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

Urinary tract infections after retrograde pyelography and prophylactic antibiotics

INTRODUCTION

Retrograde pyelography (RP) is performed for examination of upper urinary tract cancers and hydronephrosis. Although urinary tract infections (UTI) are known to be complicated by the examination, there are few reports on the frequency of occurrence and prophylactic antibiotics.

METHODS

The incidence of UTI and febrile UTI (f-UTI) and patient background information were compared in 388 patients who underwent RP at our hospital from January 2018 to December 2022. We also examined the administration of pre-RP antibiotics.

RESULTS

Of the 388 patients who underwent RP, 27 (6.9%) had UTI and 17 (4.4%) had f-UTI. Of the 27 UTI cases, 25 (92.6%) were pyelonephritis; 20 (74.0%) were hospitalized and 2 (7.4%) presented with septic shock and were managed in the intensive care unit. When comparing the background of patients with UTI, no significant differences were found in the present study, but when limited to the 17 cases of f-UTI, the presence of hydronephrosis before RP and not prescribing antibiotics before RP were associated with significantly higher incidence of f-UTI (p = 0.019, p = 0.036, respectively). Especially for patients without pyuria and bacteriuria before RP, prescribing antibiotics before RP resulted in 0 cases of f-UTI (p = 0.020).

CONCLUSION

This retrospective study showed that the presence of hydronephrosis before RP and not prescribing prophylactic antibiotics before RP are risk factors for f-UTI.

Within State Variability of Antimicrobial Susceptibility: Missouri as an Archetype to Assess Guidelines for Antimicrobial Prophylaxis for Transurethral Procedures

OBJECTIVE

To evaluate variability among hospitals in susceptibility of common uropathogens to antimicrobial agents frequently used in transurethral procedures in order to examine whether state-based guidelines might be more appropriate than national prophylactic guidelines.

METHODS

Hospital-level antibiograms were requested from all hospitals throughout the state of Missouri. We studied Escherichia coli, Klebsiella, and Proteus sensitivities to evaluate common guideline recommended antimicrobials including trimethoprim sulfamethoxazole (TMP-SMX), 3rd generation cephalosporins, cefazolin, penicillin combinations, gentamicin and fluoroquinolones. We evaluated variability and association between hospital characteristics and antimicrobial sensitivities.

RESULTS

Data was requested from 81 hospitals across the state and 38 provided the requested data (47% response rate). Susceptibility was highest for 3^rd generation cephalosporins for E coli (mean of 94%), Proteus (96%), and Klebsiella (96%). Gentamicin also had high susceptibility for the bacteria studied; 94% for E coli and 96% for Klebsiella. Current first line recommended agents showed more modest coverage for E coli (cefazolin 84%, TMP-SMX 78%), Proteus (cefazolin 82%, TMP-SMX 71%), and Klebsiella (cefazolin 90%, TMP-SMX 89%).

CONCLUSION

Post transurethral procedure infections are common. Rates can be limited with appropriate prophylaxis. Deciding on empirical coverage must take into account local resistance patterns. There is substantial variability among and within states in antimicrobial susceptibility for common uropathogens. When selecting antimicrobial prophylaxis, urologists should consider local- rather than state- or nation-level antibiograms, given the considerable variability. Future studies should consider the merits of very-broad spectrum prophylaxis and the potential role of molecular urinary pathogen (and pathogen-resistance) testing when selecting an optimal regimen.

Antimicrobial Selection for Transurethral Procedures Across the United States: A State-by-State Antibiogram Evaluation

OBJECTIVE

To evaluate optimal regimens for perioperative antimicrobial prophylaxis in transurethral procedures by examining antimicrobial susceptibility patterns in the United States.

MATERIALS AND METHODS

Through several methods, we attempted to attain an antibiogram for each state. We focused on microbes known to cause infections after transurethral surgeries and antibiotics referred to in current or prior recommendations and compared susceptibility rates across states using Kruskal Walis tests and the Dwass, Steel, Critchlow-Fligner tests. We also examined susceptibility to (non-ceftazidime) third generation cephalosporins.

