Comparison of single-dose antibiotic prophylaxis in uncomplicated transurethral resection of the prostate

Antibiotic prophylaxis for transurethral urological surgeries: Systematic review

The use of antibiotic prophylaxis to prevent urinary tract infection and bacteremia (sepsis) following endoscopic urologic procedures is a controversial topic. Evidence in the literature revealed that urological instrumentation is associated with increased incidence of urinary tract infection and bacteremia. The aim of this review is to evaluate the effectiveness of antibiotic prophylaxis in reducing the risk of urinary tract infection in patients who had transurethral urological surgeries. We have selected all RCTs of adult population who underwent all different types of transurethral urological surgery, including cystoscopy, transurethral resection of prostate and transurethral resection of bladder tumor, and received prophylactic antibiotics or placebo/no treatment. At first, more than 3000 references were identified and reviewed; of which 42 studies with a total of 7496 patients were included in the final analysis. All those trials were analyzing antibiotic prophylaxis versus placebo/no treatment, and they were significantly favoring antibiotic use in reducing all outcomes, including bacteriuria (RR 0.36, 95% CI 0.29 to 0.46, P < 0.0001) with moderate heterogeneity detected (I² 48%), symptomatic UTI (RR 0.38, 95% CI 0.28 to 0.51, P < 0.0001) with no significant heterogeneity was detected (I²= 17%), bacteremia (RR 0.43, 95% CI 0.23 to 0.82, P < 0.0001) with no noted heterogeneity (I² = 0%), and fever ≥38.5 Celsius (RR 0.41, 95% CI 0.23 to 0.73, P = 0.003); also, there was no noted heterogeneity (I² = 0%). However, using antibiotic prophylaxis did not reduce the incidence of low grade temperature (RR 0.82, 95% CI 0.61 to 1.11, P = 0.20) or in moderate grade temperature (RR 1.03, 95% CI 0.71 to 1.48, P = 0.89). Antibiotic prophylaxis appears to be an effective intervention in preventing urinary tract infections and its sequels following transurethral urological surgeries in patients with preoperative sterile urine.

Single‐dose orally administered quinolone appears to be sufficient antibiotic prophylaxis for radical retropubic prostatectomy

OBJECTIVE

To evaluate a new prophylaxis routine, which was introduced at our clinic in December 1998, comprising a single oral dose of antibiotic given prior to radical retropubic prostatectomy (RRP).

MATERIAL AND METHODS

A total of 60 men scheduled to undergo RRP were included in a prospective study and received antibiotic prophylaxis in the form of a single oral dose of quinolone. Cultures were made from the tip of the catheter and from urine sampled at the time of extraction as well as 1 and 2 weeks post-extraction. The outcome of this prospective study of 60 men was then compared to the total numbers of patients operated on in 1998 (n = 103) and 1999 (n = 140) by means of a retrospective analysis of clinical files.

RESULTS

No cases of sepsis occurred. Two weeks after catheter removal, 15/60 patients had persisting bacteriuria. No other signs of infection were detected. Six patients developed a stricture of the anastomotic area during follow-up (mean duration 18.9 months). When the study group was compared to all patients operated on in 1998 and 1999 no increases in the incidence of anastomotic strictures or serious infections or in the length of hospitalization could be detected.

CONCLUSION

A single dose of antibiotic given before RRP appears to be sufficient prophylaxis.

