EAU 袖珍指南：尿路感染
药物。此外，衣原体感染患者同时要对其性伴侣进行治疗。
泌尿系手术围手术期的预防性抗菌治疗 围手术期的预防性抗菌治疗主要是为了减少手术部位细菌的负载，预防症状性或发热性的泌尿生殖
4.细菌性前列腺炎 急性细菌性前列腺炎是一种常见的前列腺发热性感染，诊断主要依据临床表现及尿培养结果。慢性细菌 性前列腺炎则通常表现为症状反复发作及 UTI 症状。对于有前列腺炎样症状的患者，此时需要区分细菌 性前列腺炎和 CPPS。如果能够排除急性 UTI 和 STD，那么最好的区分方法便是 Meares-Stamey 尿四杯法 培养。
推荐使用 NIDDK/NIH 的分类方法（表 2），该分类只包含了急性和慢性细菌性前列腺炎。 表 2：NIDDK/NIH 前列腺炎分类
4.附睾炎，睾丸炎 大部分附睾炎，伴或不伴睾丸炎是由常见的尿路病原体造成的。膀胱出又梗阻和泌尿生殖畸形是其 危险因素。对于年轻男性人群，常考虑衣原体感染。
诊断 1.一般性 UTI 常规诊断包括病史、症状评估、体格检查以及尿试纸分析，包括白细胞、红细胞及亚硝酸反应。除
如果治疗失败，考虑可能为阴道毛滴虫或支原体感染，此时应使用甲硝唑（2 g 单剂量又服）和红霉 素（500 mg qid，又服 7 天）联合治疗。
细菌性前列腺炎 急性细菌性前列腺炎的发病率正在不断上升，治疗方案主要为注射大剂量的抗生素如氨基糖苷类和
青霉素类衍生物或三代头孢菌素，治疗持续至退热及感染指标恢复正常。感染不太严重时，可以又服氟 喹诺酮 10-14 天。
对于慢性细菌性前列腺炎及炎症性 CPPS，应在初步诊断后又服氟喹诺酮或甲氧苄啶 2 周。2 周后患 者需要进行再次评估，如果治疗前细菌培养阳性或症状得到改善，可以继续使用抗生素，整体治疗时间 在 4-6 周比较合适。
附睾炎，睾丸炎 抗菌治疗前首先要进行尿道拭子及中段尿培养检查。一线治疗药物应选择氟喹诺酮类，如氧氟沙星
EAU 袖珍指南：尿路感染
尿路感染（UTI）不仅对患者的健康造成了严重影响，也给社会带来了极大的负担。同时 UTI 也是 医疗相关感染中最常见的类型。大肠杆菌是非复杂性 UTI 中最常见的病原体，此外其他的肠杆菌、肠球 菌以及绿脓杆菌感染也会发生。
然而随着抗生素的使用，微生物耐药也在迅速增加，特别是对广谱抗生素抵抗的增加。因此针对 UTIs，特别是非复杂性和无症状细菌尿的患者，必须限制抗生素的使用尤其是氟喹诺酮类及头孢菌素类 药物。
近日，来自欧洲泌尿外科学会（EAU）的 Grabe 教授等编写了尿路感染相关指南，对尿路感染的诊 断、治疗以及预防等方面做了详细参阐述。
分类和定义 出于临床实际的考虑，同时根据症状发生部位和潜在的危险因素，UTI 和男性生殖道感染可分为表
1 中的几类。 表 1：UTI 和男性生殖道感染分类
1.无症状性细菌尿（ABU） ABU 是指病人清洁中段尿细菌定量培养连续 2 次大于 105/ml，且 2 次菌种相同而无任何尿路感染的 症状。ABU 不应该看作是感染，更多的可认为它是一种共生定殖状态，在一些临床情况下也可作为一种 危险因素。因此 ABU 可无需治疗和筛查，一些证据表明 ABU 在复发性 UTI 中甚至可以起保护作用。 2.脓尿 脓尿是指新鲜离心尿液每高倍镜视野或每 mm3 未离心尿中白细胞超过 10 个。作为常规检查，也可 以用试纸法检测是否存在脓尿，包括白细胞酯酶活性检测以及血红蛋白和亚硝酸盐评估。 3.前列腺炎/慢性盆腔疼痛综合征的分类
预防 UTI 复发 预防 UTI 复发须包括一下几点：（1）心理辅导及行为治疗，避免危险因素；（2）非抗菌措施；
（3）预防性抗菌药物使用。尽可能去除泌尿系危险因素，及时治疗残余尿过多的情况，包括必要时清洁
间歇导尿。 1.非抗菌性预防措施 （1）激素替代：雌三醇替代，尤其对于绝经后女性（GR：C）；（2）免疫活性预防：OM-89
尿道炎 淋病的一线治疗为头孢曲松钠 1.0 g iv/im 联合阿奇霉素 1.0~1.5 g p.o.SD。二线治疗包括头孢克肟
400 mg p.o. SD；阿奇霉素 1.5 g p.o. SD；头孢呋辛 400 mg p.o. SD；环丙沙星 500 mg p.o. SD；左氧氟沙 星 250 mg p.o. SD。
系感染。近年来，随着粪便菌群耐药性的不断增强（尤其是对于氟喹诺酮类），围手术期的抗菌模式也 需要随之改变。表 5 总结了泌尿系手术中一些基本的预防性抗菌治疗规范。
表 5：围手术期抗菌治疗建议
果以免遗漏或诱导出耐药菌。 5.尿脓毒症 复杂性 UTI 可发展为尿脓毒症。早期的全身炎症性反应如发热或体温过低，呼吸心跳急促，低血
压，少尿及白细胞减少等可认为是多器官衰竭的征兆。除了相应的抗生素治疗，还需联合重症监护专家 对患者进行维持生命治疗。必须解除任何的泌尿道梗阻。
UTI 患者的随访 1. 对于女性非复杂性 UTI 和肾盂肾炎患者的常规随访，进行症状评估和尿试纸分析就足够了。 2. 对于 2 周内复发的女性 UTI 患者，需重复尿培养及药敏测试，同时评估泌尿系统可能存在的问 题。 3. 对于老年、最近出现的复发性 UTI 患者，必须对整个泌尿系统进行全面评估。 4. 对于男性 UTI，青少年男性、感染复发、肾盂肾炎、前列腺炎、睾丸炎、附睾炎等情况下需进行泌 尿系统的分析评估。 5. 对于儿童，应在 UTI 发作一次（男孩）或两次（女孩）后进行泌尿系检查，如泌尿系超声和膀胱 尿道造影。
了绝经前女性偶发的非复杂性的膀胱炎，其他所有类型的 UTI 都应进行尿培养以便调整抗生素的使用。 2.肾盂肾炎 急性肾盂肾炎主要表现为胁腹疼痛，恶心呕吐，发热（>38℃），肋椎角压痛等症状，同时可能伴或
不伴膀胱炎症状。此外，还需进一步评估以排除上尿路梗阻及结石的可能。 3.尿道炎
症状性尿道炎主要表现为尿痛及尿道排脓。若尿道分泌物革兰染色或尿道涂片显示每高倍镜视野 （HPF，×1000）白细胞超过 5 个，考虑化脓性尿道炎。如果是淋病，则需注意淋球菌为革兰染色阴性双 球菌。初次尿液样本中白细胞酯酶活性检测阳性或每 HPF（×400）白细胞超过 10 个具有诊断意义。
2.抗菌性预防措施 抗菌性预防可以持续更长时间（3~6 月），只在心理辅导、行为治疗后以及非抗菌治疗失败后进 行。女性复发性 UTI 治疗方案包括复方新诺明（TMP/SMX）40/200 mg 一天一次或一周三次，呋喃妥因 50 mg 或 100 mg 一天一次，磷霉素缓血酸铵 3 g 每十天一次。怀孕期间可使用头孢氨苄 125 mg 或 250 mg 或头孢克洛 250 mg，一天一次。
由于淋病通常还伴随着衣原体感染，所以还需进行抗衣原体治疗。衣原体感染的一线治疗为阿奇霉 素 1.5 g 单剂量又服或多西环素 100 mg bid，治疗 7-14 天。二线治疗包括又服红霉素 500 mg qid，持续 7 天；氧氟沙星 300 mg bid 或左氧氟沙星 500 mg qd，持续 7 天。
EAU 袖珍指南：尿路感染
尿路感染（UTI）不仅对患者的健康造成了严重影响，也给社会带来了极大的负担。同时 UTI 也是 医疗相关感染中最常见的类型。大肠杆菌是非复杂性 UTI 中最常见的病原体，此外其他的肠杆菌、肠球
菌以及绿脓杆菌感染也会发生。 然而随着抗生素的使用，微生物耐药也在迅速增加，特别是对广谱抗生素抵抗的增加。因此针对 UTIs，特别是非复杂性和无症状细菌尿的患者，必须限制抗生素的使用尤其是氟喹诺酮类及头孢菌素类 药物。 近日，来自欧洲泌尿外科学会（EAU）的 Grabe 教授等编写了尿路感染相关指南，对尿路感染的诊 断、治疗以及预防等方面做了详细参阐述。
治疗 UTI 的治疗取决于各种因素，表 3、表 4 总结了各种不同情况下最常见的病菌、抗菌药物以及治疗
时间。 表 3：抗菌治疗的建议
表 4：男性附属腺体感染总结
特殊情况 1.孕妇 UTI 根据尿培养结果谨慎使用孕期安全的抗生素如青霉素、头孢菌素和磷霉素等。怀孕第一个月不可使
用甲氧苄啶，第三个月不可使用磺胺类药物，最后一周不可使用呋喃妥因以避免胎儿葡糖-6-磷酸缺乏。 2.儿童 UTI 治疗周期需延长至 7-10 天，避免使用对牙齿和软骨有毒副作用的四环素和氟喹诺酮类药物。 3.年轻男性急性非复杂性 UTI 首先进行尿培养，治疗应持续至少 7 天。如果考虑细菌性前列腺炎，治疗周期应更长。 4.因泌尿系统疾患引起的复杂性 UTI 如果要达到彻底治愈效果，必须对潜在的病因进行治疗。不管病因如何，治疗必须遵循尿培养的结
(Urovaxom®) 疫苗，研究证实可以明显减少疾病反复发作（GR：B）。其他一些疫苗如 Urovac®、 StroVac® 和 SolcoUrovac®等，也有少数研究表明其有效性（GR：C）；（3）益生菌；（4）甘露糖：仅 用于一些临床研究，尚需进一步证实；（4）膀胱灌注：可以灌注粘多糖（CAG）层衍生物，不过缺乏足 够证据作为常规推荐治疗。
《EAU男性下尿路症状诊治指南(2012年版)》解读
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＜ ＜ Ｅ Ａ Ｕ 男性下尿路症状诊治 指南（ ２ ０ １ ２年版 ） 》 解读
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尿路感染指南PPT课件
关于复发性尿路感染的解释
• 复发性尿路感染（Recurrent infection ) • 再感染（Reinfection ):外界细菌再次侵入泌尿系引起的新
的感染 • 细菌持续存在（Bacterical Persistence ):复发性感染由存
在泌尿系中的同一细菌（如泌尿系结石或前列腺疾病）再 次发作产生，也称为复发（Relapse )
分
类分类： 与既往文献都不同：
单纯性尿路感染
尿脓毒血症
单纯下尿路感染 单纯上尿路感染
复杂性尿路感染
尿路感染 +
获得感染的疾病 治疗失败风险
导管相关的感染属于 复杂性尿路感染
病因 症状
尿路感染临床表现 +
全身炎症反应征象
男性生殖系统 感染
流行病学
• 主要数据均来自美国的调查 • 我国缺乏大宗的社区获得性流行病学调查 • 院内感染数据来自国内文献
的感染性疾病发生率增加，而在治疗方面存在诸多问题。 目的 • 中国泌尿外科医生对泌尿系疾病的治疗和抗菌素使用规范
化。 意义 • 提高泌尿外科医师对泌尿系疾病的治疗水平，减缓细菌耐
药性的发展，保障患者用药安全和有效。
适用范围
• 成人的泌尿系感染 • 不包括男性生殖系统的非特异性感染疾病 • 不包括特异性感染（性传播疾病及泌尿系结核、寄生虫、
≥104CFU/mL、革兰氏阴性杆菌菌数≥105CFU/mL。 • 新鲜尿标本经离心应用相差显微镜检查（1×400）在每30个视野中有半数视野见
到细菌。 • 无症状性菌尿症患者虽无症状，但在近期（通常为1周）有内镜检查或留置导尿
史，尿液培养革兰氏阳性球菌菌数≥104CFU/mL、革兰氏阴性杆菌菌数 ≥105CFU/mL应视为尿路感染。 • 耻骨上穿刺抽吸尿液细菌培养只要发现细菌即可诊断尿路感染。
尿路感染及诊疗指南
尿路感染及诊疗指南尿路感染是一种常见的疾病，主要由细菌感染尿道、膀胱或肾脏引起。
尿路感染的症状包括尿频、尿急、尿痛、腹胀、血尿等。
诊断尿路感染通常通过尿液分析，确定感染的细菌和抗生素敏感性。
本文将介绍尿路感染的诊断和治疗指南，帮助读者更好地了解和应对该疾病。
一、诊断标准尿路感染的诊断主要依靠临床症状和实验室检查。
常见的诊断标准包括尿频、尿急、尿痛等下尿路症状，并伴有尿液分析或尿培养阳性结果。
确诊尿路感染需要满足以下条件：1. 存在典型的尿路感染症状，如尿痛、尿频、尿急等；2. 阳性的尿液分析或尿培养结果，细菌数量≥10^3 CFU/ml，且单一菌种生长，或酒精酸杆菌数量为10^2 CFU/ml。
