MINERVA UROL NEFROL 2004;56:15-31
Current concepts in urinary tract infections
Urinary tract infections (UTIs) are common in-
fectious diseases that can be associated with
substantial morbidity and significant expen-
ditures. This review highlights the current con-
cepts and recent advances in our understand-
ing and management of this condition. Specific
topics include pathogenesis, host factors, an-
timicrobial resistance, recurrent UTIs in
women, diagnosis, treatment of uncomplicat-
ed and complicated UTIs, prophylaxis, catheter
associated bacteriuria, pregnancy, diabetes,
UTIs in men, prostatitis, and the chronic pelvic
pain syndrome. UTIs can be viewed as an in-
teraction between specific bacterial virulence
factors and the patient. A new model explain-
ing the pathogenesis of recurrent UTIs has been
presented. There is a need to reconsider tradi-
tional treatment recommendations in the face
of local resistance patterns, as well as the need
to make better use of drugs that are currently
available. Prospects for prevention of recur-
rent UTI include natural compounds, bacterial
interference and immunization. With regard
to UTI risk in women, patients can be classi-
fied based on age, and functional and hormonal
status. Appropriate treatment approaches must
be based on this classification. In contrast to un-
complicated UTIs, management of most com-
plicated infections depends on clinical expe-
rience and resources at individual institutions
rather than on evidence based guidelines.
Asymptomatic bacteriuria generally should not
All funding departmental (internal)
Address reprint requests to: A. J. Schaeffer, MD, Department
of Urology; Northwestern University, Feinberg School of
Medicine, Tarry Building, 16th Floor, 303 East Chicago Avenue,
Chicago, IL 60611, USA. E-mail: ajschaeffer@northwestern.edu
Vol. 56, N. 1 MINERVA UROLOGICA E NEFROLOGICA
D. H. WILLIAMS, A. J. SCHAEFFER
Department of Urology
Northwestern University
Feinberg School of Medicine, Chicago, IL, USA
be treated except in high-risk catheterized pa-
tients and in pregnancy. UTIs in men general-
ly require formal urologic evaluation. Our un-
derstanding of the etiologies, diagnostic strate-
gies, and treatment options for prostatitis and
the chronic pelvic pain syndrome in men con-
tinues to evolve.
Key words: Urinary tract infections, diagnosis -
Bacteriuria - Pyelonephritis - Prostatitis - Drug
resistance, microbial - Virulence - Pregnancy -
Diabetes mellitus.
U rinary tract infections (UTIs) are one of
the most common infectious diseases in
the USA. Annually, they account for approx-
imately 7 million office visits, more than 1
million hospitalizations, and result in $1.6
billion in medical expenditures.1-3 Uropatho-
genic strains of Escherichia coli (E. coli) ac-
count for the majority of UTIs that occur in
the community.4 Acute UTIs are associated
with substantial morbidity, and this is made
worse by the likelihood of recurrent infec-
tions. An estimated 40% of women report
having had a UTI at some point in their lives,
and up 1/4 of women who have a first UTI
will have a second infection within 6 months.5
Sexually active young women are dispro-
15
WILLIAMS
portionately affected, but several other pop-
ulations are also at risk, including elderly
persons and those undergoing genitourinary
instrumentation or catheterization. By the
time men reach their eighth decade, at least
1/3 will have had an episode of bacteriuria
and 1/4 will have been diagnosed with one
of the prostatitis or chronic pelvic pain syn-
dromes (CPPS).6, 7 From a scientific stand-
point, UTIs can be viewed as interactions be-
tween the pathogen and the host, and recent
studies offer new ideas and exciting insight
into this process. We review the literature
that has added to the body of knowledge
concerning the pathogenesis, diagnosis, and
management of UTIs. Our review focuses
primarily on UTIs in the adult population.
Pathogenesis
Adherence of microbial pathogens to ep-
ithelial surfaces is considered the first step
in the pathogenesis of a UTI.8 This process is
mediated by bacterial structures called ad-
hesins, specifically via the adhesin FimH at
the tips of bacterially expressed type 1 pili
which are filamentous appendages projecting
from the bacterial cells.9-13 They are classi-
fied as either mannose-sensitive or mannose-
resistant. Mannose-sensitive adhesins are the
common type 1 pili that bind to mannose
residues on the host cell surface. In contrast,
the binding of mannose-resistant adhesins is
not inhibited in the presence of mannose.
The Gal-Gal subgroup of mannose-resistant
adhesins binds to the receptor for the P blood
group and is encoded by the pyelonephritis-
associated pili operon. The binding site ap-
pears to be -galactose-(1-4), a digalactoside
in neutral glycophospholipids found on ep-
ithelial cells and red blood cells. The other
subgroup of mannose resistant adhesins is
heterogeneous and called X adhesins.14
Initial colonization events activate inflam-
matory and apoptotic cascades in the epithe-
lium, which is normally inert and only turns
over every 6 to 12 months.15 Bladder epithe-
lial cells respond to invading bacteria in part
by recognizing bacterial lipopolysaccharide
via the Toll-like receptor 4-CD14 pathway,
16 MINERVA UROLOGICA E NEFROLOGICA
CURRENT CONCEPTS IN URINARY TRACT INFECTIONS
which results in strong neutrophil influx into
the bladder.16 In addition, FimH-mediated in-
teractions with the bladder epithelium stimu-
late exfoliation of superficial epithelial cells,
causing many of the pathogens to be shed
into the urine. Genetic programs are activat-
ed that lead to differentiation and proliferation
of the underlying transitional cells in an effort
to renew the exfoliated superficial epitheli-
um.17 Despite the robust inflammatory re-
sponse and epithelial exfoliation, bacteria of-
ten are able to maintain high titers in the blad-
der for several days.18-22
A bacterial mechanism of FimH-mediated
invasion into the superficial cells apparently
allows evasion of these innate defenses.23
Subsequent replication as disorganized bac-
terial clusters inside superficial cells leads to
high bacterial titers in the bladder. Bacteria in
these intracellular niches create a chronic
quiescent reservoir in the bladder which can
persist undetected for several months without
bacteria shedding in the urine. These bacte-
ria are completely resistant to 3 and 10 day
courses of antibiotics.23, 24 Thus, in addition to
the intestine and vagina as reservoirs for uri-
nary pathogens, the bladder itself may serve
as the source for recurrent cystitis and asymp-
tomatic bacteriuria seen in a large propor-
tion of women with UTIs.5, 23, 24 These find-
ings underscore the effect of genetic vari-
ability present in different host populations
and the importance of strategies for pathogen
persistence despite differing host defenses.25
Described by Johnson et al., the clonal hy-
pothesis offers an explanation for bacterial
virulence and states that uropathogenic E.
coli belong to a small group of genetically
related groups, or clones.11 Strains from pa-
tients with pyelonephritis or sepsis and an
anatomically normal urinary tract possess
multiple virulence factors. Strains isolated
from women with cystitis tend to have single
factors, while fecal E. coli are much less like-
ly to have virulence associated characteristics.
The clonal concept is currently understood in
terms of the E. coli genetic structure. E. coli
virulence factors tend to be organized on
large blocks of bacterial DNA called patho-
genicity islands.26-28 These islands can be lo-
cated at multiple sites within the bacterial
Marzo 2004
CURRENT CONCEPTS IN URINARY TRACT INFECTIONS
cell, such as the plasmids, bacteriophages or
bacterial chromosomes. The location of path-
ogenicity islands within the bacterial cell is
much less important than the fact that these
large blocks of DNA facilitate simultaneous
dissemination of multiple virulence factors
between distinct E. coli strains.
A recent report by Anderson et al. offers an
exciting new insight into the pathogenesis
of UTIs.25 They reported that the intracellular
bacteria matured into biofilms, creating pod-
like bulges on the bladder surface.29, 30 These
pods contain bacteria encased in a polysac-
charide-rich matrix surrounded by a protec-
tive shell of uroplakin.25 Within the biofilm,