RESULTS

Data is included from 40 states. For each microbe studied, there was significant variability in sensitivity to antibiotics studied. Current first line recommendations for antimicrobial prophylaxis include first generation cephalosporins with 82%, 80%, and 87% mean coverage for E coli, Proteus, and Klebsiella respectively and trimethoprim-sulfamethoxazole with 74%, 80%, and 93% coverage, respectively. Susceptibility to aminoglycosides is 91%, 92%, and 96%, respectively and to third generation cephalosporin, it is 92%, 99%, and 94%.

CONCLUSION

Current first line recommended antimicrobials for prophylaxis in transurethral procedures provide overall poor predicted coverage based on our database of antibiograms. Alternatives exist that have higher predicted susceptibility, though clinical significance of this and risk of resultant antimicrobial resistance is unknown. Urologists should consider local patterns when selecting antimicrobial prophylaxis for their patients.

Safely increasing nephro-ureteric stent exchange intervals, resulting in significant cost savings for the interventional radiology suite, a 2-year experience in a tertiary referral centre

Aim

To evaluate the nephro-ureteric stent (NUS) insertion and exchange practice in a tertiary referral cancer centre, and determine the safety and compliance with current guidelines. We also reviewed if increasing exchange time interval from 6 to 12 weeks was safe, and if this could be adopted into our local guidelines.

Methods

A retrospective review was performed covering 24 months from January 2017 to December 2018. All NUS insertions and exchanges performed in that period were analysed, including the number of exchanges the patient underwent, the time between subsequent exchanges, and the screening time. We also reviewed the indications for stent insertion, possible causes for failed stent exchange, and factors which led to significant delays in stent exchanges for some patients. A scatterplot of screening time versus time in situ was derived and correlation analysis performed using the Pearson coefficient.

Results

Thirty-two patients underwent de novo NUS insertion during the period, and 102 NUS exchanges were performed. The interval between stent exchanges ranged from 1 to 40 weeks, with a mean of 12.3 weeks (SD = 8.96 weeks). Screening time ranged from 33 s to 17 min, with a mean of 3 min 50 s (SD = 3 min 35 s). There were 100 successful exchanges, and two failed exchanges, accounting for 1.9% of total exchanges. In both failed cases, the reason for failed exchange was due to a prolonged period between exchanges (6 months in both cases). The reason for delay for stent exchange was due to non-attendance for scheduled appointments. There was a weakly positive correlation coefficient of 0.06 (screening time versus time period between insertions); however, this was not statistically significant (p = 0.81).

Conclusion

In this retrospective review, we have demonstrated that the recommended 6-week period between stent exchanges is unnecessary in the vast majority of cases, and that a longer interval between NUS exchanges, e.g. 8–12 weeks, is safe for the patient, and reduces screening time. This reduction in procedures also provides a significant potential saving to the radiology department in both monetary expense and limited angiography suite time.

Practice variation on use of antibiotics: An international survey among pediatric urologists

INTRODUCTION AND BACKGROUND

Although there is abundance in literature focusing on the use of prophylactic antibiotics for adult urological procedures, the evidence for using antibiotics following common pediatric urological procedures is limited with no specific guidelines for use. Consequently, current practices on antibiotic usage for common interventions may be variable among practicing pediatric urologists, lacking evidence-based support.

OBJECTIVE

The aim was to evaluate the current practice pattern on antibiotic usage for common interventions amongst pediatric urologists (PU) practicing in four English-speaking sectors of the world.

MATERIALS AND METHODS

An anonymous survey of five scenarios with multiple choice options was disseminated to all active practicing members of the Pediatric Urologist of Canada (PUC) and Society of Pediatric Urology of Australia and New Zealand (SPUNZA), as well as all those attending the 2016 British Association of Pediatric Urology (BAPU) and 2017 American Association of Pediatric Urology (AAPU) meetings. The response for each scenario was summarized for overall practice pattern variation and the pattern for each sector was compared using the Fisher exact test.

RESULTS

A total of 126 respondents completed the survey (68.5% response rate) with at least a 65% response rate for each of the four sectors. The majority of respondents do not use antibiotics for indwelling urethral (46.8%) and suprapubic catheters (53.4%); however, they do give antibiotics for J-J stent placement (65.1%) and hypospadias surgery (84.9%), and use antibiotics after hypospadias surgery where catheters or stents are left indwelling (80.9%, 84.2%, respectively). Among those surveyed, the PUC members and AAPU PU demonstrated similar practice patterns which often significantly differed from that of SPUNZA members and BAPU attendees. Specifically, a significantly larger proportion of the North American pediatric urologists do not use antibiotics for common procedures compared with Australia, New Zealand, and the UK (Table).

