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van Beek J, Sobhani H, Wöllner J, Pannek J, Krebs J. Patient-reported signs and symptoms of urinary tract infections after video-urodynamic studies in individuals with neurogenic lower urinary tract dysfunction-A single-center observational study. Neurourol Urodyn 2024; 43:1609-1616. [PMID: 38801121 DOI: 10.1002/nau.25516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/03/2024] [Accepted: 05/20/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Video-urodynamic studies (VUDS) are the recommended standard of diagnostic care to objectively assess neurogenic lower urinary tract dysfunction (NLUTD) in individuals with spinal cord injury/disease (SCI/D). This examination requires the insertion of a catheter into the bladder, which increases the risk of a urinary tract infection (UTI). Data on symptomatic UTIs after VUDS are limited. METHODS A single-center, observational study was conducted to evaluate the incidence of patient-reported UTI signs and symptoms 7 days after VUDS. No peri-interventional antibiotics were administered. The effect of sex, age, SCI/D duration, bladder evacuation method, bacteriuria, UTI prophylaxis, UTI history, or unfavorable VUDS results on the occurrence of patient-reported UTI signs or symptoms after VUDS was examined using binary logistic regression analysis. RESULTS A total of 140 individuals with a mean age of 59.1 ± 14.0 years and a median SCI/D duration of 15.0 years (6/29 years) were evaluated. Seven days (mean 7 ± 1 days) after VUDS, 42 (30%) individuals reported at least one UTI sign or symptom. In the majority, signs and symptoms resolved without the need for antibiotic treatment, which was required in seven participants (5%). Male sex significantly (p = 0.04) increased the odds (odds ratio 3.74) of experiencing UTI signs and symptoms after VUDS. CONCLUSIONS In individuals with NLUTD, 30% experienced UTI signs and symptoms 1 week after VUDS. However, these signs and symptoms were transient and only 5% required antibiotic treatment. Thus, antibiotic prophylaxis does not seem necessary in all individuals with SCI/D undergoing VUDS.
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Affiliation(s)
- Judith van Beek
- Neuro-Urology, Swiss Paraplegic Research, Nottwil, Switzerland
| | - Human Sobhani
- Neuro-Urology, Swiss Paraplegic Research, Nottwil, Switzerland
| | - Jens Wöllner
- Neuro-Urology, Swiss Paraplegic Research, Nottwil, Switzerland
- Neuro-Urology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Research, Nottwil, Switzerland
- Neuro-Urology, Swiss Paraplegic Centre, Nottwil, Switzerland
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jörg Krebs
- Neuro-Urology, Swiss Paraplegic Research, Nottwil, Switzerland
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Zhao F, Zhang L, Chen X, Lei M, Sun L, Ma L, Wang C. Construction and Verification of Urinary Tract Infection Prediction Model for Hospitalized Rehabilitation Patients with Spinal Cord Injury. World Neurosurg 2024; 188:e396-e404. [PMID: 38810877 DOI: 10.1016/j.wneu.2024.05.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVE To explore the influencing factors of urinary tract infection (UTI) in hospitalized patients with spinal cord injury and to construct and verify the nomogram prediction model. METHODS This study is a retrospective cohort study. From January 2017 to March 2022, 558 patients with spinal cord injury admitted to the Department of Rehabilitation Medicine of a tertiary hospital in Anhui Province, China, were selected as the research objects, and they were randomly divided into training group (n = 390) and verification group (n = 168) according to the ratio of 7:3, and clinical data including socio-demographic characteristics, disease-related data, and laboratory examination data were collected. Univariate analysis and multivariate logistic regression were used to analyze the influencing factors of UTI in hospitalized patients with spinal cord injuries. Based on this, a nomogram prediction model was constructed with the use of R software, and the risk prediction efficiency of the nomogram model was verified by the receiver