Does Preoperative Topical Antimicrobial Scrub Reduce Positive Surgical Site Culture Rates in Men Undergoing Artificial Urinary Sphincter Placement?

Antibiotic prophylaxis in urologic interventions: Who, when, where?

BACKGROUND

Periprocedural prophylaxis in medicine encompasses the set of measures (physical, chemical, and pharmacological) used to reduce the risk of infection. Antibiotic prophylaxis (AP) refers to the administration of a short-term regimen of antibiotics shortly before a medical procedure to reduce the risk of infectious complications that can result from diagnostic and therapeutic interventions. The outspreading growth of multidrug-resistant bacterial species and changes in the bacterial local ecosystem have impeded the development of a unique scheme of AP in urology.

OBJECTIVES

To review the literature and current guidelines regarding AP for urological diagnostic and therapeutic procedures, and to define agents, timing, and occasions when administering pharmacological prophylaxis. Secondly, according to current literature, to open new scenarios where AP can be useful or useless.

RESULTS

Major gaps in evidence still exist in this field. AP appears useful in many invasive procedures and some sub-populations at risk of infectious complications. AP is not routinely recommended for urodynamic exams, diagnostic cystoscopy, and extracorporeal shock-wave lithotripsy. The available data regarding the use of AP during the transperineal prostate biopsy are still unclear; conversely, in the case of the transrectal approach AP is mandatory. AP is still considered the gold standard for the prevention of postoperative infective complications in the case of ureteroscopy, percutaneous nephrolithotomy, endoscopic resection of bladder tumor, endoscopic resection of the prostate, and prosthetic or major surgery.

CONCLUSION

The review highlights the complexity of determining the appropriate candidates for AP, emphasizing the importance of considering patient-specific factors such as comorbidities, immunocompetence, and the nature of the urologic intervention. The evidence suggests that a one-size-fits-all approach may not be suitable, and a tailored strategy based on the specific procedure and patient characteristics is essential.

Trends over 20 years of antimicrobial prophylaxis for artificial urinary sphincter surgery

INTRODUCTION AND OBJECTIVE

Perioperative antimicrobial prophylaxis is crucial for prevention of prosthesis and patient morbidity after artificial urinary sphincter (AUS) placement. While antibiotic guidelines exist for many urologic procedures, adoption patterns for AUS surgery are unclear. We aimed to assess trends in antibiotic prophylaxis for AUS and outcomes relative to American Urological Association (AUA) Best Practice guidelines.

METHODS

The Premier Healthcare Database was queried from 2000 to 2020. Encounters involving AUS insertion, revision/removal, and associated complications were identified via ICD and CPT codes. Premier charge codes were used to identify antibiotics used during the insertion encounter. AUS-related complication events were found using patient hospital identifiers. Univariable analysis between hospital/patient characteristics and use of guideline-adherent antibiotics was done via chi-squared and Kruskal-Wallis tests. A multivariable logistic mixed effects model was used to assess factors related to the odds of complication, specifically the use of guideline-adherent versus nonadherent regimens.

RESULTS

Of 9775 patients with primary AUS surgery, 4310 (44.1%) received guideline-adherent antibiotics. The odds of guideline-adherent regimen use increased 7.7% per year with 53.0% (830/1565) receiving guideline-adherent antibiotics by the end of the study period. Patients with guideline-adherent regimens had a decreased risk of any complication (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.74-0.93) and surgical revision (OR: 0.85, 95% CI: 0.74-0.96) within 3 months; however, no significant difference in infection within was noted (OR: 0.89, 95% CI: 0.68-1.17) within 3 months.

CONCLUSIONS

Adherence to AUA antimicrobial guidelines for AUS surgery appears to have increased over the last two decades. While guideline-adherent regimens were associated with decreased risk of any complication and surgical intervention, no significant association was found with risk of infection. Surgeons appear to be increasingly following AUA recommendations for antimicrobial prophylaxis for AUS surgery, however, further level 1 evidence should be obtained to demonstrate conclusive benefit of these regimens.

Is a 10-minute surgical scrub necessary in urologic prosthetic surgery? A randomized study of the effect of a 5- vs 10-minute surgical scrub on bacterial colony counts in the genital skin

AIMS

To determine the antiseptic efficacy on bacterial colony counts of a 5- vs 10-minute surgical site scrub in urologic surgery.

