Urological Infections 2026

AIM AND OBJECTIVES\n\n* This document represents the updated European Association of Urology (EAU) Guidelines for Urological Infections 2026.\n* The guidelines provide practical recommendations for the prevention and treatment of urinary tract infections (UTIs) and male accessory gland infections.\n* Key objectives include infection control and antimicrobial stewardship.\n* Separate EAU guidelines address paediatric urological infections and infections in patients with neurological urinary tract dysfunction.\n* Guidelines are based on the best available evidence but do not replace clinical expertise or individualized patient preferences; they are not legal mandates.\n\n# PANEL COMPOSITION AND METHODS\n\n* The EAU Guidelines Panel on Urological Infections is an international multi-disciplinary group including urologists, an infectious disease specialist, and a clinical microbiologist.\n* For the 2026 update, new evidence was appraised for sections 3.17 (Fungal UTI) and 3.18.2.h (Prostate Biopsy).\n* Section 3.17 search (Unrestricted to July 2025) identified $1,295$ unique records.\n* Section 3.18.2.h search (May 2024 to June 2025) identified $159$ records.\n* Databases searched: Medline, EMBASE, and Cochrane Libraries.\n* Recommendation Strength:\n * Strong: Indicates high evidence quality, favorable benefit-to-harm balance, and consistent patient values.\n * Weak: Indicates lower quality evidence, equivocal benefit-to-harm, or variable patient preferences.\n\n# CLASSIFICATION OF UTI\n\n* The EAU Panel proposes a new classification scheme replacing the terms 'uncomplicated' and 'complicated.'\n* Localised UTI (Cystitis):\n * Symptomatic infection limited to the bladder.\n * Signs include frequency, urgency, dysuria, and suprapubic pain.\n * No signs of systemic infection.\n * Applies to all sexes.\n* Systemic UTI:\n * Infection with signs of systemic involvement (e.g., fever, chills$.\n * Includes pyelonephritis, prostatitis, and urosepsis.\n * May include localized symptoms.\n* Risk Factors for Severe Course or Treatment Failure:\n * Infants, geriatric/frail patients, and immunocompromised state.\n * Functional or anatomical abnormalities (e.g., BPO, stones, obstruction).\n * Neurourological disease and pregnancy.\n * Presence of indwelling catheters, recent instrumentation, or previous antibiotic use.\n * Resistant organisms.\n * Note: Male sex is not considered an independent risk factor according to contemporary literature.\n\n# ANTIMICROBIAL STEWARDSHIP\n\n* Overuse and misuse contribute to resistance; $20-50\%$ of hospital prescribed antibiotics are unnecessary or inappropriate.\n* Stewardship Objectives: Reduce unnecessary use, optimize outcomes, and minimize collateral damage (e.g., Clostridioides difficile).\n* Key Components:\n * Staff training and adherence to guidelines.\n * Ward visits and consultations with specialists.\n * Audit of performance and pathogen resistance profiles.\n* Effectiveness Data:\n * Guideline-driven empirical therapy results in a $35\%$ ($95\%\,CI\,20-46\%$) relative risk reduction (RRR) in mortality.\n * De-escalation (tailoring agents) shows a RRR of $56\%$ ($95\%\,CI\,34-70\%$) in mortality.\n\n# ASYMPTOMATIC BACTERIURIA (ABU) IN ADULTS\n\n* Definition: Bacterial growth of $\ge 10^5\,CFU/mL$ in midstream urine in an asymptomatic individual.\n * Women: Confirmed in two consecutive samples.\n * Men: Confirmed in a single sample.\n* Epidemiology: $1-5\%$ in healthy premenopausal females; increases to $4-19\%$ in elderly; $2-10\%$ in pregnant women; $23-89\%$ in spinal cord injury patients.\n* Diagnostic Evaluation: Digital rectal examination (DRE) in men; exclude stones if urease-producing bacteria (e.g., Proteus mirabilis) are found.\n* Recommendations Against Screening/Treatment (Strong):\n * Healthy women without risk factors.