Japanese guidelines for prevention of perioperative infections in urological field

For urologists, it is very important to master surgical indications and surgical techniques. On the other hand, the knowledge of the prevention of perioperative infections and the improvement of surgical techniques should always be considered. Although the prevention of perioperative infections in each surgical field is a very important issue, the evidence and the number of guidelines are limited. Among them, the preparation of guidelines has progressed, especially in gastrointestinal surgery. The Center for Disease Control and Prevention (CDC) proposed guidelines for the prevention of surgical site infections, which have been used worldwide. In urology, the original guidelines were different from those of general surgery, due to many endourological procedures and urine exposure in the surgical field. The Japanese Society of UTI Cooperative Study Group has thus framed these guidelines supported by The Japanese Urological Association. The guidelines consist of the following nine techniques: open surgeries, laparoscopic surgeries, transurethral resection of bladder tumor, ureterorenoscope and transurethral lithotripsy, transurethral resection of the prostate, prostate biopsy, cystourethroscope, pediatric surgeries in the urological field, and extracorporeal shock wave lithotripsy and febrile neutropenia. These are the first guidelines for the prevention of perioperative infections in the urological field in Japan. Although most of these guidelines were made using reliable evidence, there are parts without enough evidence. Therefore, if new reliable data is reported, it will be necessary for these guidelines to be revised in the future.

The postoperative bacteriuria score: a new way to predict nosocomial infection after prostate surgery

OBJECTIVE

Urinary tract infections are the leading nosocomial urologic infections and may be a cause of added morbidity and costs, and sometimes sepsis. The aim of this study was to design a predictive score for these complications after prostate surgery.

DESIGN

Multicenter prospective survey.

SETTING

Eleven French urology centers.

PATIENTS

All patients undergoing transurethral resection of prostate (TURP) during a 3-month period.

RESULTS

The overall incidence of postoperative bacteriuria was 25.0% (95% confidence interval, 17.7%-29.5%). Almost all patients (95.7%) received antibiotic prophylaxis. A predictive postoperative bacteriuria score (POBS), with a 6-point scale of 0 to 5, was constructed on the basis of independent risk factors identified in multivariate analysis of a test sample of patients (n=135) and tested in a validation sample (n=73). Significantly more infections occurred in patients with a POBS of 2 or higher (87 [8%] vs 48 [50%]; P<.0001). With the test sample, this yielded a sensitivity of 77%, a specificity of 77%, a positive predictive value of 50%, a negative predictive value of 92%, and a global accuracy of 77%.

CONCLUSIONS

POBS could be used to distinguish patients at risk of developing infection after TURP. This information might be useful for implementing selective prevention measures or for adjustment for differences in nosocomial infection rates when comparing data between urology centers.

[Urinary bacteriologic study prior to endoscopic urologic surgery]

OBJECTIVE

The objectives of this study are to know the incidence of preoperative bacteriuria in patients undergoing endoscopic urologic surgery, to analyze the most frequent microorganisms appearing in the cultures and their resistance to antibiotics in order to select the most appropriate prophylactic one for our population, and to determine the risk factors related to postoperative bacteriuria or sepsis of urologic origin.

MATERIAL AND METHODS

449 patients undergoing endoscopic urologic surgery were included in the study. Urinary samples were collected for culture prior to prophylactic antibiotic administration and again a week after bladder catheter removal once the antibiotic treatment was finished. Variables related to an increase in infectious complications were analyzed. Special attention was paid to postoperatory incidences, mainly those of infectious nature.

RESULTS

Preoperative bacteriuria was found in 66 out of 428 patients (15.4%). It was found to be related to age, sex, previous infection episodes, diabetes mellitus, indwelling catheter and to the pathology for which operation was indicated. The most frequently found microorganism was Escherichia Coli. Resistance to prophylactic antibiotic was found in 37.9% of patients with preoperatory bacteriuria. Postoperatory bacteriuria, observed in 22.0% of the patients was exclusively related to preoperatory bacteriuria. 2.9% of patients showed sepsis of urinary origin criteria during hospital staying, and it was found to be exclusively related to length of surgery and neither to preoperatory bacteriuria nor to indwelling catheter time or the "inappropriate" prophylactic antibiotic use in these cases.

CONCLUSIONS

A good part of patients who underwent endoscopic surgery showed preoperatory bacteriuria, responsible for postoperative bacteriuria in less than 25% of the cases. The length of surgery seemed to be the only related cause whit sepsis of urinary origin.