二、治疗原则尿路感染的治疗原则包括抗菌治疗和辅助治疗。
抗菌治疗是主要的治疗手段，目的是消除细菌感染并缓解症状。
辅助治疗主要包括保持良好的水分摄入、适当的休息和避免刺激性食物等。
三、抗菌治疗方案根据细菌培养结果和药物敏感性测试，选择合适的抗生素进行治疗。
一线药物包括头孢菌素类药物、氟喹诺酮类药物以及硝基呋喃类药物。
具体的治疗方案如下：1. 对于尿频、尿急等下尿路症状轻微的患者，可选择口服一线抗生素，如头孢菌素类药物。
2. 对于症状明显且泌尿系感染症状较重的患者，可选择口服或静脉注射氟喹诺酮类药物。
3. 对于复发性尿路感染的患者，应进行细菌培养和药物敏感性测试，并根据结果选择合适的抗生素治疗。
四、辅助治疗辅助治疗在尿路感染的康复中起到重要作用。
以下是一些常用的辅助治疗方法：1. 充足饮水：保持良好的水分摄入可以促进尿液排出，减少细菌滞留。
2. 休息与调节饮食：尿路感染时，适当的休息可以提高身体免疫能力，调节饮食可以减轻胃肠的负担。
3. 避免刺激性食物：辛辣食物、酒精和咖啡等刺激性食物可能会加重症状，应尽量避免。
五、注意事项在尿路感染的治疗中，需要注意以下几点：1. 坚持完成疗程：尿路感染通常需要7-14天的抗生素治疗，患者需要按时并坚持完成疗程。
2020年EAU尿道损伤诊断治疗指南(附解读)
•学习园地•2020年EAU 尿道损伤诊断治疗指南（附解读）谷遇伯 译，宋鲁杰，傅 强审校及解读（上海交通大学附属第六人民医院泌尿外科，上海东方泌尿修复重建研究所，上海200233）关键词：泌尿系损伤；尿道损伤；指南；欧洲泌尿外科学会 中图分类号:R691.6文献标志码:M2020年3月，欧洲泌尿外科学会（European As sociation of Urology, EAU ）发布 了 2020 年指南更 新。
本文为其中泌尿系统损伤章节的尿道损伤部分, 从流行病学、病因学、病理生理学、术前检查、临床诊 断和治疗等方面进行阐述，总结了尿道损伤诊疗相关证据，给出了临床推荐，并通过图示分别梳理了前、后 尿道损伤诊断和治疗的流程。
2019年的EAU 指南中，对于男性前尿道钝性损 伤的治疗，仅推荐了耻骨上膀胱造痿术的治疗方式 （推荐等级：弱）2020年更新后，则将钝性损伤区分 为部分损伤和完全损伤，明确了前尿道部分损伤可行 尿流改道（推荐等级：强），完全损伤可即刻行尿道成形术（推荐等级：弱）。
值得注意的是，指南中对于前尿道损伤后会师术的相关证据进行了大量描述，然而未予以相关推荐， 盖因这些研究并未得出一致的结论。
1流行病学、病因学和病理生理学1.1男性前尿道损伤前尿道钝性损伤最常见于球 部，该处尿道与耻骨联合发生挤压，导致断裂。
可能 的致伤原因是骑跨伤或会阴踢伤。
阴茎折断的病例 中，约有15%并发尿道损伤。
穿透性尿道损伤少见， 通常由枪伤、刺伤、犬咬伤或阴茎离断引起。
根据受伤部位，穿透性尿道损伤通常同时伴发阴茎、睾丸和/或骨盆损伤。
异物插入是前尿道损伤的另一个原因， 也较为少见，通常与患者进行自我性刺激或患有精神关'尿道损伤最常见的类型是医源性损伤。
导尿操作时，尿道损伤的发生率为6. 7%。
，其可能的原因包 括:导尿管头端导致假道，注水时球囊位于尿道中，或移除导尿管时球囊未完全排空。
2019版《中国泌尿外科疾病诊断治疗指南》：泌尿系统感染诊断治疗
---------------------------------------------------------------最新资料推荐------------------------------------------------------2019版《中国泌尿外科疾病诊断治疗指南》：泌尿系统感染诊断治疗201 4 版《中国泌尿外科疾病诊断治疗指南》：泌尿系统感染诊断治疗总论一、基本定义泌尿系感染又称尿路感染（Urinary Tract Infection），是肾脏、输尿管、膀胱和尿道等泌尿系统各个部位感染的总称。
1 ．尿路感染尿路上皮对细菌侵入的炎症反应，通常伴随有细菌尿和脓尿。
2．细菌尿正常尿液是无菌的，如尿中有细菌出现，称为细菌尿。
细菌尿可以是有症状的，也可以是无症状的。
细菌尿定义本身包括了污染，临床根据标本采集方式不同而应用不同的有意义的细菌尿计数来表示尿路感染。
3．脓尿尿中存在白细胞(WBCs)，通常表示感染和尿路上皮对细菌入侵的炎症应答。
二、分类尿路感染按感染部位可分为上尿路感染和下尿路感染。
依据两次感染之间的关系可以分为孤立或散发感染( isolated or sporadiec infection) 和反复发作性感染（recurrent infeetion），反复发作性感染可以进一步分为再感染(reinfection) 和细菌持续存在(bacterial persistence)，细菌持1/ 13续存在也称为复发( relapse) 按感染发生时的尿路状态分类：-单纯性尿路感染（单纯下尿路感染和单纯上尿路感染） -复杂性尿路感染（包括导管相关的感染等） -尿脓毒血症 -男性生殖系统感染：前列腺炎、附睾炎、睾丸炎、精囊炎等（不在本指南中）三、尿路感染的诊断 1 ．症状对尿路感染有诊断意义的症状和体征为尿频、尿急、尿痛、血尿、背部疼痛和肋脊角压痛，如果女性患者同时存在尿痛和尿频，则尿路感染的可能性为 90%。
EAU2020】男性非神经源性下尿路症状指南(一)
EAU2020】男性非神经源性下尿路症状指南（一）1. 简介目标和宗旨下尿路症状（LUTS）作为成年男性的常见疾病，对生活质量（QoL）有着巨大影响，并带来沉重的经济负担。
本指南作为基于证据的实用型指南，旨在对40岁以上因非神经源性良性疾病导致LUTS的男性患者进行评估和治疗。
LUTS所代表的功能学含义及其病因的多因素性，使得LUTS已取代之前的良性前列腺增生成为目前临床关注的焦点。
必须强调的是，临床指南的制定基于专家们所能获得的最佳证据，但是遵循指南建议并不一定会得到最佳结果。
为某一患者做出治疗决策时，指南永远不能取代临床专业知识，只是有助于集中决策。
此外，还应考虑患者的个人价值观和偏好/个体情况。
指南没有强制性，也不能作为法律依据。
2. 方法2.1. 简介在制定2020版《男性非神经源性LUTS指南》时，通过对相关文献进行结构化评价，从而鉴定、核对和评估新近的相关证据。
《男性非神经源性LUTS指南》所有章节均进行了广泛而全面的文献检索。
检索仅限于具有高水平证据的研究，即以英文发表的荟萃分析、随机对照试验（RCTs）和前瞻性非随机对照研究的系统评价。
基于修改后的GRADE证据分级方法，指南的每一项推荐都有一个相应的强度等级。
每个强度等级均涉及若干关键要素，即：1. 证据的整体质量。
根据牛津大学循证医学中心证据等级将指南引用的参考文献进行分级；2. 影响程度（个别或综合影响）；3. 结果的确定性（精确性、一致性、异质性和其他统计或研究相关因素）；4. 可取结果和不可取结果之间的平衡；5. 患者价值观和偏好对干预的影响；6. 患者价值观和偏好的确定性。
这些关键要素是专家组用来定义每项推荐强度等级的基础。
每项推荐的强度用“强”或“弱”来表示。
每项推荐的强度取决于处理策略中可取结果和不可取结果之间的平衡、证据的质量（包括评估的确定性）以及患者的价值观和偏好。
更多信息请参阅“一般方法”章节，也可在上述网站查看EAU指南认证组织列表。
尿路感染临床诊疗指南
尿路感染【概述】尿路感染是由各种病原体在泌尿系统异常繁殖所致的尿路急性或慢性炎症，简称尿感。
通常伴随有菌尿和脓尿。
【临床表现】1.急性单纯性膀胱炎发病突然，女性患者发病多与性活动有关。
主要表现是膀胱刺激征，即尿频、尿急、尿痛，膀胱区或会阴部不适及尿道烧灼感；尿频程度不一，严重者可出现急迫性尿失禁；尿混浊、尿液中有白细胞，常见终末血尿，有时为全程血尿，甚至见血块排出。
一般无明显的全身感染症状，体温正常或有低热。
2.急性单纯性肾盂肾炎（1）泌尿系统症状包括尿频、尿急、尿痛等膀胱刺激征；血尿；患侧或双侧腰痛；患侧脊肋角有明显的压痛或叩击痛等；（2）全身感染的症状如寒战、高热、头痛、恶心、呕吐、食欲不振等，常伴有血白细胞计数升高和血沉增快。
3.无症状菌尿无症状菌尿是一种隐匿性尿路感染，多见于老年女性和妊娠期妇女，患者无任何尿路感染症状，发病率随年龄增长而增加。
4.复杂性尿路感染复杂性尿路感染临床表现差异很大，常伴有增加获得感染或治疗失败风险的其他疾病，可伴或不伴有临床症状（如尿频、尿急、尿痛，排尿困难，腰背部疼痛，脊肋角压痛，耻骨上区疼痛和发热等）。
复杂性尿路感染常伴随其他疾病，如糖尿病和肾功能衰竭；其导致的后遗症也较多，最严重和致命的情况包括尿脓毒血症和肾功能衰竭，肾衰竭可分为急性和慢性，可逆和不可逆等。
【诊断要点】1.病史采集（1）临床表现尿路感染相关症状的特点、持续时间及伴随症状；（2）既往史、药物史及相关疾病史等寻找发病的可能原因、伴随疾病、曾经的药物治疗史及可能影响疾病发展、转归的因素等；2.体格检查包括泌尿外生殖器的检查；腹部和肾区的体检。
盆腔和直肠指诊对鉴别是否合并其他疾病有意义。
3.辅助检查（1）实验室检查包括血常规、尿常规、尿涂片镜检细菌、中段尿细菌培养+药敏、血液细菌培养+药敏、肾功能检查等；（2）影像学检查包括超声、腹部平片、静脉肾盂造影等，必要时可选择CT或MRI检查。
【治疗原则】1.女性非妊娠期尿路感染（1）急性单纯性膀胱炎治疗建议采用三日疗法治疗，即口服复方磺胺甲基异恶唑；或氧氟沙星；或左氧氟沙星。
2024尿路感染的用药方案要点(附图表)
2024尿路感染的用药方案要点（附图表）尿路感染的发病率高，对患者的生活质量影响较大，并且约27%的患者会在6个月内复发。
尿路感染常见的致病菌有哪些？如何诊断和治疗尿路感染？以及多重耐药菌感染的抗菌药物方案？尿路感染泌尿系统感染又称尿路感染（UTI），是肾脏、输尿管、膀胱和尿道等泌尿系统各个部位感染的总称。
尿路感染是指尿路上皮对细菌等病原体侵入的炎症反应，通常伴随有尿液病原体检测阳性（细菌性尿路感染为细菌尿）和脓尿。
按感染部位：可分为上尿路感染和下尿路感染。
前者主要是肾盂肾炎、输尿管炎，后者主要是膀胱炎、尿道炎。
按有无尿路异常：可分为非复杂性尿路感染和复杂性尿路感染。
根据欧洲泌尿外科协会（EAU）推荐的尿路感染分类方法如下：尿路感染常见的致病菌大多数尿路感染是由来源于肠道菌群的兼性厌氧菌感染引起，也可由来源于阴道菌群和会阴部皮肤的表皮葡萄球菌和白念珠菌等所起。
其中，大肠埃希菌导致了85%的社区获得性尿路感染和50%的医院获得性尿路感染。
尿路感染的诊断1、尿路感染的症状尿路感染相关症状包括尿频、尿急、尿痛、耻骨骨上区不适和腰部疼痛，门诊尿路感染就诊患者95%为急性膀胱炎，最常见的症状依次为尿痛、尿急和尿频，可有肉眼血尿。
上尿路感染患者除了排尿症状外，多以全身症状就诊，包括寒战、发热、腰痛、恶心、呕吐等，但约1/3仅有膀胱炎症状的患者经进一步检查发现同时存在上尿路病变。
对尿路感染有诊断意义的症状和体征为尿痛、尿频、血尿、背部疼痛和肋脊角压痛，如果女性患者同时存在尿痛和尿频，则尿路感染的可能性为90%。
2、实验室检查尿路感染的治疗1、一般治疗包括对症治疗、多饮水及生活方式的调整。
2、病情观察一些特殊情况下的无症状菌尿患者不需要常规行抗菌药物治疗，需要密切观察病情。
3、抗菌药物使用基本原则泌尿及男性生殖系统感染抗菌药物的使用必须参照抗菌药物的药动学／药效学（PK/PD）特点使用。
可以对有尿路感染的患者首先施行经验性抗菌药物治疗，但治疗过程中要根据患者的反应情况和药敏结果及时调整。
2014EAUESPU指南：儿童尿路感染