DISCUSSION

In the absence of prospective studies in antibiotic use for pediatric patients to guide clinicians, there is a clear variability among sectors in the use of antibiotics for most clinical scenarios investigated. With increasing resistance patterns and possible adverse effects of antibiotics, it is important that the international pediatric urology community engage in discussions and collaborations to address this issue.

CONCLUSION

Practice patterns in antibiotic usage amongst PU varies widely, some of which may be associated with their local "culture." There is a need to understand these differences and begin to standardize treatment in the hopes of increasing appropriate use of antibiotics internationally.

Antibiotic prophylaxis in ureteroscopic lithotripsy: a systematic review and meta-analysis of comparative studies

OBJECTIVE

To explore the efficacy of antibiotic prophylaxis and the different strategies used to prevent infection in ureteroscopic lithotripsy (URL) by conducting a systematic review and meta-analysis.

MATERIALS AND METHODS

A systematic literature search using Pubmed, Embase, Medline, the Cochrane Library, and the Chinese CBM, CNKI and VIP databases was performed to find comparative studies on the efficacy of different antibiotic prophylaxis strategies in URL for preventing postoperative infections. The last search was conducted on 25 June 2017. Summarized unadjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to assess the efficacy of different antibiotic prophylaxis strategies.

RESULTS

A total of 11 studies in 4 591 patients were included in this systematic review and meta-analysis. No significant difference was found in the risk of postoperative febrile urinary tract infections (fUTIs) between groups with and without antibiotic prophylaxis (OR: 0.82, 95% CI 0.40-1.67; P = 0.59). Patients receiving a single dose of preoperative antibiotics had a significantly lower risk of pyuria (OR: 0.42, 95% CI 0.25-0.69; P = 0.0007) and bacteriuria (OR: 0.25, 95% CI 0.11-0.58; P = 0.001) than those who did not. Intravenous antibiotic prophylaxis was not superior to single-dose oral antibiotic prophylaxis in reducing fUTI (OR: 1.00, 95% CI 0.26-3.88; P = 1.00).

CONCLUSIONS

We concluded that preoperative antibiotic prophylaxis did not lower the risk of postoperative fUTI, but a single dose could reduce the incidence of pyuria or bacteriuria. A single oral dose of preventive antibiotics is preferred because of its cost-effectiveness. The efficacy of different types of antibiotics and other strategies could not be assessed in our meta-analysis. Randomized controlled trials with a larger sample size and more rigorous study design are needed to validate these conclusions.

Perioperative cultures and the role of antibiotics during stone surgery

Urinary tract infection and urosepsis are the most common complications associated with the procedures urologists employ to manage stone disease. Recommendations regarding antibiotic prophylaxis and utilization of perioperative urine and stone culture prior to shockwave lithotripsy (SWL) or endoscopic intervention have evolved overtime. We sought to provide readers with a comprehensive consensus regarding these most recent recommendations.

Approach to antimicrobial prophylaxis for urology procedures in the era of increasing fluoroquinolone resistance

OBJECTIVE

To evaluate rationale antimicrobial prophylaxis options in patients undergoing urologic procedures in the era of increasing fluoroquinolone resistance.

DATA SOURCES

Literature was accessed through MEDLINE (1980-October 2013) using the search terms "urologic surgical procedures," "antibiotic prophylaxis," and "drug resistance."

STUDY SELECTION AND DATA EXTRACTION

Pertinent article titles and abstracts were reviewed by the authors in addition to reference citations from publications. All English language publications identified were evaluated.

DATA SYNTHESIS

The American Urology Association guidelines recommend fluoroquinolones (FQs) as first-line agents for preoperative prophylaxis to prevent infection after urologic procedures. Since the latest publication of these guidelines in 2008, resistance within this class of drugs has been increasing especially among common urologic pathogens like Escherichia coli. Limited data are available to support non-FQ alternatives for preoperative prophylaxis, and small studies published prior to 2000 have been conducted using such regimens with success. FQs have become the mainstay of prophylaxis in this population because of ease of administration, relatively low cost, and excellent oral bioavailability; however, β-lactam class antimicrobials may be emerging as effective alternatives based on more favorable resistance profiles.