ANTIBIOTIC PROPHYLAXIS FOR TRANSURETHRAL PROSTATIC RESECTION IN MEN WITH PREOPERATIVE URINE CONTAINING LESS THAN 100,000 BACTERIA PER ML: A SYSTEMATIC REVIEW

PURPOSE

We determined whether antibiotic prophylaxis can reduce the risk of postoperative infective complications in men undergoing transurethral resection of the prostate (TURP) who have preoperative urine with less than 100,000 bacteria per ml.

MATERIALS AND METHODS

MEDLINE, EMBASE (Elsevier B.V., Amsterdam, The Netherlands) and the Cochrane Library were searched for randomized and quasi-randomized controlled trials that compared the effects of antibiotic prophylaxis with placebo or active controls for men undergoing TURP with preoperative sterile urine. Two reviewers independently extracted patient characteristic and outcomes data based on a prospectively developed protocol.

RESULTS

A total of 28 trials, 10 placebo controlled and 18 no treatment controlled, involving 4,694 patients, met the inclusion criteria. The mean age of the subjects was 69 years and the majority underwent TURP for prostatic hyperplasia (85%). Antibiotic prophylaxis was significantly more effective than placebo in reducing postoperative TURP complications. The risk differences for post-TURP bacteriuria, high degree fever, bacteremia and use of additional antibiotic treatment were -0.17 (95% CI 0.20, -0.15), -0.11 (-0.15, -0.06), -0.02 (-0.04, 0.00) and -0.20 (-0.28, -0.11), respectively. The results were observed consistently across all classes of antibiotics assessed. There was no difference in the duration of postoperative catheterization or hospitalization. Adverse events were rare, generally mild, and included allergic reactions, pyrexia and abdominal complaints.

CONCLUSIONS

Prophylactic antibiotics decrease the incidence of post-TURP bacteriuria, high fever, bacteremia and additional antibiotic treatment. Additional research should evaluate the optimal antibiotic regimen, and whether the cost and possibility of the development of resistant strains of organisms justify the routine use of prophylactic antibiotics.

Complications after discharge for surgical patients

AIM

To measure the type and frequency of complications for surgical patients 1 month after discharge.

METHODS

A post-discharge patient survey was conducted in 2000 for patients who had undergone one of five elective operations: transurethral resection of the prostate, hysterectomy, major joint replacement, cholecystectomy, herniorrhaphy. Two hundred and fourteen patients (74%) returned the survey forms, which were sent 1 month after surgery. Patients were recruited from two teaching hospitals in the Hunter Area Health Service, New South Wales, Australia.

RESULTS

One hundred and thirty-five (63%) patients reported one or more complications and 78 (37%) received treatment for 109 complications. Eighty-six per cent reported pain after discharge and 41% reported moderate to severe pain. Seventeen per cent reported infections after discharge and 94% of these patients were given treatment. Twenty-eight per cent reported bleeding after discharge and 20% of these were given treatment. Eleven (5%) patients were readmitted for treatment of problems related to their surgery including four who required further surgery. One hundred and seventy-two patients accessed a range of health services during the first month after discharge, resulting in 266 occasions of service. Twenty-eight per cent of post-discharge services were unplanned.

CONCLUSIONS

The lack of post-discharge monitoring conceals information about surgical outcomes. Patient reporting is an effective method of monitoring post-discharge outcomes. There is scope to develop post-discharge services to improve the quality of care in the areas of post-discharge pain management, the use of prophylactic measures and to provide treatment for complications that occur during this period.