bacterial structures interact extensively with
the surrounding matrix. During infection, the
biofilm milieu renders bacteria resistant to
antibiotics and host defenses, making the in-
fection difficult to treat and leading to recur-
rent symptoms.29 The discovery of intracel-
lular biofilm-like pods explains how bladder
infections can persist in the face of robust
host defenses and establishes a new para-
digm in our understanding of acute and re-
current UTIs.25
Host factors
Host factors may be genetic or environ-
mental ones susceptible to modification. A
critical clinical issue is to find characteristics
that increase the risk of acquiring a UTI or the
chance for a poor treatment outcome. These
characteristics include anatomical, function-
al and behavioral factors that increase the
risk of complicated infection.
Vaginal colonization with uropathogens
precedes most UTIs in women.31 Receptivity
of the vaginal mucosa for uropathogens is
an essential initial step in vaginal mucosa
colonization. Vaginal and buccal epithelial
cells in patients susceptible to UTI adhere
avidly to uropathogens.32, 33 These genotyp-
ic traits for epithelial cell receptivity may be
a major susceptibility factor in UTIs, as evi-
denced by mothers and daughters frequent-
ly having similar UTI susceptibility patterns.33
The presence or absence of blood group
determinants on the surface of uroepithelial
Vol. 56, N. 1 MINERVA UROLOGICA E NEFROLOGICA
WILLIAMS
cells also may influence susceptibility to
UTIs.34 The protective effect in women with
the secretor phenotype may be due to fuco-
sylated structures at the cell surface which
decrease the availability of putative recep-
tors for E. coli.35 Susceptibility among women
who do not secrete blood group antigens
may be due to specific E. coli-binding gly-
colipids that are absent in women who se-
crete blood group antigens. Additional stud-
ies have provided information about the
chemistry and genetics of the adherence
process.36, 37 The globoseries glycosphin-
golipid sialosyl galactosyl globoside appears
to be important in this process. Women with
recurrent UTIs are more likely to be nonse-
cretors of blood group antigens than are those
who do not have UTIs. The vaginal epithelial
cells of nonsecretors show enhanced binding
of pathogenic E. coli because they selective-
ly express sialosyl galactosylgloboside.
Sialosyl galactosylgloboside is the preferred
binding site for E. coli pyelonephritis-associ-
ated pili-encoded adhesins. Recent studies
have shown that vaginal fluid, which forms
an interface between uropathogens and ep-
ithelial cells, also influences vaginal colo-
nization.38-42
UTIs increase in frequency with age and
postmenopausal status, and similar patterns
are seen in vaginal colonization.31 Genetic
factors and hormonal status are known to
influence susceptibility to UTIs.43 Differences
in perineal anatomy between women with
recurrent infections and controls have been
reported.44 It is well established that recent
sexual intercourse is a risk factor for UTIs in
women.45-48 Vaginal fluid, S-IgA, and external
agents such as spermicides have recently
been shown to alter vaginal mucosa recep-
tivity and host susceptibility to UTIs.48-52 These
findings are consistent with a growing body
of literature suggesting that the normal vagi-
nal ecosystem is an important host defense
against UTIs.
Antimicrobial resistance
Antibiotics are naturally occurring sub-
stances that possess activity against patho-
17
WILLIAMS
gens. An example of a commonly used an-
tibiotic is penicillin. The term antimicrobial
refers to any substance man-made or natu-
rally occurring that acts against a pathogen.
Fluoroquinolones are examples of antimicro-
bials as they are man-made compounds.
For UTIs in healthy outpatients, the long-
standing treatment of choice has been
trimethoprim-sulfamethoxazole (TMP-SMX).53
Fluoroquinolone antimicrobials traditionally
have been reserved for oral or parenteral
management of severe or complicated UTIs or
pyelonephritis. However, a growing rate of
resistance among common urinary tract
pathogens in certain geographical areas has
had important clinical ramifications.54-57 The
recent clinical guidelines for the management
of UTI developed by the Infectious Diseases
Society of America integrate these changes
and now recommend fluoroquinolones as
first-line therapy for uncomplicated UTI in
circumstances where resistance is likely to be
an issue.53 These variations support the need
for physicians to be familiar with resistance
patterns in their own area.58
Fluoroquinolone antimicrobials have been
available since the introduction of norfloxacin
in 1984, and in general are highly effective
against most uropathogens with low rates of
resistance. Most utilize once-daily dosing
which enhances patient adherence, and 2
agents (levofloxacin and gatifloxacin) have
same-dose bioequivalency between intra-
venous and oral formulations, enabling switch
or step-down therapy from parenteral to oral
formulations of the same agent at the same
dose.59 In addition to indications for the man-
agement of complicated and severe UTI, their
broad spectrum of coverage, low rates of re-
sistance, and good safety profile make fluo-
roquinolones a first-line treatment for acute
uncomplicated UTI diagnosed in patients
who cannot tolerate TMP or SMX, who live in
geographic areas with known significant re-
sistance to TMP-SMX, who have risk factors
for TMP-SMX resistance, or for patients di-
agnosed with a complicated UTI.59 Neverthe-
less, there is concern over the potential emer-
gence of fluoroquinolone-resistant uropatho-
gens, particularly in Europe where these
agents are more commonly used.59
18 MINERVA UROLOGICA E NEFROLOGICA
CURRENT CONCEPTS IN URINARY TRACT INFECTIONS
Resistance has also increased dramatically
in gram-positive bacteria. Vancomycin-resis-
tant enterococci are among the best known
antibiotic resistant bacteria and are common
in patients who have received multiple cours-
es of antibiotics and those who have been
hospitalized for prolonged periods.60, 61 These
organisms are often resistant to ampicillin.
Furthermore, strains resistant to gentamicin
and streptomycin are also often resistant to
fluoroquinolones, rifampin and the tetracy-
clines. This high rate of resistance has been
associated with the use of antibiotics in ani-
mal feed. Clinically vancomycin-resistant en-
terococci are important because there is no
optimal therapy and no reliable bacteriocidal
regimen.62
Currently, there are few prospects for new
antimicrobial agents. The oxazolidinones are
the first new antimicrobial class for treatment
of gram-positive bacteria in 30 years.63, 64
However, there appear to be limited pros-
pects on the horizon for major new antimi-
crobial classes for UTIs. New approaches to
older treatments are being implemented. For
example, gentamicin has been on the market
since the 1960s and now is often adminis-
tered by a single large dose administered
once a day.65, 66
Consideration of fluoroquinolones and
more frequent use of nitrofurantoin for initial
therapy in healthy outpatients should be en-
couraged. The increasing probability of re-
sistance (including quinolone resistance in
some parts of the world) supports the need
for continued monitoring of urinary tract iso-
lates with quantitative cultures and suscepti-
bility testing, especially for patients with re-
current or complicated infections.65, 67-69
Recurrent UTI risk in women
Up to 20% of young women with acute cys-
titis develop recurrent UTIs. During these re-
current episodes, the causative organism
should be identified by urine culture and then
documented to help differentiate between re-
lapse and recurrence. Fortunately, most re-
current UTIs in young women are uncompli-
cated reinfections in normal urinary tracts.
Marzo 2004
CURRENT CONCEPTS IN URINARY TRACT INFECTIONS
These infections generally are not associated
with underlying anatomic abnormalities and
typically do not require further work-up.4
However, some infections are, in fact, com-
plicated UTIs and require longer courses of an-
tibiotics and further diagnostic tests. It is a
challenge to the clinician and one of the arts
of medicine to identify these at-risk patients.
Women who have more than 3 UTI recur-
rences documented by urine culture within 1
year can be managed using 1 of 3 preventive