Guidelines –Pediatric UrologyUrinary Tract Infections in Children:EAU/ESPU GuidelinesRaimund Stein a ,*,Hasan S.Dogan b ,Piet Hoebeke c ,Radim Kocˇvara d ,Rien J.M.Nijman e ,Christian Radmayr f ,Serdar Tekgu¨l b aDivision of Paediatric Urology,Department of Urology,Mainz University Medical Centre,Johannes Gutenberg University,Mainz,Germany;bHacettepeUniversity,Faculty of Medicine,Department of Urology,Division of Paediatric Urology,Ankara,Turkey;cDepartment of Urology,Ghent University Hospital,Gent,Belgium;dDepartment of Urology,General Teaching Hospital in Praha,and Charles University 1st Faculty of Medicine,Praha,Czech Republic;eDepartment of Urology,Division of Pediatric Urology,University of Groningen,Groningen,The Netherlands;fDepartment of Urology,Medical University ofInnsbruck,Innsbruck,AustriaE U R O P E A N U R O L O G Y X X X (2014)X X X –X X Xa v a i l ab l e a t ww w.sc i e n c ed i re c t.c o mj o u r n a l h o m e p a g e :w w w.e u r o p e a n u r o l o g y.c omArticle infoArticle history:Accepted November 5,2014Keywords:Urinary tract infection ChildrenUrine sampling Diagnosis TreatmentAntibacterial treatment UltrasoundFollow-up imaging Renal scar guidelines EAU ESPUAbstractContext:In 30%of children with urinary tract anomalies,urinary tract infection (UTI)can be the first sign.Failure to identify patients at risk can result in damage to the upper urinary tract.Objective:To provide recommendations for the diagnosis,treatment,and imaging of children presenting with UTI.Evidence acquisition:The recommendations were developed after a review of the literature and a search of PubMed and Embase.A consensus decision was adopted when evidence was low.Evidence synthesis:UTIs are classified according to site,episode,symptoms,and com-plicating factors.For acute treatment,site and severity are the most important.Urine sampling by suprapubic aspiration or catheterisation has a low contamination rate and confirms ing a plastic bag to collect urine,a UTI can only be excluded if the dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is negative for both pyuria and bacteriuria.A clean voided midstream urine sample after cleaning the external genitalia has good diagnostic accuracy in toilet-trained children.In children with febrile UTI,antibiotic treatment should be initiated as soon as possible to eradicate infection,prevent bacteraemia,improve outcome,and reduce the likelihood of renal involvement.Ultrasound of the urinary tract is advised to exclude obstructive uropathy.Depending on sex,age,and clinical presentation,vesicoureteral reflux should be excluded.Antibacterial prophylaxis is beneficial.In toilet-trained children,bladder and bowel dysfunction needs to be excluded.Conclusions:The level of evidence is high for the diagnosis of UTI and treatment in children but not for imaging to identify patients at risk for upper urinary tract damage.Patient summary:In these guidelines,we looked at the diagnosis,treatment,and imaging of children with urinary tract infection.There are strong recommendations on diagnosis and treatment;we also advise exclusion of obstructive uropathy within 24h and later vesicoureteral reflux,if indicated.#2014Published by Elsevier B.V.on behalf of European Association of Urology.*Corresponding author.Division of Paediatric Urology,Department of Urology,Mainz University Medical Centre,Johannes Gutenberg University,Langenbeckstr.1,55131Mainz,Germany.Tel.+496131171;Fax:+49(0)6131177690.E-mail address:steinraimund@ (R.Stein)./10.1016/j.eururo.2014.11.0070302-2838/#2014Published by Elsevier B.V.on behalf of European Association of Urology.1.IntroductionIn 30%of children with urinary tract anomalies,urinary tract infection (UTI)can be the first sign [1].If we fail to identify patients at risk,damage to the upper urinary tract may occur.Up to 85%of infants and children with febrile UTI have visible photon defects on technetium Tc 99–labelled dimercaptosuccinic acid (DMSA)scanning,and 10–40%of these children have permanent renal scarring [2–4]that may lead to poor renal growth,recurrent pyelonephritis,impaired glomerular function,early hypertension,end-stage renal disease,and preeclampsia [5–10].Identifying children at risk of renal parenchymal damage and follow-up imaging after UTI is controversial.In these guidelines,we provide recommendations for the diagnosis,treatment,and imaging of children presenting with UTI based on evidence,and when this is lacking,based on expert consensus.2.BackgroundUTI is the most common bacterial infection in childhood [11–14],and up to 30%of infants and children experience recurrent infections during the first 6–12mo after initial UTI [15,16].In very young infants,symptoms of UTI differ in many ways from those in older infants and children.The prevalence is higher in the first age group,with a male predominance.Most infections are caused by Escherichia coli ,although in the first year of life Klebsiella pneumoniae ,Enterobacter spp,Enterococcus