performed on well-isolated colonies of similar appearance that are considered significant according to the guidelines presented above. The standardized disc-diffusion test (Kirby–Bauer) should be used. Only antimicrobials currently being used by the requesting physicians should be tested. New and expensive antimicrobials should only be tested (or reported) on special request, or when the isolate is resistant to other drugs XI.15.5.3.6.1 General principles of antimicrobial susceptibility Testing Antimicrobial susceptibility tests measure the ability of an antimicrobial agent to inhibit bacterial growth in vitro. This ability may be estimated by either the dilution method or the diffusion method. It is important that both the clinician and the laboratory worker understand the exact definitions and the clinical significance of these categories.
o Susceptible: An organism is called “susceptible” to an antimicrobial when the infection caused by it is likely to respond to treatment with this antimicrobial, at the recommended dosage.
o Intermediate susceptibility: covers two situations. It is applicable to strains that are “moderately susceptible” to an antimicrobial that can be used for treatment at a higher dosage (e.g. b-lactams) because of its low toxicity or because the antimicrobial is concentrated in the focus of infection (e.g. urine).
o The classification also applies to strains that show “intermediate susceptibility” to a more toxic antimicrobial (e.g. aminoglycoside) that cannot be used at a higher dosage. In this situation, the intermediate category serves as a buffer zone between susceptible and resistant.
o Resistant: This term implies that the organism is expected not to respond to a given antimicrobial, irrespective of the dosage and the location of the infection (55)
XI.15.6 Antibiotic resistance
XI.15.6.1 Causes of antibiotic resistance:
Antibiotic overuse leads to antibiotic resistance. Some strains of bacteria are now resistant to all of the most commonly used antibiotics. When UTIs recur or don’t go away with treatment, urine samples are usually tested at a microbiology lab, and if resistant organisms are discovered they are often found to be Extended Spectrum Beta Lactamase ESBL E. coli or (ESBL) and Klebsiella (56) or other non-bacterial causes as infection with Candida which usually occurs in patients with urinary catheters, typically after antibiotic therapy. (57). Also, chlamydia infection is other cause of resistance. (58)
XI.15.6.2 Diagnosis:

1. New and expensive antimicrobials should be tested (or reported) on special request, or when the isolate is resistant to other drugs. (1)
2. Diagnosis of candida infection by Gram stain, Germ tube test and culture on Sabouraud agar.
3. Diagnosis of chlamydia infection by either through culture or identification of the genetic material of the bacteria referred to as nucleic acid amplification tests(NAATs). (58)
XI.15.6.3 Treatment recommendations:

1. Fosfomycin is an oral broad-spectrum antibiotic that acts against many multidrugresistant pathogens in the urinary tract. (59)
2. For ESBL E. coli or ESBL Klebsiella: intravenous drip of carbapenem antibiotic. (56)
3. For candida infection:
o Symptomatic cystitis, treatment is with fluconazole 200 mg orally once a day for 2 weeks (2 doses).
o For pyelonephritis, fluconazole 200 to 400 mg orally once a day ispreferred for 2 weeks (2doses).
o For fungi resistant to fluconazole, amphotericin B is recommended at a dose of 0.3 to 0.6 mg/kg IV once a day for 2 weeks for cystitis and 0.5 to 0.7 mg/kg IV once a day for 2 weeks for pyelonephritis. (57)
4. for chlamydia infection:
o The Centers for Disease Control and Prevention (CDC) recommends azithromycin and doxycycline as first-line drugs for the treatment of chlamydial infection.
o Alternative agents include erythromycin, levofloxacin, and ofloxacin. (58)
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