CONCLUSIONS

Based on the current available literature, geographic areas with increasing FQ resistance should consider using cephalosporin agents as alternatives for prophylaxis in patients undergoing urologic procedures, reserving FQ in patients unable to tolerate β-lactams because of type-1 hypersensitivity reactions or other adverse effects.

A guide to antibiotics for the interventional radiologist

Antibiotics are among the most common pharmaceutical agents used by the interventional radiologist. This article updates some of the practical aspects of the use of antibiotics in interventional radiological practice and provides some general guidelines with respect to indications for and selection of antibiotics. In particular, the objectives of this article are to review the basic pharmacology of the common antibiotic agents, the interventional radiological procedures in which prophylactic antibiotics are usually administered, the specific antimicrobial agents recommended for prophylaxis before common interventional radiological procedures, the appropriate antibiotics for patients allergic to penicillins, and the indications for antibiotic prophylaxis to prevent bacterial endocarditis.

Preoperative antibiotics before endourologic surgery: current recommendations

The use of antibiotic prophylaxis is an accepted and widely practiced feature of modern surgery. The prevention and control of infection is a priority in healthcare worldwide, and the emergence of antibiotic resistance is a global phenomenon. Hence, rational use of antibiotics is essential. We discuss the guidelines published with regard to endourologic procedures and review the limited evidence currently available. There should be subclassification of endourologic procedures based on infection risk to guide sensible use of antibiotics before surgery.

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.

Day-case ureteroscopy: an observational study

OBJECTIVE

To evaluate the outcome after day-case ureteroscopy (used in diagnosing and managing ureteric disease, primarily urolithiasis), as awareness of reduced resources has resulted in increasing pressure to undertake procedures in a day-surgery setting.

PATIENTS AND METHODS

All patients presenting to the unit and requiring ureteroscopy between May 1995 and May 2000 were considered for a day-surgery procedure. The assessment of suitability comprised anaesthetic and social factors; no urological criteria precluded a day-surgery procedure. Outcomes after day-case ureteroscopy, including immediate or delayed admissions and subsequent inpatient management, were reviewed retrospectively.

RESULTS

Sixty-three day-case ureteroscopies were performed on 56 patients (mean age 47 years, range 19-78); eight procedures were diagnostic. Therapeutic ureteroscopies included one balloon dilatation of a ureteric stricture and 54 procedures for urolithiasis, with 98% stone clearance. Most patients were discharged with a JJ stent in situ. Of nine patients requiring immediate admission, seven were for pain control; eight were discharged on the following day. Seven patients required delayed admission 1-13 days after the procedure, three for stent-related symptoms and three for infection. No significant predictors of immediate or delayed admission were identified, although antibiotic prophylaxis was associated with a reduced admission rate.

CONCLUSION

Ureteroscopy can be used successfully as a planned day-case procedure in a dedicated day-surgery unit, with few patients requiring hospitalization. Implementation of analgesia protocols and routine antibiotic prophylaxis may reduce admission after day-case ureteroscopy.

Perioperative antibiotic prophylaxis in urology

This report reviews recent studies on infectious complications and antibiotic prophylaxis in common urological instrumentation. As a result of variations in the definitions of infectious complications and inconsistencies in study design and risk factor analysis there is presently limited clear-cut evidence for giving definite standards regarding antibiotic prophylaxis for most urological interventions. The consequences are that patients may be exposed to unnecessary hazards and the healthcare system to additional costs. Nonetheless, most authors agree that patients should have sterile urine at urological instrumentation and that any other detected risk factor should be controlled. When antibiotic prophylaxis is considered, it should be timed properly before the intervention, which varies with the type of intervention and the choice of antibiotic, and should last for a limited period of time. In most common urological manipulations, correctly administered oral prophylaxis has been shown to be as effective as intravenous prophylaxis. A series of guidelines aimed at keeping the rates of healthcare-associated infections and the level of bacterial resistance as low as possible should, in combination with the rational use of antibiotics, be one of several marks of quality of a urological centre. To achieve this goal, new well-designed studies considering different regimens, risk factor analysis and economical analysis should be encouraged.