spp,and Pseudomonas are more frequent than later in life,and there is a higher risk of urosepsis compared with adulthood [17–19].The incidence of UTIs depends on age and sex.In the first year of life,UTIs are more common in boys (3.7%)than in girls (2%).This is even more pronounced in febrile infants in the first 2mo of life,with an incidence of 5%in girls and 20.3%in uncircumcised boys,as demonstrated in one prospective study of >1000patients using urine specimens obtained by catheterisation [18].Later,the incidence changes,and about 3%of prepubertal girls and 1%of prepubertal boys are diagnosed with a UTI [17–19].3.MethodologySeveral guidelines on dealing with specific subgroups of UTI are currently available,some of which are driven by economic and health care issues [20–22].The recommen-dations in these guidelines were developed by the European Association of Urology (EAU)/European Society for Paediat-ric Urology (ESPU)Paediatric Guidelines Committee after a review of the literature and a search of PubMed and Embase for UTI and newborn,infants,preschool,school,child ,and adolescent .A consensus decision was adopted when evidence was low.In these cases,all relevant papers and statements were discussed by all the authors until a consensus was achieved.The same criteria for the levels of evidence and grades of recommendation as in the EAU guidelines were used [23].4.ClassificationThe four widely used infection classification systems depend on the site,episode,symptoms,and complicating factors.For acute treatment,the site and severity are the most important.4.1.Classification according to siteCystitis (lower urinary tract)is inflammation of the urinary bladder mucosa with symptoms including dysuria,stran-guria,frequency,urgency,malodorous urine,incontinence,haematuria,and suprapubic pain.However,in newborns and infants,these symptoms are rarely diagnosed accurately.Pyelonephritis (upper urinary tract)is diffuse pyogenic infection of the renal pelvis and parenchyma with symptoms including fever (!388C).But unlike adults,infants and young children may have nonspecific signs such as poor appetite,failure to thrive,lethargy,irritability,vomiting,or diarrhoea.4.2.Classification according to episodeClassifications are first infection and recurrent infection ,which is subdivided into unresolved or persistent and reinfection [24].4.3.Classification according to symptomsAsymptomatic bacteriuria (ABU)indicates attenuation of uropathogenic bacteria by the host or colonisation of the bladder by nonvirulent bacteria that are incapable of activating a symptomatic response (no leucocyturia or symptoms).In patients with significant bacteriuria,leuco-cyturia can be present without any symptoms.Symptomatic UTI includes irritative voiding symptoms,suprapubic pain (cystitis),fever,and malaise (pyelonephri-tis).In patients with a neurogenic bladder and malodorous urine,it is difficult to distinguish between ABU and symptomatic UTI.4.4.Classification according to complicating factorsUncomplicated UTI is an infection in a patient with a morphologic and functional normal upper and lower urinary tract,normal renal function,and a competent immune system.Complicated UTI occurs in newborns,in most patients with clinical evidence of pyelonephritis,and in children with known mechanical or functional obstructions or problems of the upper or lower urinary tract [25].5.Diagnostic work-up5.1.Medical historyThe site,episode,symptoms,and complicating factors are identified by taking the patient’s history.This includes questions on primary (first)or secondary (recurring)E U R O P E A N U R O L O G Y X X X (2014)X X X –X X X2infection,febrile or nonfebrile UTIs;malformations of the urinary tract (eg,pre-or postnatal ultrasound [US]screening),previous operations,drinking,and voiding habits;family history;whether there is constipation or the presence of lower urinary tract symptoms;and sexual history in adolescents.5.2.Clinical signs and symptomsFever may be the only symptom of UTI,especially in young children [14,26–30].Newborns with pyelonephritis or urosepsis can present with nonspecific symptoms (failure to thrive,jaundice,vomiting,hyperexcitability,lethargy,hypothermia,and sometimes without fever)[31,32].Septic shock is unusual,even with high fever [24],unless obstruction is present or the child is otherwise compro-mised.In older children,lower urinary tract symptoms include dysuria,stranguria,frequency,urgency,malodor-ous urine,incontinence,haematuria,and suprapubic pain,and for the upper urinary tract,fever and flank pain.UTI in infancy may also be accompanied by a transient pseudohypoaldosteronism with profound hyponatraemia with or without hyperkalaemia [33,34].5.3.Physical examinationA complete paediatric physical examination is required to exclude any other source of fever,and especially if the fever has no apparent cause,UTI should be ruled out.Physical examination should search for signs of constipation,palpable