Antibiotic prophylaxis in endoscopic and minimally invasive surgery

Infections are unusual following minimally invasive surgery but antibiotic prophylaxis is given in the same way as for the open surgery equivalents. Most prophylactic regimens have not been subjected to randomised placebo controlled trials. Antibiotic prophylaxis has been shown to be beneficial in transurethral resection of the prostate. In endoscopic retrograde cholangiopancreatography (ERCP) the incidence of bacteremia, but not cholangitis, is reduced by prophylaxis and some do not recommend its routine use. For arthroscopies and laparoscopies infection is too rare to warrant prophylaxis. There is a theoretical risk of infection in that endoscopes cannot withstand autoclaving so only high level disinfection can be used between patients. However, for most minimally invasive operations, the small wound size, reduced immune challenge and rapid recovery of the patient outweigh any disadvantages compared with open surgery.

Do antimicrobials have a role in preventing septicaemia following instrumentation of the urinary tract?

Urinary tract instrumentation is a significant cause of septicaemia. Review of the literature suggests that selective use of antimicrobials would reduce the risk of septicaemia as this varies between patients and with procedures. Antimicrobial prophylaxis is indicated for patients at high risk of endocarditis, or who are neutropenic. For patients without these risk factors, it is indicated for open, transurethral, or certain forms of laser prostatectomy or trans-rectal prostate biopsy. For cystoscopy, antimicrobials are indicated for patients with preoperative bacteriuria or a preoperative indwelling catheter. Single dose aminoglycosides or oral fluoroquinolones are the agents of choice with the exception of the prevention of endocarditis, where combinations active against streptococci are recommended. For other instrumentations, the risk of antimicrobial toxicity probably outweighs the benefits and a risk-reduction strategy is recommended. Further studies are required to provide definitive answers in many of these areas.

Double-blind randomized comparison of single-dose ciprofloxacin versus intravenous cefazolin in patients undergoing outpatient endourologic surgery

OBJECTIVES

To compare the efficacy of single-dose oral ciprofloxacin with intravenous cefazolin as a prophylactic agent in patients undergoing outpatient endourologic surgery.

METHODS

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.

CONCLUSIONS

A single oral dose of ciprofloxacin in patients undergoing outpatient endourologic surgery was equally effective as cefazolin in preventing postoperative urinary tract infection, but was associated with markedly lower overall costs.

Antibiotic prophylaxis in surgery: summary of a Swedish-Norwegian Consensus Conference

This consensus document sets out proposals for antibiotic prophylaxis in abdominal, urological, gynaecological, orthopaedic, vascular and thoracic surgery. As far as possible the recommendations are based on prospective controlled trials. However, for some procedures, e.g. lung surgery and implantation of pacemakers, documentation is lacking but antibiotic prophylaxis is given traditionally. The choice of antibiotics is generally conservative, emphasizing that antibiotics used for therapy should be avoided in prophylactic regimens. Most recommendations are for the use of a first- or second-generation cephalosporin or an isoxazolyl penicillin, when necessary, combined with a nitroimidazole derivative (metronidazole or tinidazole). Suggestions are given for more frequent use of orally administered antibiotics, such as co-trimoxazole, doxycycline, metronidazole or tinidazole. Emphasis is put on short-term prophylaxis. In most cases surgical antibiotic prophylaxis should be given as a single dose and in no case should the prophylaxis time exceed 24 h.

Single-dose antibiotic prophylaxis in transurethral resection of the prostate: a prospective randomized trial

OBJECTIVE

To evaluate the efficacy of single-dose antibiotic prophylaxis in transurethral resection of the prostate (TURP).

PATIENTS AND METHODS

A total of 139 patients were entered into a prospective randomized trial comparing single-dose antibiotic prophylaxis with no antibiotic before surgery. Twelve patients were excluded because they had significant bacteriuria before surgery (defined as > or = 10(5) bacteria/mL). Of the remaining 127 patients, 62 were allocated to the single-dose group (A) and 65 to the no-antibiotic group (B). All 62 patients in group A received 1 g of ceftriaxone intravenously 1-2 h before surgery with the anaesthetic premedication, the 65 in group B receiving none. Urine cultures were collected post-operatively as the catheter was removed and again 4 weeks after hospitalization.

