Urinary Tract Infections (uncomplicated)  in Young Men

Pathogenesis and Risk Factors

               It has been conventional to consider all UTIs in men as complicated because most UTIs occurring in the newborn, infant or elderly male are associated with urological abnormalities, bladder outlet obstruction or instrumentation. A UTI in an otherwise healthy adult man between the ages of 15 and 50 years is very uncommon. The large difference in the prevalence of UTIs between men and women is thought to be caused by a variety of factors, including the greater distance between the usual source of uropathogens (the anus and the urethral meatus); the drier environment surrounding the male urethra; the greater length of the male urethra; and the antibacterial activity of the prostatic fluid. It has become clear, however, that a small number of men aged 15-50 years suffer acute uncomplicated UTIs. The exact reasons for such infections are not clear, but risk factors associated with such infections include intercourse with an infected partner, anal intercourse and lack of circumcision; however, these factors are not always present. More than 90% of men with febrile UTI (fever > 38.0°C), with or without clinical symptoms of pyelonephritis, have a concomitant infection of the prostate, as measured by transient increases in serum PSA and prostate volume, irrespective of prostatic tenderness.

Diagnosis (Table: Crtiteria for The diagnosis of A UTI)

               The symptoms of uncomplicated UTIs in men are similar to those in women. Urethritis must be ruled out in sexually active men using a urethral Gram stain or a first-voided urine specimen wet mount to look for urethral leucocytosis. A urethral Gram stain demonstrating leucocytes and predominant Gram-negative rods suggests E. coli urethritis, which may precede or accompany a UTI. Dysuria is common to both UTI and urethritis. The aetiological agents that cause uncomplicated UTIs in men are also similar to those in women.

Table. Criteria for The Diagnosis of A UTI, as Modified According to IDSA/ESCMID Guidelines.

Category

Description

Clinical features

Laboratory Investigations

1

Acute uncomplicated UTI Dysuria, in women; acute uncomplicated cystitis in women

urgency, frequency, suprapubic pain, no urinary symptoms in 4 weeks before this episode

≥ 10 WBC/mm3

≥ 103 cfu/mL*

2

Acute uncomplicated Fever, pyelonephritis

chills, flank pain; other diagnoses excluded; no history or clinical evidence of urological abnormalities (ultrasonography, radiography)

≥ 10 WBC/mm3

≥ 104 cfu/mL*

3

Complicated UTI

Any combination of symptoms from categories 1 and 2 above; one or more factors associated with a complicated UTI (see text)

≥ 10 WBC/mm3

≥ 105 cfu/mL* in women

≥ 104 cfu/mL* in men,

or in straight catheter urine in women

4

Asymptomatic bacteriuria

No urinary symptoms

≥ 10 WBC/mm3

≥ 105 cfu/mL* in two consecutive MSU cultures

≥ 24 hours apart

5

Recurrent UTI (antimicrobial prophylaxis)

At least three episodes of  uncomplicated infection documented by culture in last 12 months: women only; no structural/functional abnormalities

< 103 cfu/mL*

MSU = mid-stream sample of urine; UTI = urinary tract infection; WBC = white blood cells. All pyuria counts refer to unspun urine. *Uropathogen in MSU culture.

 

Treatment (Table: Recommendations for Antimicrobial Therapy in  Urology)

               Empirical use of the agents discussed previously for uncomplicated cystitis or pyelonephritis in women are recommended. Nitrofurantoin should not be used in men with a UTI, since it does not achieve reliable tissue concentrations. For acute uncomplicated pyelonephritis, the use of a fluoroquinolone as initial empirical treatment is recommended in areas where the rate of E. coli resistance to fluoroquinolones is low (< 10%). Otherwise, alternative drugs have to be considered. Since in most men with febrile UTI or pyelonephritis, prostatic involvement also has to be considered, the goal of treatment is not only to sterilize the urine, but also to eradicate the prostatic infection. Thus, antimicrobials with good prostatic tissue and fluid penetration are preferable, e.g. fluoroquinolones.

               A minimum of 7 days of therapy is recommended, because of the relatively greater likelihood of an occult complicating factor in men compared with women. Urological evaluation should be carried out routinely in adolescents and in men with febrile UTI, pyelonephritis and recurrent infections, or whenever a complicating factor is present.

Table. Recommendations for Antimicrobial Therapy in Urology.