strategies: acute self-treatment with a 3-day
course of standard therapy; postcoital pro-
phylaxis; and continuous daily prophylaxis.70
Each of these regimens has been shown to
decrease the morbidity of recurrent UTIs with-
out a concomitant increase in antibiotic resis-
tance. Long-term studies have shown antibiotic
prophylaxis to be effective for up to 5 years
with TMP, TMP-SMX, or nitrofurantoin, without
the emergence of drug resistance. Unfortu-
nately, antibiotic prophylaxis does not appear
to alter the natural history of recurrences be-
cause 40% to 60% of these women reestablish
their pattern or frequency of infections within
6 months of stopping prophylaxis.70, 71
Insight into the pathogenesis of recurrent
UTIs can be gained from the observation of
bacteria being identified in the bladder tissue
of women with documented recurrent UTIs
in the absence of bacteriuria.72 The concept
of bacteria surviving in the bladder mucosa in
the setting of sterile urine has been shown in
a human population. These findings may also
be relevant in the significant number of cases
where women present with symptomatic UTI,
but have no culturable bacteria in their urine.71
In order to develop new and better therapies
for recurrent UTIs, the pathogenesis of these
infections needs to be more completely de-
fined. The traditional thought that all recur-
rences are a consequence of bacteria migrat-
ing from the gastro-intestinal tract, has been
challenged, as several recent findings suggest
that a more complex situation exists.73, 74
Diagnosis
The diagnosis of UTI was once based on
a quantitative urine culture yielding greater
Vol. 56, N. 1 MINERVA UROLOGICA E NEFROLOGICA
WILLIAMS
than 100 000 colony-forming units (CFU)
of bacteria per milliliter of urine. This val-
ue was chosen because of its high speci-
ficity for the diagnosis of true infection,
even in asymptomatic persons. Studies how-
ever have established that 1/3 or more of
symptomatic women have CFU counts be-
low this level and that a bacterial count of
100 CFU per mL of urine has a high positive
predictive value for cystitis in symptomatic
women.75
In view of the limited spectrum of
causative organisms and their predictable
susceptibility, urine cultures and suscepti-
bility testing often add little to the choice
of antimicrobial for the treatment of acute
uncomplicated cystitis in young women.
Therefore, urine cultures are no longer ad-
vocated as part of the routine work-up of
these patients. Instead, these patients should
undergo an abbreviated laboratory work-
up in which the presence of pyuria is con-
firmed by traditional urinalysis (wet mount
examination of spun urine), the cell-count-
ing chamber technique or a dipstick test for
leukocyte esterase.76
A positive leukocyte esterase test has a
reported sensitivity of 75% to 90% in de-
tecting pyuria associated with a UTI.3 Gram
staining of unspun urine can be used to de-
tect bacteriuria but often is not routinely
performed unless specifically requested be-
cause it is time-consuming and has low sen-
sitivity.3 The dipstick test for nitrite can be
used as a surrogate marker for bacteriuria. It
is important to note that not all uro-
pathogens reduce nitrates to nitrite. Ente-
rococci, S. saprophyticus and Acineto-bacter
species do not and therefore can give false-
negative results.
Categorization of UTIs helps divide pa-
tients into groups based on clinical factors
and their impact on morbidity and treat-
ment. Suggested categories include acute
uncomplicated cystitis in young women,
recurrent cystitis in young women, acute
uncomplicated pyelonephritis in young
women, complicated UTI and its subcate-
gories, UTI related to indwelling catheters,
UTI in men, and asymptomatic bacteri-
uria.76
19
WILLIAMS
Treatment of uncomplicated UTI
For cystitis, the current treatment trends
include empirical, short course, and patient-
initiated therapy. These infections occur main-
ly in healthy women with structurally nor-
mal urinary tracts and intact voiding, but may
occur in male infants and occasionally in ado-
lescent and adult males. Risk factors in these
populations include lack of circumcision in
infants, and anal intercourse in adults.
Empirical therapy consists of treating the
patient without obtaining a urine culture or
sensitivity testing, and sometimes even with-
out performing urinalysis. The rationale is
that in healthy outpatients, urine culture,
sensitivity testing, and susceptibility are pre-
dictable. Furthermore, cultures can be in-
sensitive and expensive. Empirical therapy
appears to be safe as well as cost-effective
in the community for isolated, seemingly
uncomplicated UTIs. It must be noted that
while some patients do have recurrent, un-
complicated UTIs, many others have con-
ditions such as vaginitis, interstitial cystitis,
urethritis, anatomical problems, and carci-
noma in situ that merit dramatically differ-
ent approaches to diagnosis and treatment.
Thus, it is advocated to perform a urine cul-
ture on patients with comorbidities or re-
current symptoms of UTI.77-80
Short course therapy, defined as 3 days or
less of oral therapy, is recommended. This
approach is based on the observation that
few existing data support the traditional 14
to 28-day treatment courses that have been
recommended even for patients with com-
plicated UTIs.4, 81-83 Treatment of cystitis with
7 or more days of antibiotics once was the
standard of therapy. Although this regimen
was highly efficacious, it was associated
with a certain, albeit low, frequency of side
effects. A number of studies support 3 days
as being more efficacious than single dose
therapy, and such therapy has less antimi-
crobial effect on the vaginal flora, ensuring
lower reinfection rates from the vaginal
reservoir.53, 84-87
Patient-initiated or self-start therapy is an
option for women with a history of recur-
rent infections. The strategy is to give the pa-
tient a self-culture device and a prescription
20 MINERVA UROLOGICA E NEFROLOGICA
CURRENT CONCEPTS IN URINARY TRACT INFECTIONS
for medication that can be utilized at the on-
set of symptoms.88 Self-start therapy appears
to be safe and effective, and recently has
gained widespread acceptance.89
Uncomplicated pyelonephritis
Current trends in the treatment of acute
uncomplicated pyelonephritis include out-
patient oral therapy and switch therapy, with
minimal anatomical evaluation. Some imag-
ing or knowledge of the urinary tract is war-
ranted given the potential life-threatening
risk of misdiagnosing a complicated pyelo-
nephritis.
For patients with mild infections, a negative
renal ultrasound, and no complicating fac-
tors, a 14 day regimen of oral quinolones has
proved effective.4, 53, 83, 90 For patients with
moderate or severe infections the tendency is
to use switch therapy whereby the patient is
stabilized in the emergency department and
treated with parenteral antibiotics with a rapid
transition to oral administration before be-
ing discharged home.4, 66 Initial therapy uses
a third generation cephalosporin, an amino-
glycoside such as a single daily dose of gen-
tamicin, or a parenteral fluoroquinolone. This
therapy is followed by an oral fluoro-
quinolone regimen after discharge from the
hospital. Some studies have demonstrated
that patients with uncomplicated acute
pyelonephritis respond well to a single large
dose of gentamicin followed by even short-
er courses of therapy such as 5 days of an oral
quinolone.91, 92
While quantitative urine culture and sen-
sitivity testing are useful for patient manage-
ment, blood cultures are not especially help-
ful because individuals with uncomplicated
pyelonephritis tend to respond equally well
whether they have a positive or negative
blood culture. Clinical improvement should
occur within 24 to 48 hours after com-
mencement of treatment. If the patient has
not responded within this period, the initial
choice of therapy should be reevaluated in
light of culture results, and appropriate imag-
ing studies should be ordered to evaluate the
possibility of an abscess or other complicat-
ing factor.
Marzo 2004
CURRENT CONCEPTS IN URINARY TRACT INFECTIONS
Treatment of complicated UTI
A complicated UTI is one that occurs be-
cause of anatomic, functional or pharmaco-
logic factors that predispose the patient to
persistent infection, recurrent infection, or
treatment failure. These factors include past
