The continued increase in the antimicrobial resistance of pathogens worldwide is of great clinical concern. In particular, health care–associated infections (HAIs) are associated with high levels of antimicrobial resistance. Health care–associated urogenital tract infections (HAUTIs) are among the most frequently occurring HAIs, with an estimated prevalence of 11–19.0% , , and . HAUTIs can pose a serious threat to the health of urology patients in terms of morbidity and mortality. Over the years, only a few surveillance studies have been performed to collect HAUTI data. Ongoing surveillance studies on antimicrobial resistance, such as the EARS-Net study by the European Centre for Disease Prevention and Control, do not specifically monitor urogenital tract infections or urology patients .
Therefore, a prevalence study of infections in urology patients was started in 2003 by the European Section of Infections in Urology (ESIU) and supported by the European Association of Urology (EAU) . The study was first started as the Pan European Prevalence (PEP) study, was extended in 2004 to the Pan EuroAsian Prevalence (PEAP) study, and since 2005 has been performed annually on a worldwide basis as the Global Prevalence of Infections in Urology (GPIU) study  and .
The GPIU aim is to record surveillance data on antibiotic resistance, type of urogenital infections, risk factors, and data on antibiotic consumption, specifically in patients in urology departments with HAUTIs  and . The primary aims of the study are to evaluate urology practice in terms of hospital infection control and antibiotic consumption practice , evaluate the frequency and circumstances of UTIs and surgical site infections in hospitalised urology patients, including the pathogens involved and their antimicrobial resistance.
Investigators register their data using a web-based application (http://gpiu.esiu.org) . Each participating department can freely choose a single study day within several periods listed during November and December of each year. On the chosen study day, all patients present in the ward at 08:00 a.m. local time should be screened and included. The presence of UTIs and/or surgical site infections is registered according to the Centers for Disease Control and Prevention definitions and should be documented and audited over the patients’ full hospital course from admission to discharge (Fig. 1).
Study algorithm for patient inclusion.
In the GPIU annual studies so far, 856 urology units in 70 countries have participated, involving a total of 27 542 patients. The initial findings of the GPIU (formerly PEP and PEAP) studies showed that the HAUTI prevalence was 11% . In the overall study, HAUTI prevalence was 9.4%, with 70.4% of those affected male and 29.6% female. The mean patient age was 59.9 ± 18.2 yr. The most frequent HAUTI forms were asymptomatic bacteriuria (29%), cystitis (26%), pyelonephritis (21%), and urosepsis (12%) .
The HAUTI bacterial spectrum has not changed throughout the study years. Escherichia coli, Enterococcus spp., Klebsiella spp., and Pseudomonas aeruginosa were the four most frequent pathogens, causing more than 70% of cases, with E. coli the predominant pathogen . Although there was no significant trend for antibiotic resistance over time, antibiotic resistance was generally high throughout the years. The only antibiotic tested for which the overall resistance rate was <10% was imipenem. For all other antibiotics the overall resistance rate was much higher, including so-called broad-spectrum antibiotics such as piperacillin/tazobactam (29%), ciprofloxacin (51%), and gentamicin (42%) . In Europe, antibiotic resistance was significantly higher for ciprofloxacin, gentamicin, and cefuroxime in Southern Europe compared to Northern Europe . Most importantly, resistance is driven by antibiotic consumption. Therefore, antibiotic consumption was also evaluated. Fluoroquinolones were preferred in 26.6% of cases, followed by cephalosporins (23.3%), aminoglycosides (14.1%), penicillins (13.8%), and broad-spectrum antibiotics .
In addition to the main GPIU study, several side studies have also been performed, dealing with transurethral resection of the prostate, prostate biopsy, and urosepsis (SERPENS study).
