Laila Schneidewind

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients. Part II: Therapy and Prevention

Background: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Results are published in 2 parts. Part 1 covers methods, the definition of patient groups, and diagnostics. This second publication focuses on treatment of acute episodes of cystitis and pyelonephritis as well as on prophylaxis of recurrent UTIs. Materials and Methods: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, EMBASE, and the Cochrane Library to identify literature published in 2010–2015. Results: For the treatment of acute uncomplicated cystitis (AUC), fosfomycin-trometamol, nitrofurantoin, nitroxoline, pivmecillinam, and trimethoprim (depending on the local rate of resistance) are all equally recommended. Cotrimoxazole, fluoroquinolones, and cephalosporins are not recommended as antibiotics of first choice, for concern of an unfavorable impact on the microbiome. Mild to moderate uncomplicated pyelonephritis should be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For AUC with mild to moderate symptoms, instead of antibiotics symptomatic treatment alone may be considered depending on patient preference after discussing adverse events and outcomes. Primarily non-antibiotic options are recommended for prophylaxis of recurrent urinary tract infection. Conclusion: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

Urological Complications and BK Virus-Associated Diseases Under Allogenic Stem Cell Transplantation.

Every year 50,000 patients receive a stem cell transplantation worldwide, but there is lack of data pertaining to urological complications. Methods: We performed a retrospective analysis of all adult patients undergoing their first allogenic stem cell transplantation from January 2011 to June 2013 in our institution. Statistical tests performed were Pearsons correlation, chi-square testing and logistic regression using SPSS 22.0. Results: We identified 39 patients (22 males, 17 females). Twenty four patients (61.5%) had a urological complication. Most frequent urologic complications were bacterial urinary tract infection (n = 13; 33.3%), acute renal failure (n = 6; 15.4%) and BK virus-associated haemorrhagic cystitis (n = 5; 12.8%). BK viruria was detected in 12 patients (30.8%). We observed an association of creatinine increase (about 20 µmol/l at time of onset of BK viruria) with BK viruria (Pearsons correlation 0.64; p = 0.01), and BK viruria is significantly linked to acute renal failure (Pearsons correlation 0.35; p = 0.029). In univariate regression, BK viruria is significantly linked to urological complication (p = 0.025). Conclusions: We suggest that BK virus infection during stem cell transplantation can lead to BK virus associated nephropathy, which is so far only known from patients after kidney transplantation.

Mulitcenter [Multicenter] study on antibiotic prophylaxis, infectious complications and risk assessment in TUR-P

Introduction Transurethral resection of the prostate is one of the most frequent urological procedures. Urinary tract infections represent major sequelae, but data about antibiotic prophylaxis in TUR-P are controversial and outdated. Material and methods We conducted a retrospective multicentre study of TUR-P in ten German hospitals. Primary endpoints were epidemiological and outcome data of TUR-P. Secondary endpoints were the identification of factors associated with febrile UTIs and sepsis after TUR-P. Results We included 444 patients with a median age of 71.0 years. Nearly every patient (93.5%) received some kind of antibiotic prophylaxis. Complication rates were 4.9% for febrile UTIs and 2.3% sepsis. Significant risk factors associated with febrile UTIs were pre-existing risk factors for UTIs (p = 0.035) and a duration of catheterization of more than three days (p <0.0001). Significant risk factors for sepsis were duration of surgery of more than 60 minutes (p = 0.030) and again a duration of catheterization of more than three days (p <0.0001). Interestingly, 50.8% of the cases had evidence of chronic prostatitis in their histological specimen. This evidence of chronic prostatitis was significantly associated with febrile UTIs (p = 0.019) and sepsis (p = 0.018). Conclusions Duration of catheterization is one of the major risk factors for infectious complications after TUR-P. Antibiotic prophylaxis in TUR-P needs prospective investigation. These future studies should also address chronic prostatitis a priori.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients: Part 1

Objectives: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Materials and Methods: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, EMBASE, and the Cochrane Library to identify literature published in 2010–2015. Results: We provide 75 recommendations and 68 statements in the updated evidence- and consensus-based national clinical guideline. The diagnostics part covers practical recommendations on cystitis and pyelonephritis for each defined patient group. Clinical examinations, as well as laboratory testing and microbiological pathogen assessment, are addressed. Conclusion: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

Antibiotic Prophylaxis in Prostate Biopsies: Contemporary Practice Patterns in Germany

Purpose Prostate biopsy (pbx) is the most common outpatient procedure in urology. Complications are urinary tract infections, including hospitalization and sepsis. Recommendations on antibiotic prophylaxis (apx) are scarce, and healthcare data are not available. The study addressed the following endpoints: the duration and spectrum of antimicrobial prophylaxis in transrectal and transperineal pbx in the hospital and the practice setting. Methods A questionnaire compiled data about age, gender, board certification, and place of work. Information about the frequency of pbx, duration and type of apx, usage of disinfecting lubricant, and urine or rectal swab cultures was collected. The study refers to German urologists. Results Overall 478 urologists answered the questionnaire. 15.5% (74) of respondents were residents. 50.8% (243) of urologists work in a practice; the rest in a hospital. Only 4.8% do not perform pbx. Transrectal pbx are performed a median of two times a week. The majority (446, 98%) prescribe an apx, mostly fluoroquinolones (407, 89.5%). In total, 10.1% (46) of the participants use a single-shot-apx. apx has a median duration of 4 days. One-third uses a disinfecting lubricant. Urine and rectal swab cultures are analyzed by 45.5% (207) and 24.4% (111), respectively. Conclusion Most urologists prescribe an extended apx for both transrectal and transperineal pbx. Perineal pbx is still a deviation from everyday practice and not an established alternative to transrectal pbx. Urologists are aware of the increasing fluoroquinolone-resistance and are adapting with rectal swab and urine cultures. Further studies need to evaluate alternatives to 5-day apx and results should be addressed in our guidelines. This is of importance in light of the increasing resistance rates and fluoroquinolone side effects.