medical history, failure to respond to prior
therapy, history of UTI as a child, and con-
ditions often encountered in elderly men
such as enlargement of the prostate gland,
blockages and other problems necessitating
the placement of indwelling urinary devices,
and the presence of bacteria that are resistant
to multiple antibiotics.76
Clinically, the spectrum of complicated
UTIs may range from cystitis to urosepsis
with shock. These infections often pose a di-
agnostic and treatment challenge, and
anatomical evaluation is critical. Effective
management depends more on clinical ex-
perience and resources at individual institu-
tions than on evidence based guidelines.
Accurate urine culture and susceptibility in-
formation are necessary to best target and erad-
icate the pathogens in complicated UTIs. These
infections are usually associated with high-
count bacteriuria (greater than 100 000 CFU
per mL of urine). Occasionally, lower quanti-
tative counts may be encountered in patients
who are undergoing diuresis or who are in re-
nal failure. The initial empiric therapy for these
patients should include an agent with a broad
spectrum of activity against the expected
uropathogens, such as an oral fluoroquinolone
or a parenteral agent with antipseudomonal
activity. Enterococci also are frequently en-
countered uropathogens in complicated UTIs.81
Patients with complicated UTIs require at
least 10 to 14 days of antimicrobial therapy.
Patients initially placed on parenteral thera-
py generally can be switched to oral therapy
when they are clinically improving and able
to tolerate the oral agent.4 Follow-up urine
cultures should be performed 10 to 14 days
after treatment to ensure that the uropathogen
has been eradicated.
Renal abscess and emphysematous
pyelonephritis
Classic management of renal abscesses in-
cludes surgical exploration, incision and
Vol. 56, N. 1 MINERVA UROLOGICA E NEFROLOGICA
WILLIAMS
drainage, and nephrectomy. However, re-
cent reports have established more conserv-
ative therapies of percutaneous drainage and
parenteral antimicrobials as safe alternatives
to surgery in select patients. Siegel et al. re-
viewed their experience with 52 patients with
renal abscesses and concluded that in their se-
ries percutaneous drainage was as effective as
open surgery for large and medium renal ab-
scesses in properly selected patients.93
Percutaneous drainage has minimal morbid-
ity and is nephron-sparing, yet it does not
preclude open surgical intervention and may
serve to convert an emergency surgery to a
well-planned urgent or elective procedure.
It also permits cytological evaluation of the as-
pirate, which may identify an obscured ma-
lignancy.
Emphysematous pyelonephritis is a life-
threatening infection characterized by necro-
sis and gas within the renal parenchyma. It
occurs mostly in diabetic patients and re-
quires early, aggressive therapy. Traditional
management is nephrectomy or open surgi-
cal drainage with the use of appropriate
antmicrobials. Recent series have reported
the use of percutaneous drainage in this con-
dition.94 Chen et al. reported their 10-year
experience with 25 patients treated with CT-
guided percutaneous drainage.95 Twenty pa-
tients required no further intervention, 3 im-
proved and subsequently underwent elec-
tive nephrectomy, and 2 died of multiple or-
gan failure. They concluded that, in a similar
fashion to renal abscesses, conservative treat-
ment of emphysematous pyelonephritis is an
acceptable therapy to surgical intervention
in select patients.
Prophylaxis
The use of natural compounds, bacterial
interference, and immunization are current
topics being investigated for UTI prophy-
laxis.
Cranberry juice is a natural compound un-
der investigation. The theory is that cranber-
ry juice contains hippuric acid, which is an
antiseptic and reduces adherence of bacteria
in vitro.96-98 It has been shown to reduce bac-
teriuria with pyuria, but not the overall rate
of bacteriuria or the number of symptomatic
21
WILLIAMS
UTIs.99-102 Other studies demonstrated a 20%
decrease in absolute risk of symptomatic
UTIs, but clinical outcomes remain uncer-
tain.103, 104
Bacterial interference refers to asympto-
matic colonization by good bacteria that pre-
vents symptomatic UTIs caused by bad bac-
teria. The concept of intentional coloniza-
tion with a known benign strain holds con-
siderable appeal and has been shown to re-
duce symptomatic UTIs in patients with spinal
cord injury.105 These provocative data sug-
gest that someday benign bacterial colo-
nization may be prescribed to prevent symp-
tomatic UTIs in high-risk patients.
Several investigative groups are actively
pursuing immunization to prevent UTIs.
Different strategies are being applied, in-
cluding use of whole killed uropathogens
and the particular structures that mediate at-
tachment.106, 107 Vaccines have been devel-
oped against the FimH subunit of type 1 fim-
briated E. coli and its chaperone molecule
FimCH, which appear to be important de-
terminants of bacterial adherence and colo-
nization of the urinary tract.108-110 Early re-
sults have shown an increase in median time
to reinfection using these vaccines. Thus, im-
munization is an attractive theoretical ap-
proach to preventing UTIs, but much work
remains to be done before this theory be-
comes a clinical reality.
Two other areas of UTI prophylaxis deserve
comment. First, sexually active women with
recurrent UTIs should be advised to stop using
spermicide-containing contraceptives and take
a prophylactic antimicrobial around the time of
intercourse. Second, postmenopausal women
with recurrent UTIs can take oral or vaginal
estrogen that will shift the vaginal flora from
uropathogens to lactobacillus while lowering
the vaginal pH and may protect them from as-
cending recurrent UTIs.39
Catheter-associated bacteriuria and UTI
Between 10% and 20% of patients who are
hospitalized receive an indwelling urethral
catheter, and in this setting, the risk of bac-
teriuria is approximately 5% per day. With
long-term catheterization, bacteriuria is in-
evitable, and prevention strategies have large-
22 MINERVA UROLOGICA E NEFROLOGICA
CURRENT CONCEPTS IN URINARY TRACT INFECTIONS
ly been unsuccessful. In such patients,
catheters should be changed periodically to
prevent the formation of concretions that can
lead to obstruction. Prophylactic systemic an-
tibiotics have been shown to transiently de-
lay the onset of bacteriuria in catheterized
patients, but this strategy may lead to in-
creased bacterial resistance.111 Catheter-as-
sociated UTIs account for 40% of all noso-
comial infections and are the most common
source of gram-negative bacteremia in hos-
pitalized patients.111
The diagnosis of catheter-associated bac-
teriuria can be made when the urine culture
shows 100 or more CFU per mL of urine from
a catheterized patient. The diagnosis of in-
fection (UTI), however, is based on symp-
toms since pyuria is unreliable and non-spe-
cific in patients with indwelling catheters.
The microbiology of catheter-associated
UTIs reflects the nosocomial origin of the in-
fections, as they commonly are acquired ex-
ogenously via manipulation of the catheter
and drainage device. Bacteriuria is often
polymicrobic, especially in patients with long-
term indwelling catheters.111
Symptomatic bacteriuria (i.e. UTI) in a pa-
tient with an indwelling urethral catheter
should be treated with antibiotics that cover
potential nosocomial uropathogens. Patients
with mild to moderate infections (cystitis)
may be treated with an oral flouroquinolone,
usually for 10 to 14 days. However, parenteral
antibiotic therapy may be necessary in pa-
tients with febrile infections or patients who
are unable to tolerate oral medications. The
recommended duration of therapy for febrile
infections is 14 to 21 days.111
It must be emphasized that treatment is
not recommended for catheterized patients
who have asymptomatic bacteriuria, with the
following exceptions: patients who are im-
munosuppressed after organ transplantation,
patients at risk for bacterial endocarditis and
patients who are about to undergo urinary
tract instrumentation.111
Asymptomatic bacteriuria and
bacteriuria of pregnancy
Asymptomatic bacteriuria is defined as the
presence of more than 100 000 CFU per mL of
Marzo 2004
CURRENT CONCEPTS IN URINARY TRACT INFECTIONS WILLIAMS