and painful kidney,palpable bladder (stigmata of spina bifida or sacral agenesis spine and feet),for genital disorders (phimosis,labial adhesion,postcircumcision meatal stenosis,abnormal urogenital confluence,cloacal malformations,vulvitis,epididymoorchitis),and measure temperature.5.4.Urine sampling,analysis,and cultureBefore any antimicrobial agent is given,urine sampling must be performed.The technique used to obtain urine for urinalysis or culture affects the rate of contamination that in turn influences interpretation of the results,especially in early infancy [29,35].5.4.1.Urine sampling5.4.1.1.Newborns,infants,and non–toilet-trained children.In new-borns,infants,and non–toilet-trained children,there are four main methods for obtaining urine with varying contamination rates and invasiveness.A plastic bag attached to the cleaned genitalia is the technique used most often in daily practice.It is helpful when the culture result is negative.UTI can be excluded without the need for confirmatory culture if the dipstick is negative for both leukocyte esterase and nitrite,or microscopic analysis is negative for both pyuria and bacteriuria [36].As a result of the high contamination rate and high incidence of false-positive results,urine bag culture alone is not sufficiently reliable for diagnosing UTI.For clean-catch urine collection,the infant is placed in the lap of a parent or nurse holding a sterile foil bowl underneath the infant’s genitalia [37].This is time consuming and requires careful instructing of the parents.There seems to be a good correlation between the results of a urine culture obtained by this method and by suprapubic bladder aspiration (SPA)[20,37].However,the contamina-tion rates were 26%in clean-catch urine compared with 1%in the SPA group in a 2012study [38].Bladder catheterisation may be an alternative to SPA,although the rates of contamination are higher [39].The risk factors for a high contamination rate using this technique are patients <6mo of age,difficult catheterisation,and uncircumcised boys [40].Therefore,in children 6mo of age and uncircumcised boys,use of a new sterile catheter with each repeated attempt at catheterisation may reduce contamination [40].Otherwise,SPA should be the method of choice.Catheterisation is preferable in children with urosepsis when a permanent catheter may be considered in the acute phase.SPA is the most sensitive method for obtaining an uncontaminated urine ing US to assess bladder filling simplifies the aspiration [41,42].Bladder puncture causes more pain than catheterisation in infants <2mo of age [43].The Eutectic Mixture of Local Anesthetics,an emulsion containing a 1:1mixture of lidocaine and prilocaine,can be used topically to reduce pain [44].5.4.1.2.Toilet-trained children.In toilet-trained children,a cleanvoided midstream urine sample has a good rate of accuracy [45].It is important to clean the genitalia beforehand to reduce the contamination rate [46].In this age group,clean-catch voided urine,preferably midstream,has a sensitivity of 75–100%and a specificity of 57–100%,as shown in five studies using an SPA urine sample as the reference standard [45].If there is strong suspicion of upper UTI and for the differential diagnosis of sepsis,it is appropriate to obtain an adequate urine sample by catheterisation or SPA [20].In infants,the use of a bag is reliable only if the dipstick is negative;otherwise,the urine should be obtained through catheterisation or SPA.This is also recommended for exclusion or confirmation of UTI in older children who are severely ill.5.4.2.Urine analysisDipsticks and microscopy are commonly used for urinalysis.Some centres use flow imaging analysis technology.Most dipsticks test for nitrite,leukocyte esterase,protein,glucose,and blood.A dipstick test that is positive for leucocyte esterase and nitrite is highly sensitive for UTI [20,45,47].A test that is negative for leukocyte esterase and nitrite is highly specific for ruling out UTI [45].A few studies have suggested that glucose is also a useful marker [45].Only one study has looked at the diagnostic accuracy of a dipstick test for blood.It found that blood demon-strated poor sensitivity (25%)and high specificity (85%)[48].E U R O P E A N U R O L O G Y X X X (2014)X X X –X X X3Microscopy is used to detect pyuria and bacteriuria.Bacteriuria alone has a higher sensitivity than pyuria alone,although if both are positive,there is a high likelihood of UTI [45].Flow imaging analysis technology is increasingly used to classify particles in uncentrifuged urine specimens [49].The numbers of white blood cells,squamous epithelial cells,and red cells correlate well with those found by manual methods [20].5.4.3.Urine cultureIn patients with negative results on dipstick,microscopic,or automated urinalysis,urine culture is unnecessary if there is an alternative cause of the fever or inflammatory signs.However,if the dipstick and/or urinalysis are