Diagnosis

 Most frequent pathogen/species

Initial, empirical antimicrobial therapy

Therapy duration

Cystitis   

acute,

uncomplicated

• E. coli

• Klebsiella

• Proteus

• Staphylococci

 

• Trimethoprim-sulphamethoxazole°

3 days

• Fluoroquinolone*

(1-)3 days

• Fosfomycin trometamol

1 day

• Pivmecillinam

(3-)7 days

• Nitrofurantoin

(5-)7 days

Cystitis   

acute,

uncomplicated

• E. coli

• Klebsiella

• Proteus

• Staphylococci

• Trimethoprim-sulphamethoxazole°

3 days

• Fluoroquinolone*

(1-)3 days

• Fosfomycin trometamol

1 day

• Pivmecillinam

(3-)7 days

• Nitrofurantoin

(5-)7 days

Pyelonephritis

acute,

uncomplicated

• E. coli

• Proteus

• Klebsiella

• Other enterobacteria

• Staphylococci

• Fluoroquinolone*

• Cephalosporin (group 3a)

Alternatives:

• Aminopenicillin/BLI

• Aminoglycoside

7-10 days

UTI with complicating factors

 

Nosocomial UTI 

 

Pyelonephritis acute, 

complicated

• E. coli

• Enterococci

• Pseudomonas

• Staphylococci

• Klebsiella

• Proteus

• Enterobacter

• Other enterobacteria

 

 

 

• Fluoroquinolone*

• Aminopenicillin/BLI

• Cephalosporin (group 2)

• Cephalosporin (group 3a)

• Aminoglycoside

In case of failure of initial therapy within 1-3 days or in clinically severe cases:

Anti-Pseudomonas active:

• Fluoroquinolone, if not used initially

• Acylaminopenicillin/BLI

• Cephalosporin (group 3b)

• Carbapenem

• ± Aminoglycoside

3-5 days after defeverescence or control/elimination of complicating factor

 

 

 

• Candida

 

• Fluconazole

• Amphotericin B

Prostatitis

acute, chronic 

 

• E. coli

• Other enterobacteria

• Pseudomonas

Fluoroquinolone*

Alternative in acute bacterial prostatitis:

• Cephalosporin (group 3a/b)

Acute:

2-4 weeks

Chronic:

4-6 weeks or longer

Epididymitis

acute

• Enterococci

• Staphylococci

• Chlamydia

• Ureaplasma

In case of Chlamydia or Ureaplasma:

• Doxycycline

• Macrolide

 

10 days

Urosepsis

• E. coli

• Other enterobacteria

 

After urological interventions – multi-resistant pathogens:

• Pseudomonas

• Proteus

• Serratia

• Enterobacter

• Cephalosporin (group 3a/b)

• Fluoroquinolone*

• Anti-Pseudomonas active acylaminopenicillin/BLI

• Carbapenem

• Aminoglycoside

 

 

3-5 days after defeverescence or control/elimination of complicating factor

BLI = ί-lactamase inhibitor; UTI = urinary tract infection. *Fluoroquinolone with mainly renal excretion

(see text). °Only in areas with resistance rate < 20% (for E. coli).

Asymptomatic Bacteriuria

               Asymptomatic bacteriuria is common. Populations with structural or functional abnormalities of the genitourinary tract may have an exceedingly high prevalence of bacteriuria, but even healthy individuals frequently have positive urine cultures. Asymptomatic bacteriuria is seldom associated with adverse outcomes.

               Pregnant women and individuals undergoing traumatic genitourinary interventions are at risk for complications of bacteriuria and show benefit from screening and treatment programmes. Screening for or treatment of asymptomatic bacteriuria is not recommended for the following persons:

• pre-menopausal, non-pregnant women

• diabetic women

• older persons living in community

• elderly institutionalized subjects

• persons with spinal cord injury

• catheterized patients while the catheter remains in situ.

               In fact, treatment of bacteriuria may be associated with harmful outcomes, such as increased shortterm frequency of symptomatic infection, adverse drug effects, and re-infection with organisms of increased antimicrobial resistance. Screening for asymptomatic bacteriuria and treatment is recommended only for selected groups where benefit has been shown:

• pregnant women

• before transurethral resection of the prostate and other traumatic urological interventions.

               Antimicrobial therapy should be initiated before the procedure. Short-term antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 hours after removal of the indwelling catheter may be considered.