operating characteristic curve and calibration curve. RESULTS Logistic regression analysis showed that the American Spinal Cord Injury Association (ASIA)-E grade (compared with ASIA-A grade) was an independent protective factor for UTI in hospitalized patients with spinal cord injury (odds ratio < 1, P < 0.05), while white blood cell count and indwelling catheter were independent risk factors for UTI in hospitalized patients with spinal cord injury (odds ratio > 1, P < 0.05). Based on this, a nomogram risk predictive model for predicting UTI in hospitalized rehabilitation patients with spinal cord injury was constructed, which proved to have good predictive efficiency. In the training group and the verification group, the area under the receiver operating characteristic curve of the nomogram model is 0.808 and 0.767, and the 95% confidence interval of the area under the receiver operating characteristic curve of the nomogram in the training group and the verification group is 0.760∼0.856 and 0.688∼0.845, respectively, indicating the nomogram model has good discrimination. According to the calibration curve, the prediction probability of the nomogram model and the actual frequency of UTI in the training group and the verification group are in good consistency, and the results of the Hosmer-Lemeshow bias test also suggest that the nomogram model has a good calibration degree in both the training group and the verification group (P = 0.329, 0.067). CONCLUSIONS ASIA classification level, white blood cell count, and indwelling catheter are independent influencing factors of UTI in hospitalized patients with spinal cord injury. The nomogram prediction model based on the above factors can simply and effectively predict the risk of UTI in hospitalized patients with spinal cord injury, which is helpful for clinical medical staff to identify high-risk groups early and implement prevention, treatment, and nursing strategies in time.
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Affiliation(s)
- Fangfang Zhao
- Department of Rehabilitation Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Lixiang Zhang
- Department of Cardiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Xia Chen
- Department of Nursing, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Mengling Lei
- Department of Rehabilitation Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China; The Graduate School, Bengbu Medical University, Bengbu, Anhui, China
| | - Liai Sun
- Department of Rehabilitation Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Lina Ma
- Department of Rehabilitation Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Cheng Wang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China.
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Averbeck MA, Kennelly M, Thiruchelvam N, Konstantinidis C, Chartier-Kastler E, Krassioukov A, Landauro M, Jacobsen L, Vaabengaard R, Islamoska S. Risk factors for urinary tract infections associated with lower quality of life among intermittent catheter users. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:S8-S16. [PMID: 37830866 DOI: 10.12968/bjon.2023.32.18.s8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND Evidence shows that intermittent catheterisation (IC) for bladder emptying is linked to urinary tract infections (UTIs) and poor quality of life (QoL). AIM To investigate the association between UTI risk factors and QoL and patient-reported UTIs respectively. METHODS A survey was distributed to IC users from 13 countries. FINDINGS Among 3464 respondents, a significantly poorer QoL was observed when experiencing blood in the urine, residual urine, bowel dysfunction, recurrent UTIs, being female, and applying withdrawal techniques. A lower UTI risk was found when blood was not apparent in urine (RR: 0.63; 95% CI: 0.55-0.71), the bladder was perceived empty (RR: 0.83; 95% CI: 0.72-0.96), not having bowel dysfunction (RR: 0.86; 95% CI: 0.76-0.98), and being male (RR: 0.70; 95% CI: 0.62-0.79). CONCLUSION This study underlines the importance of risk factors and their link to QoL and UTIs, highlighting the need for addressing symptoms before UTIs become problematic.