positive,confirmation of UTI by urine culture is mandatory.The classical definition of >105CFU/ml of voided urine is still used to define significant UTI in adult women [50,51].However,the count can vary and be related to the method of specimen collection,diuresis,and the duration and temperature of storage between collection and cultivation [52].The recent American Academy of Pediatrics (AAP)Guidelines on UTI suggest that the diagnosis should be based on the presence of both pyuria and at least 50000CFU/ml in an SPA sample.However,some studies have shown that in voided specimens, 10000organisms may indicate significant UTI [53,54].If urine is obtained by catheterisation,1000–50000CFU/ml is considered positive,and any counts obtained after SPA should be considered significant.Mixed cultures indicate contamination (Table 1).5.5.Blood testSerum electrolytes and blood cell counts should be obtained for monitoring ill patients with febrile UTI.C-reactive protein has a lower specificity for identifying patients with renal parenchymal involvement [55],whereas serum procalcitonin (>0.5ng/ml)can be used as a reliable serum marker [55–58].In a severely ill child,blood cultures should be taken as well as US imaging of the urinary tract.5.6.UltrasoundEarly US examination is indicated in children with febrile UTI and urosepsis to discriminate initially between complicated and uncomplicated UTI.It is also indicated if UTI is associated with pain or haematuria,or according to the preference of the treating physician/surgeon.6.TherapyBefore any antibiotic therapy is started,a urine specimen should be obtained for urinalysis and urine culture.In febrile children with signs of UTI (clinical signs,positive dipstick and/or positive microscopy),antibiotic treatment should be initiated as soon as possible to eradicate the infection,prevent bacteraemia,improve clinical outcome,diminish the likelihood of renal involvement during the acute phase of infection,and reduce the risk of renal scarring [31,59–61].In children with febrile UTI and no previous normal US examination,US of the urinary tract within 24h is advised to exclude obstructive uropathy,depending on the clinical situation.6.1.Asymptomatic bacteriuriaIn ABU without leucocyturia,antibiotic treatment should be avoided unless UTI causes problems or an operative procedure is planned.In a screening study from Sweden,2.5%of the boys and 0.9%of the girls <1yr of age had ABU verified by SPA.Among those infants,one girl and one boy developed symptoms of pyelonephritis close to the time of detection;the others remained asymptomatic.The median persistence of bacteriuria was 2mo in girls and 1.5mo in boys [62].Therefore screening for and treatment of ABU should be discouraged,irrespective of the method of urine sampling.6.2.Cystitis in children >3mo of ageThere are conflicting data concerning the duration of antibiotic therapy in this scenario,although there seems to be an advantage in treating these children for >1–2d [63–65].Therefore,in patients with uncomplicated cystitis,oral treatment should be given for at least 3–4d.6.3.Febrile children:administration routeWhen choosing between oral and parenteral therapy,these factors should be considered:patient age;clinical suspicion of urosepsis;severity of illness;refusal of fluids,food,and/or oral medication;vomiting;diarrhoea;noncompli-ance;and complicated febrile UTI (eg,upper tract dilatation).As a result of the increased incidence of urosepsis and severe pyelonephritis in newborns and infants <2mo of age,parenteral antibiotic therapy is recommended.Elec-trolyte disorders with life-threatening hyponatraemia and hyperkalaemia based on pseudohypoaldosteronism canTable 1–Criteria for urinary tract infections in children from the EAU guidelines on urological infectionsUrine specimen from suprapubic bladder punctureUrine specimen from bladder catheterisationUrine specimen from midstream voidAny number of CFU per millilitre (at least 10identical colonies)!1000–50000CFU/ml!104CFU/ml with symptoms !105CFU/ml without symptomsCFU =colony-forming units.Modified with permission from the European Association of Urology [75].E U R O P E A N U R O L O G Y X X X (2014)X X X –X X X4occur in such cases [33,34,66].Combination treatment with ampicillin and an aminoglycoside (eg,tobramycin or gentamicin)or a third-generation cephalosporin achieves excellent therapeutic results.A daily single dose of aminoglycosides is safer and equally effective as twice daily [66–68].The prevalence of antibiotic resistance in uropathogenic E coli differs markedly among countries,with high resistance in Iran and Vietnam [69].There are upcoming reports of UTIs caused by extended-spectrum b -lactamase (ESBL)–producing Enterobacteriaceae in children.In one study from Turkey,49%of the children <1yr of age and 38%of those >1yr of age had ESBL-producing bacteria.Within these groups 83%were resistant to trimethoprim/sulfamethoxazole,18%to nitrofurantoin,47%to