METHODS

A prospective cohort study was conducted in 101 patients presenting for elective urological procedures. Patients were randomized to a 5- or 10-minute groin scrub with Betadine (povidone-iodine). Skin swabs were taken immediately after skin clipping and following routine painting with Betadine. A third swab was taken after the betadine skin scrub. Bacterial colony counts were reported as a number of colony-forming units (CFUs). The primary outcome measure was a quantitative comparison of CFUs in the two arms.

RESULTS

Fifty-three patients were randomized to a 5-minute scrub and 48 to a 10-minute scrub. After Betadine painting, CFUs were present in 38% of patients in the 5-minute group (mean, 33.5 CFU) and in 27% of the 10-minute group (mean, 45.4 CFU). Following the surgical scrub, only 7.5% of the 5-minute group and 8.3% of the 10-minute group had a measurable CFU count of greater than or equal to 1, and colony counts were low in both groups (5- minute group: mean, 1.5 CFU; 10-minute group: mean, 2.0 CFU). There was no significant difference in CFUs following a 5- or 10-minute scrub (P = 0.28).

CONCLUSIONS

The addition of a surgical skin scrub leads to a fourfold reduction in the skin CFU count compared with Betadine painting. However, there is no difference between the antibacterial effects of a 5- and 10-minute scrub. A 5-minute scrub may be sufficient in urologic prosthetic surgery.

Artificial urinary sphincter

Although currently still the gold standard treatment for post-prostatectomy urinary incontinence, the artificial urinary sphincter (AUS) (AMS800) is an invasive procedure with associated risks factors. In this paper, we aim to outline what the scientific literature and what we personally believe are the factors that are useful and/or necessary to mitigate these risks, including both patient factors and surgeon factors. We also review special populations, including transcorporal (TC) AUS approach, AUS with inflatable penile prosthesis, AUS after male urethral sling, AUS erosion management, and AUS after orthotopic urinary diversion.

Artificial Urinary Sphincter: Report of the 2015 Consensus Conference

PURPOSE

The AMS800™ device, by far the most frequently implanted artificial urinary sphincter (AUS) worldwide, is considered to be the "gold-standard" when male incontinence surgical treatment is contemplated. Despite 40 years of experience, it is still a specialized procedure with a number of challenges. Here, we present the recommendations issued from the AUS Consensus Group, regarding indications, management, and follow-up AMS800™ implantation or revision.

MATERIALS AND METHODS

Under ICS auspices, an expert panel met on July 10, 2015 in Chicago, IL, USA in an attempt to reach a consensus on diverse issues related to the AMS800™ device. Participants were selected by the two co-chairs on the basis of their practice in a University hospital and their experience: number of implanted AUSs according to AMS (American Medical System Holdings Inc., Minnetonka, MN) records and/or major published articles. Topics listed were the result of a pre-meeting email brainstorming by all participants. The co-chairs distributed topics randomly to all participants, who then had to propose a statement on each topic for approval by the conference after a short evidence-based presentation, when possible.

RESULTS

A total of 25 urologists were invited to participate, 19 able to attend the conference. The present recommendations, based on the most recent and relevant data available in literature as well as expert opinions, successively address multiple specific and problematic issues associated with the AMS800™ trough a eight-chapter structure: pre-operative assessment, pre operative challenges, implantation technique, post-operative care, trouble-shooting, outcomes, special populations, and the future of AUSs.

CONCLUSION

These guidelines undoubtedly constitute a reference document, which will help urologists to carefully select patients and apply the most adapted management to implantation, follow-up and trouble-shooting of the AMS800™.

Effect of 4% chlorhexidine gluconate predisinfection skin scrub prior to hepatectomy: a double-blinded, randomized control study

This trial was designed to compare the efficacy of 4% chlorhexidine gluconate (CHG) with normal saline (NS) as a predisinfection skin-scrub solution prior to standard presurgical skin preparation. Data was collected at a single transplantation center where patients electing resection of hepatic tumors were recruited between October 2011 and September 2012. In total, 100 patients were consecutively enrolled for random assignment to either 4% CHG or NS as a predisinfection skin-scrub solution prior to surgery. Our aim was to assess the comparative antiseptic efficacy of CHG in this setting, focusing on cutaneous microbial colonization (at baseline, preoperatively, and postoperatively) and postsurgical site infections as primary outcome measures. Positivity rates of baseline, preoperative, and postoperative cultures were similar for both groups, showing significant declines (relative to baseline) after skin preparation and no significant postsurgical rebound. Rates of surgical site infection were also similar in both groups (CHG, 6.0%; NS, 4.1%; P = 1.0). For patients with hepatic tumors undergoing hepatectomy, the effect of 4% CHG as a predisinfection scrub solution was similar to that of NS in terms of skin decontamination and surgical site infections.