TABLE I.Antimicrobial prophylaxis for common procedures in genitourinary surgery.

Procedure Organisms Suggested antimicrobials

Endoscopic surgery and ESWL

Bladder biopsy, retrograde pyelo- Prophylaxis against common GU tract Aminoglycosideampicillin, TMP/ SMX,
graphy, transurethral stent placement, organisms: E. coli, Proteus, Enterococcus, fluoroquinolone, cephalosporin, ampi-
ureteroscopy Klebsiella cillin/clavulanate
ESWL See above See above
In patients with a negative urine cultu- In patients with a negative urine cultu-
re and no need for endoscopy, some re and no need for endoscopy, some
argue against antimicrobial prophylaxis argue against antimicrobial prophylaxis
Minimally invasive surgery
Laparoscopic: adrenalectomy, neph- Prophylaxis against skin organism: S. First generation cephalosporin. Alterna-
rectomy, node dissection, orchiopexy aureus, coagulase negative Staph, tively: penicillinase-resistant penicillin,
Group A Strep clindamycin. If suspicious for MRSA:
vancomycin
Laparoscopic: prostatectomy, neph- Prophylaxis against skin and common Cephalosporin or ampicillinaminogly-
rouretectomy, cystectomy, pyelopla- GU tract organisms coside, ampicillin/sdulbactam. Alternati-
sty, ureteral reimplantation vely: levofloxacin. If suspicious for MR-
SA: vancomycinaminoglycoside
Percutaneous renal surgery Prophylaxis against skin and common Cephalosporin or ampicillinaminogly-
GU tract organisms coside, ampicillin/sulbactam. Alternati-
vely: levofloxacin. If suspicious for MR-
SA: vancomycinaminoglycoside
Prostatic brachytherapy Prophylaxis against skin organisms First generation cephalosporin. Alterna-
tively: penicillinase-resistant penicillin,
clindamycin. If suspicious for MRSA:
vancomycin
Transrectal ultrasound-guided biopsy Prophylaxis against E. coli and anaero- Fluoroquinolone: pre-procedure enema
of the prostate bes recommended to reduce bacterial counts
Open urologic surgery
Adrenalectomy, nephrectomy, lym- Prophylaxis against skin organisms: S. First generation cephalosporin. Alterna-
phadenectomy aureus, coagulase negative Staph, tively: penicillinase-resistant penicillin,
Group A Strep clindamycin. If suspicious for MRSA:
vancomycin
Cystectomy, radical and simple pro- Prophylaxis against skin and common Cephalosporin or ampicillinaminogly-
statectomy, nephroureterectomy GU tract organisms coside, ampicillin/sulbactam. Alterna-
tively: levofloxacin. If suspicious for
MRSA: vancomycinaminoglycoside
Artificial urinary sphincter, penile pro- Prophylaxcis against skin and common Vancomycinaminoglycoside, cephalo-
sthesis, testicular prosthesis GU tract organisms. High suspicion for sporin or ampicillinaminoglycoside,
MRSA ampicillin/sulbactam, ticarcillin/ clavu-
lanate, piperacillin/tazobactam
Female urology: pubovaginal sling, Prophylaxis against skin and common Cephalosporin or ampicillinaminogly-
cystocele repair GU tract organisms+vaginal group B coside, ampicillin/sulbactam. Alternati-
Strep vely: levofloxacin. If suspicious for
MRSA: vancomycinaminoglycoside
Reconstructive urology: diversion or Prophylaxis against intestinal organisms: Cefatetan, aminoglycoside plus metro-
augmentation involving intestine E. coli, Klebsiella, Enterobacter, Serratia, nidazole or clindamycin, cefazolin plus
Proteus, Enterococcus. Note: Mechanical metronidazole. Alternatively: ampicil-
and antibiotic bowel preparation pre- lin/sulbactam, ticarcillin/clavulanate, pi-
operatively are beneficial in lowering peracillin/tazobactam
infection risk
Modified from Weiser et al.120 ESWL: extracorporeal shock wave lithotripsy