quinolones,and 40%to aminoglycosides [70].Fortunately,the outcome appears to be the same as for children with non–ESBL-producing bacteria,despite the fact that initial intravenous empirical antibiotic therapy was inappropriate in one study [71].The choice of agent is also based on local antimicrobial sensitivity patterns and should be adjusted later according to sensitivity testing of the isolated uropathogen [20].Not all available antibiotics are approved by national health authorities for use in paediatric populations,especially in infants.6.4.Duration of therapy in febrile urinary tract infectionThe duration of parenteral application is still controversial [20,66,72,73].The consensus of the guideline panellists,as well as the AAP recommendations,is that parenteral antibiotic therapy should be continued until the child is afebrile,after which oral antibiotics should be given for 7–14d [20].If ambulatory (outpatient)therapy is chosen in late infancy,adequate surveillance,medical supervision,and,if necessary,adjustment of therapy must be guaranteed.In the initial phase of therapy,close contact with the family is advised [74].In complicated UTI with uropathogens other than E coli ,parenteral treatment with broad-spectrum antibiotics is preferred [66].Temporary urinary diversion may be required in obstructive uropathy,depending on clinical status and/or response to antibiotic therapy.6.5.Antimicrobial agentsTables 2–4list the recommended antibacterial therapies for different urogenital infections [75].6.6.ProphylaxisSome prospective randomised studies have challenged the efficacy of antibacterial prophylaxis [76–80].However,a subgroup of patients,missed by the large randomised studies,benefits from prophylaxis (Table 5).The Swedish reflux study [81]clearly demonstrated that chemoprophy-laxis is effective in preventing new renal scars in infant girlswith reflux III and IV.No patients in the prophylaxis group developed new renal scars,whereas 8of 43girls in the surveillance group and 5of 42in the endoscopically treated group had new renal scars at DMSA scanning after 2yr.None of the 75boys developed a new renal scar [81].A recent study compared children with infantile vesicoureteral reflux (VUR)with recurrent UTI (33male,11female;mean age: 3.2mo)and without recurrent UTI (40male,7female;mean age: 4.8mo)[82].They demonstrated that during the first year of life,the earlier the first UTI occurs,the higher the chance of recurrence.Higher grades of reflux,bilateral VUR,and the first infection not caused by E coli significantly increase the risk of recurrent UTIs [82].Clearly,there is a benefit for girls with dilating reflux,and long-term antibacterial prophylaxis should be considered in those cases of high susceptibility to UTI and risk of acquired renal damage.The recently published Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR)trial including 607children (280with a reflux I or II and 322with a reflux III or IV)demonstrated that antimicrobial prophylaxis with trimethoprim/sulfamethoxazole reduced the risk of recur-rence by 50%.In particular,children with a febrile index infection,bladder and bowel dysfunction (BBD),or dilating reflux benefitted from prophylaxis.The number of new renal scars was not different in this study [83].The indication for using cephalosporins for chemopro-phylaxis should be reconsidered in regions with a high incidence of ESBL-producing bacteria in children [70,71].Cranberry juice is increasingly used to prevent UTI.In one randomised Finnish trial,cranberry juice did not significantly reduce the number of children who experi-enced recurrence of UTI,but it was effective in reducing the actual number of recurrences and related antimicrobial use [84].In another study of only 40children,cranberry juice with high concentrations of proanthocyanidin (37%)re-duced the average incidence of UTI over a 12-mo period to 0.4patient/year with 1.15in the placebo group [85].Compliance with prophylaxis is important.In some studies,between 17%and 69%of the patients were compliant [86–88].Compliance depends greatly on parent and patient education [89].In boys with phimosis,early treatment should be discussed (local corticosteroid or surgery).7.Monitoring of urinary tract infectionWith successful treatment,urine usually becomes sterile after 24h,and leucocyturia normally disappears within 3–4d.Normalisation of body temperature can be expected within 24–48h after the start of therapy in 90%of cases.In patients with prolonged fever and failing recovery,treat-ment-resistant uropathogens or the presence of congenital uropathy or acute urinary obstruction should be considered.Immediate US examination is necessary,if not performed initially as recommended.Procalcitonin (among other laboratory inflammatory parameters such as C-reactive protein and leukocyte count)can be used as a reliable serum marker for early predictionE U R O P E A N U R O L O G Y X X X (2014)X X X –X X X5of renal