\n * Patients with well-regulated diabetes mellitus.\n * Post-menopausal women and elderly institutionalized patients.\n * Patients with dysfunctional/reconstructed lower urinary tracts (e.g., neobladders).\n * Renal transplant recipients.\n * Prior to arthroplasty surgery (hip/knee).\n * Patients with recurrent UTI (ABU may be protective; treatment increases subsequent symptomatic UTI risk: $RR 0.28, 95\%\,CI\,0.21-0.38$).\n* Recommendations For Screening/Treatment:\n * Pregnant Women (Weak): Screen and treat with standard short-course or single-dose fosfomycin trometamol. Treatment reduces symptomatic UTI ($RR 0.22$) and preterm delivery ($RR 0.34$).\n * Prior to Urological Surgery (Strong): If procedures breach mucosa (endourological surgery). Treatment reduces postoperative fever and septicaemia ($RR 0.20$).\n\n# CYSTITIS IN WOMEN\n\n* Definition: Symptomatic lower UTI limited to the bladder without systemic signs.\n* Diagnosis: Focused history of dysuria, frequency, urgency, and absence of vaginal discharge ($LE 2b$).\n* Laboratory Diagnosis:\n * Use dipsticks for diagnosis ($Weak$).\n * Perform cultures in: suspected systemic UTI, atypical symptoms, failing therapy, recurrence within $4$ weeks, or pregnancy ($Strong$).\n* Non-Antibiotic Management:\n * Nutraceuticals: Xyloglucan, hibiscus, and propolis combination reduces recurrence ($OR 0.13$).\n * Phytotherapeutics: Centaurii herba, Levistici radix, and Rosmarini folium (BNO 1045) shown non-inferior to fosfomycin trometamol ($LE 1b$).\n * NSAIDs: Ibuprofen/Diclofenac reduce antibiotic use by $63\%$, though success rates may be lower than antibiotics.\n* Antimicrobial Therapy (First-line):\n * Fosfomycin trometamol: $3\,g$ single dose.\n * Nitrofurantoin macrocrystal: $100\,mg$ b.i.d for $5$ days.\n * Pivmecillinam: $400\,mg$ t.i.d for $3-5$ days.\n * Note: Avoid aminopenicillins and fluoroquinolones for cystitis due to resistance and side-effect profiles ($Strong$).\n\n# RECURRENT CYSTITIS\n\n* Definition: $\ge 3$ episodes/year or $\ge 2$ in last $6$ months.\n* Risk Factors (Premenopausal): Intercourse, spermicides, new partner, history of childhood UTI.\n* Risk Factors (Postmenopausal): Atrophic vaginitis, incontinence, cystocele, increased post-void residual, history of premenopausal UTI.\n* Management Hierarchy:\n 1. Behavioral Modifications: Increased hydration ($+1.5\,L/day$ reduces episodes in low-drinkers).\n 2. Non-Antimicrobial Prophylaxis:\n * Vaginal oestrogen for postmenopausal women ($Strong$).\n * Immunomodulation (e.g., OM-89, MV140) in the context of trials ($Weak$).\n * D-mannose or Cranberry (proanthocyanidins) ($Weak$).\n * Endovesical instillations (Hyaluronic acid + Chondroitin sulphate) ($Weak$).\n * Methenamine hippurate: $1\,g$ b.i.d ($Strong$).\n 3. Antimicrobial Prophylaxis: Continuous low-dose (e.g., Nitrofurantoin $50\,mg$ or $100\,mg$ q.d) or postcoital prophylaxis ($Strong$).\n\n# PYELONEPHRITIS\n\n* Signs: Fever ($> 38^{\circ}\text{C}$), chills, flank pain, nausea, vomiting, or CVA tenderness.\n* Diagnosis:\n * Urinalysis and mandatory urine culture/susceptibility ($Strong$).\n * Ultrasound (US) to rule out obstruction or stones.\n * CT or MRI if patient stays febrile after $72$ hours of treatment ($Strong$).\n* Management (Outpatient):\n * Ciprofloxacin: $500-750\,mg$ b.i.d ($7$ days).\n * Levofloxacin: $750\,mg$ q.d ($5$ days).\n * Trimethoprim-sulfamethoxazole: $160/800\,mg$ b.i.d ($14$ days) if local resistance $< 20\%$.\n* Management (Inpatient / Systemic UTI):\n * Initial IV therapy: Ciprofloxacin ($400\,mg$ b.i.d), Ceftriaxone ($2\,g$ q.d), Cefotaxime ($2\,g$ t.i.d).\n * Last-line / MDR coverage: Imipenem/Cilastatin ($0.5-1\,g$ q.i.d), Ceftolozane/Tazobactam ($1.5\,g$ t.i.d), Meropenem-Vaborbactam ($2\,g$ t.i.d), Plazomicin ($15\,mg/kg$ o.d).