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Affiliation(s)
| | - Michael Kennelly
- Professor and Director, Atrium Health, Carolinas Medical Center, Charlotte, NC, USA
| | | | | | - Emmanuel Chartier-Kastler
- Professor and Head of Urology, Sorbonne Université, Academic hospital Pitié Salpétrière, Paris, France
| | - Andrei Krassioukov
- Principal Investigator, Professor and Associate Director, International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, The University of British Columbia; GF Strong Rehabilitation Centre, Vancouver Coastal Health Authority; Division of Physical Medicine and Rehabilitation, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Malene Landauro
- Senior Medical Writer, Clinical Strategies, Coloplast A/S, Humlebæk, Denmark
| | - Lotte Jacobsen
- Principal Biostatistician, Clinical Strategies, Coloplast A/S, Humlebæk, Denmark
| | - Rikke Vaabengaard
- Lead Medical Specialist, Medical Affairs, Coloplast A/S, Humlebæk, Denmark
| | - Sabrina Islamoska
- Senior Evidence Manager, Medical Affairs, Coloplast A/S, Humlebæk, Denmark
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Botter SM, Kessler TM. Neuro-Urology and Biobanking: An Integrated Approach for Advancing Research and Improving Patient Care. Int J Mol Sci 2023; 24:14281. [PMID: 37762582 PMCID: PMC10531693 DOI: 10.3390/ijms241814281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Understanding the molecular mechanisms underlying neuro-urological disorders is crucial for the development of targeted therapeutic interventions. Through the establishment of comprehensive biobanks, researchers can collect and store various biological specimens, including urine, blood, tissue, and DNA samples, to study these mechanisms. In the context of neuro-urology, biobanking facilitates the identification of genetic variations, epigenetic modifications, and gene expression patterns associated with neurogenic lower urinary tract dysfunction. These conditions often present as symptoms of neurological diseases such as Alzheimer's disease, multiple sclerosis, Parkinson's disease, spinal cord injury, and many others. Biobanking of tissue specimens from such patients is essential to understand why these diseases cause the respective symptoms and what can be done to alleviate them. The utilization of high-throughput technologies, such as next-generation sequencing and gene expression profiling, enables researchers to explore the molecular landscape of these conditions in an unprecedented manner. The development of specific and reliable biomarkers resulting from these efforts may help in early detection, accurate diagnosis, and effective monitoring of neuro-urological conditions, leading to improved patient care and management. Furthermore, these biomarkers could potentially facilitate the monitoring of novel therapies currently under investigation in neuro-urological clinical trials. This comprehensive review explores the synergistic integration of neuro-urology and biobanking, with particular emphasis on the translation of biobanking approaches in molecular research in neuro-urology. We discuss the advantages of biobanking in neuro-urological studies, the types of specimens collected and their applications in translational research. Furthermore, we highlight the importance of standardization and quality assurance when collecting samples and discuss challenges that may compromise sample quality and impose limitations on their subsequent utilization. Finally, we give recommendations for sampling in multicenter studies, examine sustainability issues associated with biobanking, and provide future directions for this dynamic field.
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Affiliation(s)
- Sander M. Botter
- Swiss Center for Musculoskeletal Biobanking, Balgrist Campus AG, 8008 Zürich, Switzerland
| | - Thomas M. Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland;
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Neumeier V, Stangl FP, Borer J, Anderson CE, Birkhäuser V, Chemych O, Gross O, Koschorke M, Marschall J, McCallin S, Mehnert U, Sadri H, Stächele L, Kessler TM, Leitner L. Indwelling catheter vs intermittent catheterization: is there a difference in UTI susceptibility? BMC Infect Dis 2023; 23:507. [PMID: 37533010 PMCID: PMC10398982 DOI: 10.1186/s12879-023-08475-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/20/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Patients with neurogenic lower urinary tract dysfunction (NLUTD) often rely on some type of catheterization for bladder emptying. Intermittent catheterization (IC) is considered the gold standard and is preferred over continuous catheterization, since it is considered to cause fewer urinary tract infections (UTIs) than indwelling catheterization. The main objective of our study was to describe UTI prevalence (at visit) and incidence (within the last 12 months) and urine culture characteristics between patients using an indwelling catheter versus (vs) those performing IC. METHODS In this cross-sectional study, we prospectively evaluated from 02/2020 to 01/2021 patients with NLUTD undergoing urine cultures for prophylactic reasons or due to UTI symptoms. At visit, all patients underwent a standardized interview on current UTI symptoms as well as UTI history and antibiotic consumption within the past year. Patients using an indwelling catheter (n = 206) or IC (n = 299) were included in the analysis. The main outcome was between-group differences regarding UTI characteristics. RESULTS Patients using an indwelling catheter were older (indwelling catheter vs IC: median 66 (Q1-Q3: 55-77) vs 55 (42-67) years of age) and showed a higher Charlson comorbidity index (indwelling catheter vs IC: median 4 (Q1-Q3: 2-6) vs 2 (1-4) (both p < 0·001). A total of 40 patients from both groups were diagnosed with a UTI at visit (indwelling catheters vs IC: 8% (16/206) vs 8% (24/299); p = 0·782), and the number of UTIs within the past 12 months was not significantly different between groups. Overall, Escherichia coli (21%), Enterococcus faecalis (17%), and Klebsiella spp. (12%) were the most frequently detected bacteria. CONCLUSIONS In this cohort of patients with NLUTD, we did not find relevant differences in UTI frequency between groups. These results suggest that UTI-related concerns should not be given undue emphasis when counseling patients for catheter-related bladder emptying methods.