parenchymal inflammation with a first febrile UTI [56].In patients with febrile UTI,serum electrolytes and blood cell counts should be obtained.7.1.Patients at riskPatients at risk are those with antenatally diagnosed uropathy,photopaenia on DMSA scanning after UTI,abnor-mal US examination (eg,upper urinary tract dilatation,small duplex kidney [or even small/dysplastic kidney],thick bladder wall,postvoid residual urine [if possible,US should always be performed with a full and empty bladder]),ureterocele,posterior urethral valves,urogenital abnormali-ties,intestinal connections to the perineum,previous UTI,dysfunctional voiding,enlarged bladder,poor urine flow,constipation,abdominal mass,spinal anomaly,family history of VUR,and those with poor family compliance.If no other cause is found,additional imaging is recommended for those with recurrent fever,poor growth,failure to thrive,or high blood pressure.If the parents refuse further imaging (voiding cystourethrography [VCUG]or DMSA scanning),they must be informed that there is at least a 30%chance of reflux and that renal scarring can develop.8.Imaging8.1.UltrasoundRenal and bladder US is advised in all children with febrile UTI to exclude dilatation or anomalies of the upper and lower urinary tract if no improvement is seen within 24h because some conditions are life threatening.It can be delayed in those with a previous normal US examination,depending on the clinical situation.Abnormal results are found in approximately 15%of cases,and 1–2%have abnormalities that require prompt action (eg,additional evaluation,referral,diversion,or surgery)[20].In other studies,renal US has revealed abnormalities in up to 37%of cases,whereas VCUG showed VUR in 27%of cases [1].Dilating VUR (with [intermittent]dilatation of the renal pelvis and calices)was missed by US in 24–33%of cases;in two published series [90,91],14of 23patients with normal US had recurrent pyelonephritis [90],with another study finding the figure to be approximately two of three patients <2yr of age who presented with febrile UTI [92].Postvoid residual urine should be measured in toilet-trained children to exclude voiding abnormalities.If pelvic US shows filling of the rectum >30mm,constipation mustTable 2–Frequently used antibacterial agents for treatment of paediatric urinary tract infectionsChemotherapeuticsDaily dosageApplicationComments0–12yrAdolescents,if differentParenteral cephalosporins Group 3a (eg,cefotaxime)Group 3b (eg,ceftazidime)Ceftriaxone100–200mg/kg 100–150mg/kg 75mg/kg3–6g 2–6gIV in 2–3D IV in 2–3D IV in 1DOral cephalosporinsGroup 3(eg,ceftibuten)Group 3(eg,cefixime)Group 2(eg,cefpodoxime proxetil)Group 2(eg,cefuroxime axetil)Group 1(eg,cefaclor)9mg/kg 8–12mg/kg 8–10mg/kg 20–30mg/kg 50–100mg/kg 0.4g 0.4g 0.4g0.5–1.0g 1.5–4.0g PO in 1–2D PO in 1–2D PO in 2D PO in 3D PO in 2–3D TMP orTMP/Sulfamethoxazole 5–6mg/kg5–6mg/kg (TMP fraction)–320mg POin2DPO in 2D Ampicillin AmoxicillinAmoxicillin/clavulanic acid (parenteral)Amoxicillin/clavulanic acid (oral)Piperacillin 100–200mg/kg 50–100mg/kg60–100mg/kg45mg/kg (amoxicillin fraction);maximum:500mg clavulanic acid per day300mg/kg per day 3–6g 1.5–6.0g3.6–6.6g1500and 375mgIV in 3–4D PO in 2–3D *IV in 3D IV in 3D PO in 3D PO in 3D;IV in 3–4DAmpicillin and amoxicillin are not eligible for calculated therapyTobramycin Gentamicin 5mg/kg5mg/kg 3–5mg/kg;maximum:0.4g3–5mg/kg;maximum:0.4gIV in 1DIV in 1DDrug monitoringCiprofloxacinChildren and adolescents (1–17yr):20–30mg/kg (maximum dose:400mg)(parenterally)Children and adolescents (1–17yr):20–40mg/kg (maximum dose:750mg)(PO)IV in 3DPO in 2DApproved in most Europeancountries as second-or third-line medication for complicated UTIs;antibiotic of last resortNitrofurantoin3–5mg –PO in 2DContraindicated in the case of renal insufficiencyD =doses per day;IV =intravenous;PO =oral;TMP =trimethoprim;UTI =urinary tract infection.*Infants:2D;children 1–12yr:3D;adolescents:2–3D.Modified with permission from the European Association of Urology [75].E U R O P E A N U R O L O G Y X X X (2014)X X X –X X X6。
中国肾脏移植受者尿路感染临床诊疗指南完整版
中国肾脏移植受者尿路感染临床诊疗指南完整版尿路感染是肾脏移植术后最常见的感染性并发症。
有报道表明，肾脏移植受者中尿路感染的发生率为7%～80%，而肾脏移植受者中37.8% 的菌血症继发于尿路感染。
尿路感染是肾脏移植术后最常见的感染性并发症。
有报道表明，肾脏移植受者中尿路感染的发生率为7%～80%，而肾脏移植受者中37.8% 的菌血症继发于尿路感染。
01 流行病学和临床分类临床问题1：肾脏移植受者发生尿路感染的危险因素有哪些？推荐意见1：肾脏移植受者发生尿路感染的危险因素是由供者、受者和解剖异常等多因素之间的相互作用决定的（推荐强度B，证据等级2a）。
临床问题2：根据感染发生时不同的部位及症状，肾脏移植受者发生尿路感染有哪些类型？推荐意见2：肾脏移植受者尿路感染分为非复杂性尿路感染和复杂性尿路感染（推荐强度D，证据等级5）。
临床问题3：肾脏移植受者尿路感染的常见致病微生物包括哪些？推荐意见3：在肾脏移植受者尿路感染中，大肠杆菌是最常见的致病微生物。
其他较为常见的致病微生物包括肠杆菌科、肠球菌、假单胞菌和表皮葡萄球菌（推荐强度B，证据等级2b）。
临床问题4：肾脏移植受者尿路感染的高发时间是什么？推荐意见4：肾脏移植受者尿路感染好发于肾脏移植术后的3 个月内（推荐强度A，证据等级1b）。
02 诊断和治疗临床问题5：诊断尿路感染最常用的检验方法是什么？如何正确留取尿液标本？推荐意见5：中段尿液标本分析和培养是诊断尿路感染最常用且准确的方法（推荐强度A，证据等级1a）。
推荐意见6：精确的尿液留取方式是耻骨上膀胱穿刺抽吸尿液标本（推荐强度A，证据等级1a）。
推荐意见7：正常排尿的肾脏移植受者，清洁会阴或阴茎头后留取中段尿液，如果无法自行排尿，应行导尿留取尿液标本（推荐强度A，证据等级1a）。
临床问题6：高通量测序在诊断复杂尿路感染病原体中的应用价值是什么？推荐意见8：推荐高通量测序用于复杂或传统培养未能明确病原菌的尿路感染受者，尤其是在怀疑多重病原体感染或非典型性病原体感染时应用价值更高（推荐强度B，证据等级2b）。