The study on prostate biopsy in 2010 and 2011 included a total of 702 men from 84 GPIU participating centres worldwide, and showed that antibiotic prophylaxis was administered before biopsy in 98.2% of men, predominantly using a fluoroquinolone (92.5%). Outcome data were available for 521 men (74%): symptomatic UTI was seen in 27 men (5.2%), which was febrile in 18 cases (3.5%) and required hospitalisation in 16 cases (3.1%) . However, multivariate analysis did not identify any patient subgroups at a significantly higher risk of infection after prostate biopsy .
The prospective SERPENS study on urosepsis was started in 2014 because the annual GPIU data revealed high rates of antibiotic resistance in urology patients with urosepsis , including 45% multidrug-resistant pathogens, and that the frequency of urosepsis increased from approximately 15% in 2003 to 25% in recent years .
The GPIU study also offers participating urology departments and urologists an instrument for quality control of HAIs and acknowledgment of active involvement in an ESIU/EAU infection control programme, with the possibility of gaining a certificate for infection control.
The GPIU study is currently the only study registering HAUTIs, especially in urology patients, in an ongoing surveillance protocol that can help to deliver data on adequate empirical antibiotic therapy in hospitalised urology patients according to guideline recommendations. The annual GPIU study will continue to be performed in November of each year. The SERPENS study on urosepsis intends to recruit 600 patients with urosepsis and has currently achieved approximately half of its recruitment plan.
Conflicts of interest
Florian Wagenlehner has served as a paid consultant for Astellas, Bionorica, Cubist, Galenus, Leo Pharma, Merlion, OM Pharma, Pierre Fabre, Perell Research, Rosen Pharma, and Zambon. He has received payments for presenting at continuing medical education events from Astellas, Bionorica Cubist, Galenus, Leo Pharma, Merlion, OM Pharma, Pierre Fabre, Rosen Pharma, and Zambon. He has also received payment for carrying out clinical trials on behalf of Astellas, Bionorica, Calixa, Cerexa, Cubist, The German Research Foundation (Deutsche Forschungsgemeinschaft), the European Association of Urology, Galenus, The Hessen State Ministry of Higher Education, Research and the Arts, Merlion, OM-Pharma, Rosen Pharma, and Zambon. Truls E. Bjerklund Johansen has served as a paid consultant for Zambon and Galil Medical, and has received payment for carrying out clinical trials on behalf of Cubist and the European Association of Urology Research Foundation. The remaining authors have nothing to disclose.
This study was organized by the board of the ESIU, endorsed and sponsored by the EAU and performed in collaboration with the Asian Association of UTI and STD, the International Society of Chemotherapy for Infection and Cancer and the Interregional Association of Clinical Microbiology and Antimicrobial Chemotherapy, as well as numerous regional urologic and infectious diseases societies. The GPIU study group is most grateful to the altruistic contributions of the GPIU investigators. The SERPENS study is supported by the EAU research foundation, with an unrestricted grant from Merck Sharp & Dohme.
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a Department of Urology, Paediatric Urology and Andrology, Justus Liebig University, Giessen, Germany
b Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne, UK
c Department of Experimental and Clinical medicine, University of Florence, Florence, Italy
d Department of Urology, Santa Chiara Regional Hospital, Trento, Italy
e Department of Urology, Trakya Medical School, Edirne, Turkey
f TB Research Institute, Novosibirsk, Russia
g Jahn Ferenc Dél-pesti Teaching Hospital, Budapest, Hungary
h Department of Urology, Technical University of Munich, Munich, Germany
i S.R. Urology Institute, Moscow, Russia
j Department of Microbiology, Immunology and Glycobiology, Lund University, Lund, Sweden
k Department of Bioinformatics, Technische Hochschule Mittelhessen, Giessen, Germany
l Department of Urology, Oslo University, Oslo, Norway
Corresponding author. Department of Urology, Paediatric Urology and Andrology, Justus-Liebig-University, D-35392 Giessen, Germany. Tel. +49 641 98544500.
These authors contributed equally to this work.
The GPIU Investigators are listed in the Supplementary material.
© 2016 European Association of Urology, Published by Elsevier B.V.