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Affiliation(s)
- Vera Neumeier
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Fabian P Stangl
- Department of Urology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Joëlle Borer
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
- Department of Urology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Collene E Anderson
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Oksana Chemych
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Oliver Gross
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Miriam Koschorke
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Jonas Marschall
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis Missouri, USA
| | - Shawna McCallin
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Helen Sadri
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Lara Stächele
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland.
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Stangl FP, Schneidewind L, Kiss B, Kranz J, Wagenlehner FM, Johansen TEB, Köves B, Medina-Polo J, Tapia AM, Tandogdu Z. Non-Antibiotic Prophylaxis for Recurrent UTIs in Neurogenic Lower Urinary Tract Dysfunction (NAPRUN): Study Protocol for a Prospective, Longitudinal Multi-Arm Observational Study. Methods Protoc 2023; 6:52. [PMID: 37367996 DOI: 10.3390/mps6030052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
INTRODUCTION Patients with neurogenic lower urinary tract dysfunction (NLUTD) reliant on intermittent self-catheterization for bladder emptying are at an increased risk of recurrent urinary tract infections (rUTI). So far, the most common practice in the prevention of rUTIs is long-term low-dose antibiotic prophylaxis, phytotherapy, and immunomodulation, whereby antibiotic prophylaxis inevitably leads to the emergence of drug-resistant pathogens and difficulty in treating infections. Therefore, non-antibiotic alternatives in the prevention of rUTIs are urgently required. We aim to identify the comparative clinical effectiveness of a non-antibiotic prophylaxis regimen in the prevention of recurrent urinary tract infections in patients with neurogenic bladder dysfunction who practice intermittent self-catheterization. METHODS AND ANALYSIS In this multi-centre, prospective longitudinal multi-arm observational study, a total of 785 patients practising intermittent self-catheterisation due to NLUTD will be included. After inclusion, non-antibiotic prophylaxis regimens will be instilled with either UroVaxom® (OM-89) standard regimen, StroVac® (bacterial lysate vaccine) standard regimen, Angocin®, D-mannose (oral dose 2 g), bladder irrigation with saline (once per day). The management protocols will be pre-defined, but the selection of the protocol will be at the clinicians' discretion. Patients will be followed for 12 months from the onset of the prophylaxis protocol. The primary outcome is to identify the incidence of breakthrough infections. The secondary outcomes are adverse events associated with the prophylaxis regimens and the severity of breakthrough infections. Other outcomes include the exploration of change in susceptibility pattern via the optional rectal and perineal swab, as well as health-related quality of life over time (HRQoL), which will be measured in a random subgroup of 30 patients. ETHICS AND DISSEMINATION Ethical approval for this study has been granted by the ethical review board of the University Medical Centre Rostock (A 2021-0238 from 28 October 2021). The results will be published in a peer-reviewed journal and presented at relevant meetings. STUDY REGISTRATION NUMBER German Clinical Trials Register: Number DRKS00029142.
