The amalgamation of current knowledge on Antibiotic prophylaxis in urology according to resources like AUA, EUA and Campbell

1. ANTIBIOTIC PROPHYLAXIS IN
UROLOGICAL SURGERY
Dr. Vijayant Govinda
MBBS MS MCh Urology
Govinda Healthcare
Best Urologist in Delhi

2. Source
• American Urological Association (AUA)
BEST PRACTICE POLICY STATEMENT ON ANTIMICROBIAL PROPHYLAXIS IN UROLOGICAL SURGERY
2008
• European Urological Association (EUA)
GUIDELINES ON UROLOGICAL INFECTIONS
2011
• Campbell Walsh Urology
10TH EDITION 2011

3. “Antimicrobial prophylaxis is the periprocedural
systemic administration of an antimicrobial
agent intended to reduce the risk of
postprocedural local and systemic infections”

4. Benefit
Cost

5. Potential Benefits depend on
• Patient Factors
• Procedural Factors
• Potential Morbidity of Surgery

6. Patient Factors (AUA)
• Advanced age
• Anatomic anomalies of the urinary tract
• Poor nutritional status
• Smoking
• Chronic corticosteroid use
• Immunodeficiency
• Externalized catheters
• Colonized endogenous/exogenous material
• Distant coexistent infection
• Prolonged hospitalization
Bacteria have a basic survival strategy: to
colonize surfaces and grow as biofilm
communities embedded in a gel-like
polysaccharide matrix. The catheterized
urinary tract provides ideal conditions for
the development of enormous biofilm
populations.
Bacterial colonization on intraluminal surface of urethral catheter
The catheters had been mainly placed to monitor urine output after
urologic surgery, and their median indwelling period was 3.0 days
(range 1 to 35). The overall positive rate of catheter culture was
significantly greater than that of urine culture (53.5% and 30.2%,
respectively, P <0.01), even in patients without a recent antibacterial
agent history. The difference was observed at day 2 (60% and 13.3%,
catheter versus urine culture, respectively, P = 0.011) and days 3 to 6
(52.4% and 14.3%, respectively, P = 0.010) of the indwelling period,
but was indistinguishable at day 14 and thereafter.
Masanori Matsukawa, Yasuharu Kunishima, Satoshi Takahashi, Kou Takeyama, Taiji Tsukamoto
Urology - March 2005

7. EUA
• American Society of Anesthesiology (ASA)
score
• Extreme weight
• History of UTI

8. Procedural Factors
The estimated risk of infectious complication is
related to the surgical class or category

9. Simple nephrectomy
Planned scrotal
surgery
Vasectomy
Varicocele surgery
Pelvio-ureteric
junction
repair
Nephron-sparing
tumour
resection
Total/radical
prostatectomy
Bladder surgery and
partial cystectomy
Incl. Vaginal surgery

10. Tentative list of essential criteria for assessment of surgical wound class/surgical field contamination level of common urological procedures: The estimated risk of infectious complication is related to the
surgical class or category (Urogenital infections, EAU/ICUD,2010, p 674-75
TURB (minor,
fulguration)

11. Costs
• Financial Costs
• Convenience
• Safety
• Society Costs
1. Cost of medicine
2. Dosage
3. Mode of administration
4. Frequency of administration1. Route of administration
2. Dosage
3. Frequency
1. Side Effect profile
2. Allergic reactions
3. Safety in special conditions eg renal
failure
Bacterial Resistance

12. Timing
Start
Within 60 minutes
of incision
(AUA)
Oral: 60 minutes
prior
IV: Time of Induction
(EUA)
Maintain
If more than 2 half
lives elapsed –
repeat dose
Stop
Within 24 hours
until indicated
In case of vancomycin and
fluoroquinolones – can be
started upto 120 minutes
before incision
To be extended beyond 24
hours:
Foreign material – eg
penile prosthesis or
externalised stents or
catheterized
2. In case of documented
infection preoperatively
or post operatively when
it is treatment and not
prophylaxis

13. Oral Antibiotics
• Oral antibiotics are as effective as iv
antibiotics when they have sufficient bio
availability and are administered at least one
hour prior to surgery
• One of the unique aspects of urological
surgery is use of oral fluoroquinolones

14. The use of oral fluoroquinolines as a
prophylactic agent in urologic endoscopic
surgery is a special situation. This
antimicrobial regimen is rarely used for
prophylaxis outside of urologic surgery
Level I evidence
Christiano AP, Hollowell CM, Kim H, Kim J, Patel R, Bales GT et al: Double-blind
randomized comparison of single-dose ciprofloxacin versus intravenous cefazolin in patients
undergoing outpatient endourologic surgery. Urology 2000; 55 -182.
One hundred patients were enrolled in a double-blind, randomized study to
receive either ciprofloxacin (500 mg) or cefazolin (1 g) before surgery. A
postoperative clinical evaluation and urine cultures were performed 5 to 10
days after surgery. Patients undergoing ureteral stent insertion or exchange,
ureteroscopy, bladder biopsy, retrograde pyelography, collagen injection, and
internal urethrotomy were included.
RESULTS:
Postoperative urinary tract infection occurred in 7 (9.1%) of 77 patients,
including 3 (8.1%) of 37 and 4 (10.0%) of 40 of those who
received ciprofloxacin and cefazolin, respectively (P =
0.77). There were no episodes of sepsis, and no patient
with infection required hospitalization. The total cost
associated with the administration of prophylactic antibiotics in the study
population was $3657 less in those 50 patients who received ciprofloxacin
than in the 50 patients who received cefazolin.