\n * Transition: Switch to oral once clinically improved and results available ($Strong$).\n\n# CATHETER-ASSOCIATED UTI (CA-UTI)\n\n* Definition: UTI in a person catheterized or removed within past $48$ hours.\n* Incidence: $3-8\%$ per day for bacteriuria.\n* Diagnosis: Microbial growth $\ge 10^3\,CFU/mL$ plus systemic signs. Do not use pyuria or foul smell alone for diagnosis.\n* Prevention:\n * Place catheters only when indicated ($Strong$).\n * Use hydrophilic-coated catheters ($Strong$).\n * Limiting duration is critical ($Strong$).\n* Treatment: Obtain culture from freshly placed catheter before antibiotics ($Strong$). \n * Duration: $7$ days for prompt resolution, $14$ days for delayed response.\n\n# URETHRITIS\n\n* Signs: Dysuria, urethral discharge, itching.\n* Diagnosis: Gram stain ($\ge 5\,PMNL/HPF$ indicates urethritis). Mandatory NAAT for N. gonorrhoeae, C. trachomatis, and M. genitalium ($Strong$).\n* Treatment (Suspected Gonococcal): Ceftriaxone ($1-2\,g$ IV/IM single dose) + Doxycycline ($100\,mg$ b.i.d, $7$ days).\n* Treatment (Suspected NGU): Doxycycline ($100\,mg$ b.i.d, $7$ days).\n* Treatment (M. genitalium): Azithromycin ($1\,g$ day $1$, then $500\,mg$ days $2-4$); if macrolide resistant, Moxifloxacin ($400\,mg$ q.d, $7$ days).\n\n# BACTERIAL PROSTATITIS\n\n* Classification:\n * Type I (Acute): Abrupt, voiding symptoms, fever. Avoid prostatic massage ($Strong$).\n * Type II (Chronic): Symptoms $> 3$ months (pain at perineum, inner leg, scrotum).\n* Diagnosis (Chronic): Meares and Stamey $2$- or $4$-glass test ($Strong$).\n* Treatment:\n * ABP: Parenteral bactericidal antibiotics (Cephalosporins, Penicillins, Fluoroquinolones) for $2-4$ weeks.\n * CBP: Fluoroquinolones (Ciprofloxacin, Levofloxacin) for $4-6$ weeks ($Strong$).\n * Use Macrolides/Tetracyclines if intracellular pathogens identified.\n\n# FOURNIER’S GANGRENE\n\n* Definition: Necrotising fasciitis of the perineum/genitalia.\n* Diagnosis: Painful scrotum swelling, necrotic skin, crepitus, foul-smelling exudate. Perform CT/MRI for extent.\n* Management:\n * Immediate broad-spectrum IV antibiotics (e.g., Piperacillin-tazobactam + Vancomycin ($Strong$).\n * Surgical debridement within $24$ hours of presentation ($Strong$).\n * Adjuvant therapy (Hyperbaric oxygen) lacks consistent evidence ($Weak$).\n\n# FUNGAL URINARY TRACT INFECTION\n\n* Epidemiology: Candida albicans ($50-70\%$), C. glabrata, and C. tropicalis. Higher in ICU patients.\n* Risk Factors: Diabetes, SGLT2 inhibitors ($glucosuria$), immunosuppression, catheters.\n* Management:\n * Asymptomatic: Do not treat unless neutropenic, low-birth-weight infant, or before mucosa-breaching surgery.\n * Symptomatic (Cystitis): Fluconazole ($200\,mg/day$ for $2$ weeks). Double loading dose on day $1$.\n * Fluconazole-resistant (e.g., C. krusei, C. glabrata): Amphotericin B deoxycholate (IV or bladder instillations), Flucytosine, or Caspofungin.\n\n# PERIPROCEDURAL ANTIBIOTIC PROPHYLAXIS\n\n* General Principles: Detect bacteriuria via culture prior to intervention. Gentamicin ($eGFR > 20\,mL/min$) or Cephalosporins are common choices.\n* Recommendations (Against Prophylaxis): Urodynamics, Cystoscopy, or ESWL with sterile urine ($Strong$).\n* Recommendations (For Prophylaxis): Ureteroscopy ($Weak$), PCNL (single-dose, $Strong$), TURP ($Strong$).\n* Prostate Biopsy:\n * Approach: Perform biopsy using the transperineal approach ($Strong$); it has lower sepsis risk ($0.1\%$ vs $0.9\%$ for transrectal).\n * Prophylaxis (Transperineal): May be omitted in low-risk patients ($Weak$).\n * Prophylaxis (Transrectal): If transrectal used, use rectal cleansing with povidone-iodine ($Strong$).\n * ** Stewardship**: Do not use fluoroquinolones for biopsy ($Strong$). Use targeted (swab-based) or augmented (two classes) prophylaxis.