Guidelines for the management of male urinary tract infections in primary care: a lack of international consensus-a systematic review of the literature.

BACKGROUND

The management of adult male urinary tract infections (mUTIs) in primary care lacks international consensus. The main objective of this study was to describe the different guidelines for the diagnosis and management of mUTIs in primary care, to assess their methodological quality, and to describe their evidence-based strength of recommendation (SoR).

METHODS

An international systematic literature review of the electronic databases Medline (PubMed) and EMBASE, and gray-literature guideline-focused databases was performed in 2021. The Appraisal of Guidelines for Research and Evaluation (AGREE II) assessment tool was used by 2 independent reviewers to appraise each guideline.

RESULTS

From 1,678 records identified, 1,558 were screened, 134 assessed for eligibility, and 29 updated guidelines met the inclusion criteria (13 from Medline, 0 from EMBASE, and 16 from gray literature). Quality assessment revealed 14 (48%) guidelines with high-quality methodology. A grading system methodology was used in 18 (62%) guidelines. Different classifications of mUTIs are described, underlining a lack of international consensus: an anatomic classification (cystitis, prostatitis, pyelonephritis) and a symptomatic classification (approach based on the intensity and tolerance of symptoms). The duration of antibiotic treatment for febrile mUTIs has been gradually reduced over the last 20 years from 28 days to 10-14 days of fluoroquinolones (FQ), which has become the international gold standard. Guidelines from Scandinavian countries propose short courses (3-5 days) of FQ-sparing treatments: pivmecillinam, nitrofurantoin, or trimethoprim. Guidelines from French-speaking countries use a watchful waiting approach and suggest treating mUTIs with FQ, regardless of fever.

CONCLUSIONS

This lack of scientific evidence leads to consensus and disagreement: 14 days of FQ for febrile mUTIs is accepted despite a high risk of antimicrobial resistance, but FQ-sparing treatment and/or short treatment for afebrile mUTIs is not. The definition of afebrile UTIs/cystitis is debated and influences the type and duration of antibiotic treatment recommended.

The definition and the treatment of adult male urinary tract infections (mUTIs) are imprecise compared with female UTIs. We aimed to describe the different guidelines for the diagnosis and management of mUTIs in primary care and to assess their methodological quality. Our international systematic review included 29 updated regional/national guidelines. The management of male UTIs is not specific to primary care. Guidelines are mainly based on expert opinion, so definition and therapeutic proposals differ according to the prescribing practices of each country. Different classifications of mUTIs are described, underlining a lack of international consensus: an anatomic classification (cystitis, prostatitis, pyelonephritis) and a symptomatic classification (approach based on the intensity and tolerance of symptoms). Cytobacteriological examination of urine is systematically performed in the management of all mUTIs. A prostate-specific antigen test is not necessary for the positive diagnosis of mUTI. Over the past 20 years, the duration of treatment with fluoroquinolone antibiotics has decreased from 4 to 2 weeks. Fluoroquinolones (FQ) remain the reference treatment but there is a high risk of antimicriobial resistance. Guidelines from Scandinavian countries propose short courses (3–5 days) of FQ-sparing treatments: pivmecillinam, nitrofurantoin, or trimethoprim. Guidelines from French-speaking countries use a watchful waiting approach and suggest treating mUTIs with FQ, regardless of fever. This lack of scientific evidence leads to consensus and disagreement: 14 days of FQ for febrile mUTIs is accepted despite a high risk of antimicrobial resistance, but FQ-sparing treatment and/or short treatment for afebrile mUTIs is not. The promotion of interventional trials will be necessary in primary care to confirm the efficacy of short treatment without FQ in afebrile mUTIs.

Informations de copyright

© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [e-mail].