voided urine in persons with no symptoms Rates of asymptomatic bacteriuria range from
of UTI. The largest patient population at risk 15% to 30% in men and 25% to 50% in
for asymptomatic bacteriuria is the elderly.112 women.113, 114 In this patient population symp-

Vol. 56, N. 1 MINERVA UROLOGICA E NEFROLOGICA 23

WILLIAMS CURRENT CONCEPTS IN URINARY TRACT INFECTIONS

TABLE II.Antimicrobial treatment regimens for UTIs in pregnancy.

Antimicrobial Regimen Other

Safe throughout all of pregnancy

Amoxicillin 250 mg t.i.d.7 days Up to 30% incidence of urinary tract E. coli re-
sistance
250 mg t.i.d.3 days Safe throughout pregnancy
3 g dose followed by 3 g dose 12 hours later
2 g plus 1 g probenecid
Amoxicillin/clavulinic 250 mg/125 mg t.i.d.7 days Less resistance than amoxicillin alone. Safe
acid throghout pregnancy
Cephalexin 250-500 mg q.i.d.7 days Safe throughout pregnancy
Safe in selected trimesters of pregnancy
Nitrofurantoin 100 mg q.i.d.7 days Associated with risk of hemolytic anemia in
presence of G6PD deficiency in either mother
or fetus
100 mg q.i.d.3 days Contraindicated at term (38-42 weeks), during
labor and delivery, or when onset of labor is
imminent
Sulfisoxalone 1 g then 500 mg q.i.d.7 days May be associated with neonatal hyperbili-
rubinemia when administered in third tri-
mester
TMP-SMX TMP 320 mg/SMX 1 600 mg b.i.d.3 days Possible antifolate teratogenicity issues when
used in first trimester. May be associated with
neonatal hyperbilirubinemia when admini-
stered in third trimester
Unsafe during pregnancy
Fluoroquinolones Contraindicated in pregnancy Adverse effects on fetal cartilage
Tetracyclines Contraindicated in pregnancy Can cause acute maternal liver decompen-
sation and fetal malformations
Erythromycin Contraindicated in pregnancy Can cause cholestatic jaundice in pregnant
fermales
Chloramphenicol Contraindicated in pregnancy Gray Baby Syndrome

Modified from Weiser et al.120

tomatic UTI is also common and represents the
most common bacterial infection.104, 115
Determining whether or not an elderly person
is symptomatic from bacteriuria often is diffi-
cult as it can be associated with conditions
common in this population like dementia and
urinary and fecal incontinence. Furthermore,
high rates of resistant organisms in this set-
ting are related to co-morbidities, functional
impairment, and antimicrobial use.112, 113, 116
Interpretation of positive urine cultures
and pyuria in the long-term care setting is
difficult because of a low positive predictive
value for symptomatic UTI. Additionally, treat-
ing asymptomatic bacteriuria and pyuria does
not change the rate of development of symp-
tomatic UTI, nor does treatment reduce mor-
tality or improve chronic symptoms such as
incontinence. Even in the presence of fever,
there is considerable diagnostic uncertainty,
as only 10% of fever in patients with bac-
teriuria without localizing symptoms arises
from the urinary tract.116 Also, 30% of pa-
tients without bacteriuria have pyuria.84
Therefore, in the absence of symptoms,
screening cultures are unnecessary, and
asymptomatic bacteriuria and pyuria should
not be treated empirically.114, 116
In addition to the elderly, nontreatment is
indicated in 2 other populations with a high
prevalence of asymptomatic bacteriuria-
school girls and patients with spinal cord in-
jury.112, 117-119 In these populations there is no
benefit from antibiotic treatment and, in fact,