15. Antimicrobial prophylaxis is only one
of several measures thought to
reduce SSI.
• Hand Washing
•Proper Technique
•Sterile Precautions
•Operative planning
•Preoperative patient
optimization
•Bowel preparation

16. Urethral Catheterization
The risk of infection after one-time
urethral catheterization is 1%
to 2% in healthy domiciliary women;
however, this risk rises significantly in
hospitalized patients (Turck et al,
1962; Thiel and Spuhler, 1965).
• Oral single dose of antibiotic indicated if risk
factors present (Campbell Walsh Urology).
• If documented infection by culture then full
course of therapy indicated (EUA).

17. Removal of External Urinary Catheter
The rate of bacteriuria in short term
catheterized patients is 5% to 10% for each
day the catheter is in place.
AUA recommends prophylactic antibiotics in
patients with risk factors
Prophylactic antibiotics can be empirical or
culture directed (then treatment)
No treatment if culture sterileNo antibiotics in asymptomatic patients on CIC
antimicrobial treatment
before removal of an
indwelling catheter in a
patient suspected of
having bacteriuria is not
considered prophylaxis
but rather is treatment for
a presumptive UTI

18. Post operative drainage (EUA)
• EUA recommends against prolongation of
antibiotics in cases of uncomplicated surgery
unless documented colonization or surgery
complicated by infection
• E.g. no prolonged antibiotics for indwelling
drains in cases of clean laparoscopic surgery.

19. UDS/CYSTOGRAPHY/SIMPLE
CYSTOSCOPY
• AUA is ambiguous
Antimicrobial prophylaxis for cystography,
urodynamic study, or simple cystourethroscopy is
probably not necessary if the urine culture shows
no growth
• EUA recommends against prophylaxis but for
patients with complex clinical features and
large post voids it recommends for prophylaxis
But both
recommend a single
oral dose of
antibiotic if
antibiotic indicated

20. Cystourethroscopy with manipulation
TURP/TURBT
Concurrent view is antibiotic
prophylaxis indicated in all
patients
Berry A and Barratt A: Prophylactic antimicrobial use in
transurethral prostatic resection: a meta-analysis. J Urol 2002;
167:571.

21. Transrectal Prostate Biopsy
Concurrent view is antibiotic
prophylaxis indicated in all
patients
In a three-armed RCT (231 patients) comparing placebo, a single dose of
ciprofloxacin and tinidazole, and the same combination twice a day for three
days, the incidence of all infectious complications, and specifically UTI was
significantly lower in both antimicrobial groups. Moreover, the single dose
was as effective as the three-day dosing.
Aron M, Rajeev TP and Gupta NP: Antimicrobial prophylaxis for transrectal
needle biopsy of the prostate: a randomized controlled study. BJU Int 2000;
85:682.)

22. ESWL
• AUA
“Revised recommendation to : Indicated if risk
factors – on 09/2/2012”
A recent prospective case-series of 526 shockwave lithotripsy patients, of
whom only 10 received antimicrobial prophylaxis, documented very
low rates of UTI (0.2%) and asymptomatic bacteriuria (0.8%).
Wiesenthal JD, Ghiculete D, Ordon M, Pace KT and John D'A Honey R: A Prospective Study Examining the Incidence
of Bacteriuria and Urinary Tract Infection PostShockwave Lithotripsy: The Case Against Universal Antibiotic
Prophylaxis. J Urol 2011; 185: e472.
But EUA also
recommends
antibiotics in cases of
indwelling stents/
PCN tubes/ Infected
Stones/ And
documented UTI

23. Percutaneous Renal Sugery
Concurrent view is antibiotic
prophylaxis indicated in all
patients

24. Ureteroscopy
• AUA recommends prophylaxis in all patients
• EUA differentiates:
– Recommends against for distal stone treatments
and simple diagnostic procedures
– Recommends for proximal stones and renal
interventions

25. Basis for AUA
• Diagnostic and therapeutic upper tract
studies are performed with pressurized
irrigants and may induce urothelial injury
• increased trauma to the mucosa, increased
duration and/or degree of difficulty of most
ureteroscopic procedures, increased pressure
of irrigants

26. Vaginal Surgery
Concurrent view is antibiotic
prophylaxis indicated in all
patients

27. Open or laparoscopic surgery without
entering urinary tract
prophylaxis indicated if risk factors
Radical
Nephrectomy is
also included in
this
Radical
Nephrectomy is a
clean surgery
Clean surgeries do not
require prophylaxis as
evidenced thoroughly
in general surgery
literature
EUA recommends
against prophylaxis on
this basis

28. Open or laparoscopic surgery with
entering urinary tract
Concurrent view is antibiotic
prophylaxis indicated in all
patients

29. Open or laparoscopic surgery with
use of bowel segments
Concurrent view is antibiotic
prophylaxis indicated in all
patients

30. Open or laparoscopic surgery with
implantable foreign material
Concurrent view is antibiotic
prophylaxis indicated in all
patients

31. INDIAN PERSPECTIVE

32. Cefoperazone