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Affiliation(s)
- Fabian P Stangl
- Department of Urology, University Hospital of Bern, 3010 Bern, Switzerland
| | - Laila Schneidewind
- Department of Urology, University Medical Center Rostock, 18055 Rostock, Germany
| | - Bernhard Kiss
- Department of Urology, University Hospital of Bern, 3010 Bern, Switzerland
| | - Jennifer Kranz
- Department of Urology and Paediatric Urology, Uniklinik RWTH Aachen, 52074 Aachen, Germany
- Department of Urology and Kidney Transplantation, Martin Luther University, 06120 Halle (Saale), Germany
| | - Florian M Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen, 35390 Giessen, Germany
| | - Truls E Bjerklund Johansen
- Institute of Clinical Medicine, University of Aarhus, 8200 Aarhus, Denmark
- Department of Urology, Oslo University Hospital, 0315 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway
| | - Béla Köves
- Department of Urology, University of Szeged, 6725 Szeged, Hungary
| | - Jose Medina-Polo
- Department of Urology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
| | - Ana Maria Tapia
- Department of Urology, Hospital Universitario Río Hortega, 47012 Valladolid, Spain
| | - Zafer Tandogdu
- Department of Urology, University College London Hospitals, London W1G 8PH, UK
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Hernández-Hernández D, Ortega-González Y, Padilla-Fernández B, Gutiérrez-Hernández PR, Castro-Díaz DM. Management of Acute Cystitis in the Era of COVID-19. CURRENT BLADDER DYSFUNCTION REPORTS 2023; 18:10-15. [PMID: 36466948 PMCID: PMC9684745 DOI: 10.1007/s11884-022-00677-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/24/2022]
Abstract
Purpose of Review No specific guidelines have been developed for acute cystitis management during the COVID-19 pandemic. This review aims to provide up-to-date information about treatment and follow-up in patients with symptoms suggesting lower urinary tract infection. Recent Findings Uncomplicated cystitis does not need microbiological confirmation; thus, clinical diagnosis via telephone interview or questionnaires may be done. When complicated infections are suspected, in-person evaluation or close follow-up is mandatory. Antibiotic treatment is still the gold standard for treatment, although non-pharmacological strategies have also been suggested and further investigations are warranted. Summary Urinary tract infections are still a frequent reason for consultation that needs to be addressed in both primary care and specialized levels. Their management during the pandemic is similar than in precedent years, but telehealth options have emerged which can facilitate diagnosis and treatment.
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Affiliation(s)
- David Hernández-Hernández
- Department of Urology, Hospital Universitario de Canarias, Carretera de Ofra, S/N, 38320 San Cristóbal de La Laguna, Tenerife Spain
| | - Yanira Ortega-González
- Department of Urology, Hospital Universitario de Canarias, Carretera de Ofra, S/N, 38320 San Cristóbal de La Laguna, Tenerife Spain
| | - Bárbara Padilla-Fernández
- Department of Urology, Hospital Universitario de Canarias, Carretera de Ofra, S/N, 38320 San Cristóbal de La Laguna, Tenerife Spain ,Departamento de Cirugía, Universidad de La Laguna, San Cristóbal de La Laguna, Tenerife Spain
| | - Pedro Ramón Gutiérrez-Hernández
- Department of Urology, Hospital Universitario de Canarias, Carretera de Ofra, S/N, 38320 San Cristóbal de La Laguna, Tenerife Spain ,Departamento de Cirugía, Universidad de La Laguna, San Cristóbal de La Laguna, Tenerife Spain
| | - David Manuel Castro-Díaz
- Department of Urology, Hospital Universitario de Canarias, Carretera de Ofra, S/N, 38320 San Cristóbal de La Laguna, Tenerife Spain ,Departamento de Cirugía, Universidad de La Laguna, San Cristóbal de La Laguna, Tenerife Spain
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