EURURO-6207; No. of Pages 2 EUROPEAN UROLOGY XXX (2015) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
Acute Epididymitis: What You Think Is Not Always What You Get Jean-Nicolas Cornu a,*, Franck Bruye`re b,c a
Department of Urology, Charles Nicolle University Hospital, University of Rouen, Rouen, France;
b
Department of Urology, Hoˆpital Bretonneau, Tours,
c
France; Universite´ Franc¸ois Rabelais de Tours, PRES Centre Val de Loire Universite´, Tours, France
Acute infections of the genitourinary tract are highly prevalent in the Western world, and virtually all urologists have to deal with such cases on a daily basis in their clinical practice. Similar to other acute infectious diseases, a very important issue at the diagnosis phase is to suspect the right causative pathogen to begin the best antimicrobial treatment, often in an emergency setting. In this context, knowledge about the pathophysiology of the disease, the relative frequencies of putative micro-organisms, the antimicrobial resistance profile and epidemiology, and the performance and interpretation of the usual tests required for uropathogen identification are crucial. In the field of urinary tract infections, urine culture is the cornerstone of the basic initial work-up. Some recent papers have shown that urine-sampling methods and interpretation of the results have a major influence and that further progress can still be made in this field [1]. Within the specific area of male urinary tract infection, acute epididymitis presents a very common clinical picture in which two types of causative agents are usually considered: sexually transmitted organisms and common urinary pathogens. Suspecting the right one is of importance because it conditions the choice of treatment. Currently, the European Association of Urology (EAU) guidelines state that in young, sexually active men, Chlamydia trachomatis is usually causative, and in older men with benign prostatic hyperplasia or other micturition disturbances, the most common uropathogens are involved. Fluoroquinolones with action on C. trachomatis are the treatment of choice until a specific microbial agent is identified [2]. The main issue in the field is that those recommendations are based on very old studies [3,4] that do not necessarily reflect the current reality, especially regarding the causative pathogens. Furthermore,
acquired resistance is more controversial in Chlamydiae. In two different studies, the basis of quinolone resistance was a mutation in gyrA leading to an isoleucine for serine substitution at position 83 in DNA gyrase [5,6]. Clinical treatment failures have been attributed to C. trachomatis strains exhibiting heterotypic multidrug resistance. Induction of resistance has been observed in vitro, but homotypic stable resistance has been demonstrated only in swine isolates. Heterotypic stable resistance could correspond more to the induction of a persistent phenotype refractory to multiple antibiotics, and its responsibility in therapeutic failure is still not clear. High levels of resistance to ciprofloxacin and ofloxacin have also been reported [7]. In this month’s issue of European Urology, Pilatz et al address this issue through the results of a landmark prospective study [8]. Using adequate bacterial and virologic diagnostic tools, they investigated the etiology of acute epididymitis in a cohort of men. Among those patients, reflecting the reality of an academic medical center, they identified patients who were antibiotic naı¨ve, those who had previous treatments, and a specific group with patients who had an indwelling catheter. Major findings of the study were (1) that a bacterial infection was diagnosed in 87% of naı¨ve cases but also in 51% of those who already received antibiotics (meaning that antimicrobial investigations are bankable in those patients) and (2) that common enteric pathogens were responsible for many cases including those in patents aged
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
Acute Epididymitis: What You Think Is Not Always What You Get Jean-Nicolas Cornu a,*, Franck Bruye`re b,c a
Department of Urology, Charles Nicolle University Hospital, University of Rouen, Rouen, France;
b
Department of Urology, Hoˆpital Bretonneau, Tours,
c
France; Universite´ Franc¸ois Rabelais de Tours, PRES Centre Val de Loire Universite´, Tours, France
Acute infections of the genitourinary tract are highly prevalent in the Western world, and virtually all urologists have to deal with such cases on a daily basis in their clinical practice. Similar to other acute infectious diseases, a very important issue at the diagnosis phase is to suspect the right causative pathogen to begin the best antimicrobial treatment, often in an emergency setting. In this context, knowledge about the pathophysiology of the disease, the relative frequencies of putative micro-organisms, the antimicrobial resistance profile and epidemiology, and the performance and interpretation of the usual tests required for uropathogen identification are crucial. In the field of urinary tract infections, urine culture is the cornerstone of the basic initial work-up. Some recent papers have shown that urine-sampling methods and interpretation of the results have a major influence and that further progress can still be made in this field [1]. Within the specific area of male urinary tract infection, acute epididymitis presents a very common clinical picture in which two types of causative agents are usually considered: sexually transmitted organisms and common urinary pathogens. Suspecting the right one is of importance because it conditions the choice of treatment. Currently, the European Association of Urology (EAU) guidelines state that in young, sexually active men, Chlamydia trachomatis is usually causative, and in older men with benign prostatic hyperplasia or other micturition disturbances, the most common uropathogens are involved. Fluoroquinolones with action on C. trachomatis are the treatment of choice until a specific microbial agent is identified [2]. The main issue in the field is that those recommendations are based on very old studies [3,4] that do not necessarily reflect the current reality, especially regarding the causative pathogens. Furthermore,
acquired resistance is more controversial in Chlamydiae. In two different studies, the basis of quinolone resistance was a mutation in gyrA leading to an isoleucine for serine substitution at position 83 in DNA gyrase [5,6]. Clinical treatment failures have been attributed to C. trachomatis strains exhibiting heterotypic multidrug resistance. Induction of resistance has been observed in vitro, but homotypic stable resistance has been demonstrated only in swine isolates. Heterotypic stable resistance could correspond more to the induction of a persistent phenotype refractory to multiple antibiotics, and its responsibility in therapeutic failure is still not clear. High levels of resistance to ciprofloxacin and ofloxacin have also been reported [7]. In this month’s issue of European Urology, Pilatz et al address this issue through the results of a landmark prospective study [8]. Using adequate bacterial and virologic diagnostic tools, they investigated the etiology of acute epididymitis in a cohort of men. Among those patients, reflecting the reality of an academic medical center, they identified patients who were antibiotic naı¨ve, those who had previous treatments, and a specific group with patients who had an indwelling catheter. Major findings of the study were (1) that a bacterial infection was diagnosed in 87% of naı¨ve cases but also in 51% of those who already received antibiotics (meaning that antimicrobial investigations are bankable in those patients) and (2) that common enteric pathogens were responsible for many cases including those in patents aged