24 MINERVA UROLOGICA E NEFROLOGICA Marzo 2004

CURRENT CONCEPTS IN URINARY TRACT INFECTIONS
untreated individuals have lower rates of
pyelonephritis.
Three groups of patients with asympto-
matic bacteriuria have been shown to bene-
fit from treatment: pregnant women, patients
with renal transplants, and patients who are
about to undergo genitourinary tract proce-
dures.76 Suggested antimicrobial prophylax-
is for genitourinary surgery is summarized in
Table I.120
Between 2% and 10% of pregnancies are
complicated by UTIs, usually in women with
persistent bacteriuria. If left untreated, 25% to
30% of these women develop pyelonephri-
tis.121, 122 Pregnancies that are complicated by
pyelonephritis have been associated with
low-birth-weight infants and prematurity.
Thus, pregnant women should be screened
for bacteriuria by urine culture at 12 to 16
weeks of gestation. The presence of 100 000
CFU of bacteria per mL of urine is consid-
ered significant. Pregnant women with
asymptomatic bacteriuria should be treated
with an antimicrobial for 3 to 7 days, and the
urine should subsequently be cultured to en-
sure cure and the avoidance of recurrence.
Pregnant women with pyelonephritis should
be hospitalized and initially should receive in-
travenous antimicrobial therapy. They should
complete 14 days of acute therapy followed
by nightly prophylactic therapy until deliv-
ery.121 Choice of antimicrobial should be
based on the results of susceptibility tests as
pathogens are now becoming more resistant
to traditional therapies. Treatment regimens
for UTIs in pregnancy are summarized in
Table II.120
UTIs in diabetes
Previously, it was thought that diabetics
should be screened for asymptomatic bac-
teriuria since they potentially would be at
higher risk of progressing to symptomatic
UTI. However, recent prospective cohort
studies of diabetic women report no differ-
ences in symptomatic UTI, mortality, or pro-
gression to diabetic complications between
initially bacteriuric and non-bacteriuric
Vol. 56, N. 1 MINERVA UROLOGICA E NEFROLOGICA
WILLIAMS
women at 18 months or 14 years. 123, 124
Harding et al. reported that antimicrobial
therapy for diabetic women with asympto-
matic bacteriuria did not alter the frequency
of UTIs compared to those without thera-
py.125 Women receiving treatment had more
side effects related to antimicrobial use. Thus,
screening for and treatment of asymptomatic
bacteriuria in diabetic women is not indi-
cated.
Acute pyelonephritis occurs more com-
monly in diabetics with one study docu-
menting a rate as high as 5-fold that of non-
diabetic patients.126 In addition, complica-
tions, such as renal corticomedullary abscess,
renal carbuncle, emphysematous pyelone-
phritis or perinephric abscess, are frequent-
ly encountered in the diabetic population.127
Therefore, a plain abdominal radiograph is
recommended as a minimum screening tool
in febrile diabetics with UTIs. A plain ab-
dominal radiograph detects renal emphyse-
matous pyelonephritis in about 90% of cases
and will also identify most calculi. Ultrasono-
graphy initially should be used if parenchy-
mal lesions or obstructive uropathy is sus-
pected. If there is a high degree of clinical
suspicion for renal abscess, computerized to-
mography should be performed even if ul-
trasonography is unrevealing.
Empiric antimicrobial therapy of diabetic
patients with complicated UTIs is similar to
that of nondiabetic patients with acute
pyelonephritis because the pathogens are
usually Enterobacteriaceae. However, inva-
sive staphylococcal infection is not uncom-
mon in the infected diabetic patient and
should be considered as an etiological agent
of urinary tract sepsis, particularly if the clin-
ical presentation is that of renal carbuncle. If
staphylococcus species are isolated or sus-
pected, coverage should include oxacillin,
nafcillin, or vancomycin based on suscepti-
bilities. Oral outpatient therapy is not rec-
ommended as the initial treatment of dia-
betic patients with complicated UTIs. Intrave-
nous therapy is recommended until fever and
symptomatology are resolved, which usual-
ly occurs within the first 2 or 3 days of initi-
ating appropriate treatment. An oral regimen
25
WILLIAMS
may then be instituted and should be con-
tinued for at least 14 days.127
In treating diabetics with symptomatic
UTIs, TMP-SMX, should be used with cau-
tion because it can potentiate the hypo-
glycemic effect of oral hypoglycemic drugs.
This potentiation tends to occur with larger
doses of TMP-SMX. Fluoroquinolones appear
more effective than TMP-SMX in treating di-
abetic patients and do not potentiate hypo-
glycemic effects.
UTI in men
By the time men reach their eighth decade,
at least 1/3 will have had an episode of bac-
teriuria.6 Up to half of male nursing home
residents have bacteria in their urine.128 In
elderly men, bacteriuria tends to be inter-
mittent and episodic, and is more often re-
lated to conditions such as prostatic en-
largement or bladder dysfunction than to ex-
posure to virulent uropathogens.128 Asym-
ptomatic bacteriuria is not useful in predict-
ing the risk of developing a symptomatic UTI
in elderly men residing in long-term care fa-
cilities.129 Occasionally, symptomatic bac-
teriuria occurs in young men who partici-
pate in anal sex, who are not circumcised, or
whose sexual partner is colonized with
uropathogens.130, 131
Low levels of bacteriuria in men are clini-
cally meaningful, because collecting an un-
contaminated urine specimen is easier than in
women. A urine culture from a man that
grows more than 1 000 CFU of a pathogen
per mL of urine is the best sign of a UTI, with
a sensitivity and specificity of 97 %.6, 132 Men
with symptomatic UTIs should receive a min-
imum of 7 days of antimicrobial therapy, and
data favoring treatment with fluoroquinolones
are generally accepted.133, 134
Urologic work-up in men with UTIs is
based on presenting symptoms, age, and re-
sponse to therapy. Among young men with
acute cystitis who respond to 7 days of treat-
ment, diagnostic work-ups beyond cultures
are generally unrewarding.24 Most elderly
men with recurrent bacteriuria have some
26 MINERVA UROLOGICA E NEFROLOGICA
CURRENT CONCEPTS IN URINARY TRACT INFECTIONS
anatomic abnormality detectable by excre-
tory urography or intravenous pyelography,
as do about 30% of young men with a single
episode of bacteriuria.135 More sensitive tests,
like urodynamic pressure-flow videocystog-
raphy, detect abnormalities in 80% of bac-
teriuric men.135 These findings have led to
recommendations to image the urinary tract
and perform urologic evaluations in older
men with pyelonephritis or recurrent infec-
tions, and in young men after their first in-
fection.4, 135
Prostatitis
By the time men reach their eighth decade
1/4 will have been given the diagnosis of
prostatitis.7 About 50% of all men will have
symptoms consistent with prostatitis at some
time, and about 1/4 of visits to physicians
for male genitourinary complaints are attrib-
uted to one of the prostatitis syndromes.6
These are the most common urologic prob-
lems in men younger than 50 years of age
and the third most common in older men.136
Many men present with a constellation of
symptoms that include irritative voiding
symptoms and pelvic pain that now is called
the chronic pelvic pain syndrome (CPPS).
CPPS impairs quality of life to a magnitude
similar to that of coronary artery disease or
Crohns disease.137
Acute and chronic bacterial prostatitis ac-
count for about 5% of the prostatitis syn-
dromes. They are caused by uropathogens,
