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Editorial

Beware of Bugs! Hot Issues in Urinary Tract Infections and Inflammation

By: Gianluca Giannarinia , Tobias Klatteb, James W. Cattoc and Alberto Brigantid

EU Focus, Volume 2 Issue 4, October 2016, Pages 339-340

Published online: 01 October 2016

Abstract Full Text Full Text PDF (151 KB)

Urinary tract infections (UTIs) have often been considered the Cinderella of the urologic discipline, with little attention paid by both academic researchers and practicing physicians. This view has dramatically changed in recent years, and the most likely reasons for a scientific and clinical reappraisal of this area have been highlighted in the articles we have assembled for this issue of European Urology Focus, which is entirely devoted to infections and inflammation in urology.

The reasons to dedicate an issue to these topics arise from their increasing importance and impact on our clinical practice.

First, there is an alarming continued increase in bacterial resistance to antimicrobial agents worldwide, as described by Ashiru-Oredope et al [1], largely because of misuse of agents, with a worsening virulence profile for causative pathogens, especially in health care–associated UTIs. So how can we improve our practice in order to decrease the overuse of unnecessary antimicrobial prophylaxis and treatment in urology? There are certainly a number of different interventions that can be adopted for this aim. For example, Cai et al [2] have shown that implementing use of a standardised protocol for antimicrobial prophylaxis for urologic interventions was able to significantly decrease antimicrobial use and resistance without increasing postoperative infection rates. Moreover, use of such a standardised protocol was associated with significant cost savings. Harmonising patient care by using standardised approaches and interventions could also limit the incidence of UTIs and thus indirectly reduce the need for an antimicrobial therapy and the possible onset of antimicrobial resistance. For example, it has recently been shown that a multiphase programme based on standardised recommendations and proper interventions significantly decreased the rate of catheter-associated UTIs in acute care [3]. Taken together, all these data support the need to implement standardised protocols to optimise the use of antimicrobial agents and thus to decrease the onset of antimicrobial resistance over time.

Second, owing to the increasing complexity and comorbidity burden of contemporary patients, urologists are more and more often faced with a diagnosis of UTIs in frail individuals, and their treatment becomes a true challenge. Tandogdu et al [4] provide an overview of UTIs in immunocompromised patients, as exemplified by conditions such as diabetes mellitus, chronic kidney disease, and solid organ transplantation, that are commonly encountered in urologic practice. Although morbidity and mortality are high in this setting, accurate identification of risk factors, the utility of targeted preventative measures, and the optimal duration of treatment remain largely unexplored.

Third, there is increasing preclinical and clinical evidence that several malignancies may have an infectious/inflammatory aetiology exerted either directly or indirectly by human-associated microbial communities, the so-called “microbiome”. Recent data suggest that the microbiome can represent a microenvironment that contributes to the onset and progression of cancer [5]. Moreover, it has recently been shown that the composition of the gut microbiome may be able to regulate the response to anticancer treatment [6]. Puhr et al [7] review the literature for studies assessing the role of chronic prostatic infections and inflammation in the development of prostate cancer. In this context, several genetic and epigenetic alterations have been identified in men with prostate inflammation, and a putative role has been attributed to interleukins as mediators of the chronic oxidative stress that can lead to carcinogenesis.

Fourth, a particular focus has been placed on the role of sexually transmitted diseases not only in male infertility but also in other benign and malignant diseases [8] and [9]. A comprehensive review of the role of human papilomavirus (HPV) as the most common sexually transmitted pathogen potentially linked to the onset of benign and malignant diseases in males has been compiled by Ventimiglia et al [9]. Promising results have been achieved with male vaccination, which, despite still being underused, is the only reliable method to provide protection against new HPV infections and their long-term sequelae, including external genital lesions and cancer.

In conclusion, increasing efforts should be put by the entire urologic community to properly manage infections and inflammatory processes that are now known to be involved in the pathophysiology of commonly managed diseases much more than was believed in the past. This will help to optimise both diagnostic and therapeutic pathways, and ultimately improve patient care.

Conflicts of interest

The authors have nothing to disclose.

References

  • [1] Ashiru-Oredope D, Upton M, Leibovici L. Trends and patterns in antimicrobial resistance. Eur Urol Focus. In press.
  • [2] T. Cai, P. Verze, A. Brugnolli, et al. Adherence to European Association of Urology guidelines on prophylactic antibiotics: an important step in antimicrobial stewardship. Eur Urol. 2016;69:276-283
  • [3] S. Saint, M.T. Greene, S.L. Krein, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374:2111-2119
  • [4] Tandogdu Z, Cai T, Koves B, Wagenlehner F, Bjerklund-Johansen TE. Urinary tract infections in immunocompromised patients with diabetes, chronic kidney disease, and kidney transplant. Eur Urol Focus. In press.
  • [5] M. Alfano, F. Canducci, M. Nebuloni, M. Clementi, F. Montorsi, A. Salonia. The interplay of extracellular matrix and microbiome in urothelial bladder cancer. Nat Rev Urol. 2016;13:77-90
  • [6] M. Vetizou, J.M. Pitt, R. Dalliere, et al. Anticancer immunotherapy by CTLA-4 blockade relies on the gut microbiota. Science. 2015;350:1079-1084
  • [7] Puhr M, De Marzo A, Isaacs W, et al. Inflammation, microbiota, and prostate cancer. Eur Urol Focus. In press. http://dx.doi.org/10.1016/j.euf.2016.08.010.
  • [8] Fode M, Fusco F, Lipshultz L, Weidner W. Sexually transmitted disease and male infertility: a systematic review. Eur Urol Focus. In press. http://dx.doi.org/10.1016/j.euf.2016.08.002.
  • [9] Ventimiglia E, Horenblas S, Muneer A, Salonia A. HPV infection and vaccination in males. Eur Urol Focus. In press.

Footnotes

a Urology Unit, Academic Medical Centre Hospital “Santa Maria della Misericordia”, Udine, Italy

b Department of Urology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna General Hospital, Vienna, Austria

c Academic Urology Unit, University of Sheffield, Sheffield, UK

d Division of Oncology / Urology Unit, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy

Corresponding author. Urology Unit, Academic Medical Centre Hospital “Santa Maria della Misericordia”, Piazzale Santa Maria della Misericordia 15, IT-33100 Udine, Italy. Tel. +39 04 32552931; Fax: +39 04 32552930.

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