Infections Associated with Inflatable Penile Prostheses

INTRODUCTION

The implantation of inflatable penile prosthesis (IPP) has become a successful method for the treatment of erectile dysfunction. Infections are rare but they can result in devastating complications following surgical implantation of the prosthesis.

AIM

To discuss pathogenesis, risk factors, and microbiology of IPP infections, summarize clinical manifestation and diagnostic methods, and discuss future directions of prevention and management.

METHODS

A PubMed search was performed of all articles published from 1960 to present relating to IPP infections.

MAIN OUTCOME MEASURE AND RESULTS

Skin flora organisms such as Staphylococcus epidermis are the most common source of infection. Several host and surgical risk factors for prosthesis infection have been demonstrated, including uncontrolled diabetes mellitus and previous surgical interventions. Biofilms play an important role in the pathogenesis of device-related infections. Pain, fever, drainage, and device extrusions are suggestive of IPP infection. Preventive methods include preoperative skin cleansing, systemic antibiotic prophylaxis, and the use of surface-modified prostheses. The most frequently utilized surgical management is a single-stage approach that comprises aggressive irrigation and debridement, removal of all components of the infected prosthesis, and placement of a new IPP in the same surgical setting.

CONCLUSION

Advances in systemic antimicrobial prophylaxis, skin cleansing and surface-modification of the devices, as well as a number of other potentially protective measures, have decreased the rates of infections. Currently, most infected IPP are surgically managed by adopting the salvage approach. Al Mohajer M and Darouiche RO. Infections associated with inflatable penile prostheses. Sex Med Rev 2014;2:134-140.

Preoperative Skin Antiseptic Preparations for Preventing Surgical Site Infections: A Systematic Review

Objective.

To evaluate the clinical effectiveness of preoperative skin antiseptic preparations and application techniques for the prevention of surgical site infections (SSIs).

Design.

Systematic review of the literature using Medline, EMBASE, and other databases, for the period January 2001 to June 2011.

Methods.

Comparative studies (including randomized and nonrandomized trials) of preoperative skin antisepsis preparations and application techniques were included. Two researchers reviewed each study and extracted data using standardized tables developed before the study. Studies were reviewed for their methodological quality and clinical findings.

Results.

Twenty studies (n = 9,520 patients) were included in the review. The results indicated that presurgical antiseptic showering is effective for reducing skin flora and may reduce SSI rates. Given the heterogeneity of the studies and the results, conclusions about which antiseptic is more effective at reducing SSIs cannot be drawn.

Conclusions.

The evidence suggests that preoperative antiseptic showers reduce bacterial colonization and may be effective at preventing SSIs. The antiseptic application method is inconsequential, and data are lacking to suggest which antiseptic solution is the most effective. Disinfectant products are often mixed with alcohol or water, which makes it difficult to form overall conclusions regarding an active ingredient. Large, well-conducted randomized controlled trials with consistent protocols comparing agents in the same bases are needed to provide unequivocal evidence on the effectiveness of one antiseptic preparation over another for the prevention of SSIs.

Preparation and evaluation of lidocaine hydrochloride in cyclodextrin inclusion complexes for development of stable gel in association with chlorhexidine gluconate for urogenital use

Inclusions of lidocaine hydrochloride in cyclodextrins were prepared to obtain stable complexes compatible for association with chlorhexidine in a new gel formulation for use in urogenital applications. Two cyclodextrins, β-cyclodextrin and methyl-β-cyclodextrin, were used for encapsulating lidocaine hydrochloride through solubilization and kneading techniques. The lidocaine–cyclodextrin complexes were characterized by ultraviolet spectroscopy, Fourier transform infrared spectroscopy, differential scanning calorimetry, and X-ray diffraction. The results revealed that the techniques generated good yields of inclusion products that maintained the functional properties of lidocaine. In addition, the inclusion products obtained improved the compatibility of lidocaine hydrochloride with chlorhexidine in solution and a gel formulation. The gel formulation displayed desirable rheological and physicochemical properties. The results presented here are the first description of the inclusion of lidocaine with cyclodextrins, which improves compatibility with chlorhexidine in formulations for simultaneous delivery.