typically E. coli. Acutely, patients present
with a tender prostate gland and should re-
spond promptly to antimicrobial therapy.
Chronic bacterial prostatitis is a subacute in-
fection that is often asymptomatic, but may al-
so present with recurrent UTIs and a variety
of pelvic pain and voiding symptoms.
Effective treatment may be difficult and re-
quires prolonged antimicrobial therapy with
an agent that penetrates prostatic tissue and
secretions, such as TMP-SMX or, preferably,
a fluoroquinolone. Eradication often requires
6 to 12 weeks of therapy and in rare instances
even longer, as antimicrobial levels attained
Marzo 2004
CURRENT CONCEPTS IN URINARY TRACT INFECTIONS
in prostatic fluid are generally lower than
those in tissue.133, 138 Long-term suppressive
antimicrobial therapy and nonspecific mea-
sures aimed at palliation may be useful in
selected patients with recurrent bacteriuria
or persistent symptoms of chronic bacterial
prostatitis.139
Nonbacterial prostatitis and CPPS account
for approximately 95% of the prostatitis syn-
dromes. Their etiologies are largely unknown.
The Chronic Prostatitis Collaborative Research
Network Study Group recently published its
findings regarding the chronic prostatitis/
chronic pelvic pain syndrome (CP/CPPS) and
the utility of segmented urine samples and ex-
pressed prostatic secretions in the diagnosis
of this condition.140 Men with CP/CPPS had
significantly higher leukocyte counts in all
segmented urine samples and EPS but not
in semen as compared to asymptomatic con-
trols. There was no difference in rates of lo-
calization of bacterial cultures for men with
CP/CPPS compared to control men. They al-
so found a high prevalence of white blood
cells and positive bacterial cultures in the
asymptomatic control population, which rais-
es questions about the clinical usefulness of
the standard 4-glass test as a diagnostic tool
in men with CP/CPPS.141
Many men with CP/CPPS have psycho-
logical disturbances, especially depression
and somatization, which may contribute to,
or result from, the syndrome.142 Urogenital
physical examination is unremarkable, as are
urine and hematologic tests. Uroflow studies
are abnormal in about 30% of cases, with
nonrelaxation of the pelvic floor striated mus-
cles or spasm of the internal urinary sphinc-
ter.143 This may lead to elevated prostatic ure-
thral pressure and intraprostatic reflux.
Suggested explanations for CPPS include a
dyssynergia between bladder detrusor and
internal sphincter muscles (stress prostatitis)
or pelvic floor tension myalgia.144
Therapy for CP/CPPS is poorly defined,
largely empirical, and primarily symptomatic.
Suggested approaches include muscle relax-
ants, analgesics, biofeedback, sitz baths, re-
laxation exercises, and psychotherapy.145 Re-
sults with antibiotic therapy are mixed.143, 145, 146
Vol. 56, N. 1 MINERVA UROLOGICA E NEFROLOGICA
WILLIAMS
A single 4-week course of antibiotics initially
is reasonable. However, repeated or prolonged
antibiotic courses generally should be avoid-
ed. Other strategies have been implemented,
including nonsteroidal anti-inflammatory
drugs, -blockers, finasteride, allopurinol, nu-
tritional supplements (such as saw palmetto or
zinc sulfate), lifestyle changes (such as diet, ex-
ercise, or sexual practices), and prostatic mas-
sage, but few are evidence-based.145, 146 It is im-
portant to note that persistent or severe symp-
toms may be caused by interstitial cystitis or
carcinoma of the bladder and must be ex-
cluded.
Conclusions
This review has highlighted the science
and application of new developments in
UTIs. From a scientific standpoint, UTIs can
be viewed as an interaction between specif-
ic bacterial virulence factors and the patient.
A new model explaining the pathogenesis
of recurrent UTIs has been presented. The is-
sue of antimicrobial resistance also has been
reviewed, highlighting both the need to re-
consider traditional treatment recommenda-
tions in the face of local resistance patterns,
as well as the need to make better use of
drugs that are currently available.
Prospects for prevention of recurrent UTI
include natural compounds, bacterial inter-
ference and immunization. With regard to
UTI risk in women, patients can be classified
based on age, and functional and hormonal
status. Appropriate treatment approaches must
be based on this classification. In contrast to
uncomplicated UTIs, management of most
complicated infections depends on clinical
experience and resources at individual insti-
tutions rather than on evidence based guide-
lines. Asymptomatic bacteriuria generally
should not be treated except in high-risk
catheterized patients and in pregnancy. UTIs
in men generally require formal urologic eval-
uation. Our understanding of the etiologies,
diagnostic strategies, and treatment options
for prostatitis and the chronic pelvic pain syn-
drome in men continues to evolve.
27
WILLIAMS
Riassunto
Aggiornamenti sulle infezioni delle vie urinarie
Le infezioni delle vie urinarie rappresentano delle
malattie infettive di comune riscontro, che possono
essere associate a unimportante morbilit e a costi sa-
nitari significativi. Questa review tratta gli aggiorna-
menti e le nuove scoperte riguardanti la comprensio-
ne e il trattamento di queste patologie. In particolare,
gli argomenti trattati comprendono la patogenesi, i fat-
tori relativi allospite, le resistenze antimicrobiche, le in-
fezioni ricorrenti delle vie urinarie nella donna, la dia-
gnosi, il trattamento delle infezioni delle vie urinarie con
e senza complicanze, la profilassi, la batteriuria asso-
ciata al cateterismo vescicale, la gravidanza, il diabete,
le infezioni delle vie urinarie nelluomo, la prostatite e
la sindrome da dolore pelvico cronico. Le infezioni
delle vie urinarie possono essere considerate come
conseguenze dellinterazione tra gli specifici fattori di
virulenza batterici e il paziente. stato proposto un
nuovo modello per spiegare la patogenesi delle infe-
zioni ricorrenti delle vie urinarie. necessaria una ri-
valutazione delle tradizionali raccomandazioni tera-
peutiche, a fronte di quadri di resistenza locale e vi
lesigenza di un migliore utilizzo dei farmaci attual-
mente a disposizione. Tra le prospettive terapeutiche
per la prevenzione delle infezioni ricorrenti delle vie
urinarie figurano i composti naturali, linterferenza bat-
terica e limmunizzazione. In relazione al rischio di in-
fezioni delle vie urinarie nelle donne, possibile clas-
sificare le pazienti in base allet e allo stato funzionale
e ormonale. Gli approcci terapeutici pi appropriati de-
vono essere calibrati su questa classificazione.
Contrariamente alle infezioni delle vie urinarie non
complicate, il tipo di trattamento della maggior parte
delle infezioni complicate dipende dallesperienza cli-
nica e dalle risorse a disposizione della singola strut-
tura, piuttosto che dalle linee guide basate sullevi-
denza. La batteriuria asintomatica solitamente non de-
ve essere trattata, con leccezione dei pazienti catete-
rizzati che presentano un rischio elevato e delle pazienti
in gravidanza. Le infezioni delle vie urinarie nelluomo
generalmente richiedono una valutazione urologica. Le
nostre conoscenze circa i meccanismi eziologici, le
strategie diagnostiche e le opzioni terapeutiche per la
prostatite e per la sindrome da dolore pelvico cronico
nelluomo sono in continua evoluzione.
Parole chiave: Infezioni delle vie urinarie, diagnosi - Bat-
teriuria - Pielonefriti - Prostatiti - Farmacoresistenza -
Virulenza - Gravidanza - Diabete mellito.
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