RESULTS

The incidence of post-operative bacteriuria was statistically significantly different, occurring in five patients (9%) in group A and 16 patients (26%) in group B (Fisher's exact test, one-tail P = 0.009). There was no significant difference between the groups 4 weeks after hospitalization. The overall incidence of bacteriuria post-operatively and 4 weeks after hospitalization was 11 patients (18%) in group A and 22 patients (34%) in group B (P = 0.03).

CONCLUSION

Single-dose antibiotic prophylaxis with 1 g of ceftriaxone intravenously is effective in patients undergoing TURP and is recommended for such surgery.

Antibiotic prophylaxis for patients undergoing transurethral resection of the prostate

OBJECTIVES

To evaluate the prevention of urinary tract infections (UTIs) after transurethral resection of the prostate (TURP) in a prospective randomized study using a quinolone antibiotic (fleroxacin) to compare the efficacy of: (1) a single oral dose, (2) a single intravenous (IV) dose, and (3) an extended regimen consisting of an initial IV dose followed by oral therapy until removal of the urinary catheter, but for less than 6 days.

METHODS

We excluded from study patients who received antimicrobial agents within 48 hours of surgery. Single-dose prophylaxis consisted of 400 mg of fleroxacin given either orally or intravenously. The extended regimen consisted of an initial 400 mg IV dose followed by 400 mg oral each day (patients older than 75 years, or with a creatinine clearance less than 40 mL/min, received 200 mg/day). UTI was defined as clinical evidence of infection plus the presence of more than 10 white blood cells (WBC)/mm3 in any urine specimen plus the presence of more than 10(4) cfu/mL in midstream urine specimens or more than 10(2) cfu/mL in catheter specimens.

RESULTS

Prior to TURP, 30% (25/84) of the patients had a urethral catheter in situ and 12% (3/25) of these patients had bacteriuria. Only 1 patient developed a UTI and that was 22 days after a TURP (intergroup comparisons, Fisher's exact test greater than 0.05). There were no instances of urosepsis.

CONCLUSIONS

A single oral dose of a fluoroquinolone agent provided optimum prophylaxis for patients undergoing TURP.

[Antibiotic prophylaxis in urology. Surgical and endoscopic surgery. Lithotripsy. Transplantation]

The opening of the urinary tract switches surgical and endoscopic urology to the clean contaminated category and therefore for each of them antibiotic prophylaxis has to be considered. Prophylactic antibiotics are only recommended before surgery in patients with sterile urine. Those with infected urine should have curative antibiotics. Prophylactic antibiotics are commonly recommended for transurethral resection of the prostate, transrectal biopsy of the prostate, renal transplant and radical cystectomy with ileal or colonic pouch for urinary diversion. It is worthless in diagnostic cystoscopy. ESWL and scrotal surgery. For other procedures more data are required to conclude.

Randomized controlled study of chemoprophylaxis in transurethral prostatectomy

We studied 599 evaluable patients with benign prostatic hypertrophy at 7 urological units. Before transurethral prostatectomy the patients were randomized into 3 groups: group 1--197 patients given single-dose ceftriaxone (2 gm.), group 2--203 patients given 160/800 mg. trimethoprimsulfamethoxazole and group 3--199 controls given no antimicrobial prophylaxis. Patients with a preoperative indwelling catheter, positive urine culture, signs of active infection or preoperative antibiotic treatment were excluded. Postoperative infectious complications were demonstrated in 15 of 197 (7.6%), 25 of 203 (12.3%) and 43 of 199 (21.6%) patients in the study groups, respectively. The difference in infectious complications between groups 1 and 3 was statistically highly significant (p < 0.01) and between groups 2 and 3 it was significant (p < 0.05). Single-dose antibiotic prophylaxis proved to be useful in the prevention of serious infectious complications after transurethral prostatectomy.