Are the Polyomaviruses BK and JC Associated with Opportunistic Infections, Graft-versus-Host Disease, or Worse Outcomes in Adult Patients Receiving Their First Allogeneic Stem Cell Transplantation with Low-Dose Alemtuzumab?

Background: The association of polyomaviruses BK and JC with other opportunistic infections and graft-versus-host disease (GvHD) in allogeneic stem cell transplantation is controversially discussed. Methods: We conducted a retrospective study of 64 adult patients who received their first allogeneic stem cell transplantation between March 2010 and December 2014; the follow-up time was 2 years. Results: Acute leukemia was the most frequent underlying disease (45.3%), and conditioning included myeloablative (67.2%) and nonmyeloablative protocols (32.8%). All patients received 10 mg of alemtuzumab on day -2 (20 mg in case of mismatch) as GvHD prophylaxis. Twenty-seven patients (41.5%) developed cytomegalovirus (CMV) reactivation. BKPyV-associated hemorrhagic cystitis was diagnosed in 10 patients (15.6%). Other opportunistic infections caused by viruses or protozoa occurred rarely (<10%). There was no association of BKPyV or JCPyV with CMV reactivation, Epstein-Barr virus reactivation, human herpes virus 6, or parvovirus B19 infection requiring treatment. There was a significant correlation of BKPyV-associated hemorrhagic cystitis with toxoplasmosis (p = 0.013). Additionally, there was a significant link of simultaneous BKPyV and JCPyV viruria with toxoplasmosis (p = 0.047). BKPyV and JCPyV were not associated with GvHD, relapse, or death. Conclusion: We found no association of BKPyV or JCPyV with viral infections or GvHD. Only the correlation of both polyomaviruses with toxoplasmosis was significant. This is a novel and interesting finding.

Significance of Hyperbaric Oxygenation in the Treatment of Fournier's Gangrene: A Comparative Study.

Introduction: Hyperbaric oxygenation (HBO), in addition to anti-infective and surgical therapy, seems to be a key treatment point for Fournier’s gangrene. The aim of this study was to investigate the influence of HBO therapy on the outcome and prognosis of Fournier’s gangrene. Patients and Methods: In the present multicenter, retrospective observational study, we evaluated the data of approximately 62 patients diagnosed with Fournier’s gangrene between 2007 and 2017. For comparison, 2 groups were distinguished: patients without HBO therapy (group A, n = 45) and patients with HBO therapy (group B, n = 17). The analysis included sex, age, comorbidities, clinical symptoms, laboratory and microbiological data, debridement frequency, wound dressing, antibiotic use, outcome and prognosis. The statistical analysis was performed with GraphPad Prism 7® (GraphPad Software, Inc., La Jolla, USA). Results: Demographic data showed no significant differences. The laboratory parameters C-reactive protein and urea were significantly higher in group B (group B: 301.7 vs. 140.6 mg/dL; group A: 124.8 vs. 54.7 mg/dL). Sepsis criteria were fulfilled in 77.8 and 100% of the patients in groups A and B respectively. Treatment in the intensive care unit (ICU) was therefore indicated in 69% of the patients in group A and 100% of the patients in group B. The mean ICU stay was 9 and 32 days for patients in groups A and B respectively. The wound debridement frequency and hospitalization stay were significantly greater in group B (13 vs. 5 debridement and 40 vs. 22 days). Initial antibiosis was test validated in 80% of the patients in group A and 76.5% of the patients in group B. Mortality was 0% in group B and 4.4% in the group A. Conclusion: The positive influence of HBO on the treatment of Fournier’s gangrene can be estimated only from the available data. Despite poorer baseline findings with comparable risk factors, mortality was 0% in the HBO group. The analysis of a larger patient cohort is desirable to increase the significance of the results.

Comparison of intravenous or intravesical cidofovir in the treatment of BK polyomavirus-associated hemorrhagic cystitis following adult allogeneic stem cell transplantation-A systematic review

BK polyomavirus can lead to hemorrhagic cystitis (BKPyV‐HC) in allogeneic stem cell transplantation and therefore to increased morbidity. No causal therapy has been established yet. Cidofovir (CDV) is a nucleotide analog of cytosine that is active against various DNA viruses and it has been described for therapy of BKPyV‐HC using 2 admission routes: intravenous and intravesical.

No indication of increased infection rates using low-dose alemtuzumab instead of anti-thymocyte globulin as graft-versus-host disease prophylaxis before allogeneic stem cell transplantation

Alemtuzumab as part of the conditioning protocol is effective in reducing graft‐versus‐host disease (GvHD), but may be associated with increased infection rates, especially when using high doses (ie, 100 mg).

Current Evidence on Nonantibiotic Prevention of Recurrent Urinary Tract Infections

Clinicians should be aware of the limited evidence on nonantibiotic prophylactic treatment for recurrent urinary tract infections. Owing to the rising antibiotic resistance rates worldwide, nonantibiotic prevention strategies should be considered for patient care. Further research is necessary to evaluate nonantibiotic treatment strategies using a robust randomised controlled trial methodology to contribute to a strong evidence basis.