Antibiotic prophylaxis may not be necessary in patients with asymptomatic bacteriuria undergoing intradetrusor onabotulinumtoxinA injections for neurogenic detrusor overactivity

Antibiotic prophylaxis for onabotulinum toxin A injections: systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

To our knowledge, there are no evidence-based recommendations regarding the optimal prophylactic antibiotic regimen for intradetrusor onabotulinum toxin type A (BTX) injections. This systematic review and meta-analysis was aimed at investigating the optimal prophylactic antibiotic regimen to decrease urinary tract infection (UTI) in patients undergoing BTX for overactive bladder syndrome (OAB).

METHODS

A systematic search of MEDLINE, Embase, CINAHL, and Web of Science was conducted from inception through 30 June 2022. All randomized controlled trials and prospective trials with > 20 subjects undergoing BTX injections for OAB in adults that described prophylactic antibiotic regimens were included. Meta-analysis performed to assess UTI rates in patients with idiopathic OAB using the inverse variance method for pooling.

RESULTS

A total of 27 studies (9 randomized controlled trials, 18 prospective) were included, representing 2,100 patients (69% women) with 19 studies of idiopathic OAB patients only, 6 of neurogenic only, and 2 including both. No studies directly compared antibiotic regimens for the prevention of UTI. Included studies favor the use of antibiotics in patients with idiopathic OAB and favor continuing antibiotics for 2-3 days after the procedure for prevention of UTI. Given the heterogeneity of the data, direct comparisons of antibiotic type or duration could not be performed. Meta-analysis found a 10% UTI rate at 4 weeks and 15% at 12 weeks post-injection.

CONCLUSIONS

Although there are insufficient data to support the use of a specific antibiotic regimen, available studies favor the use of prophylactic antibiotics for 2-3 days in idiopathic OAB patients undergoing BTX injection. Future trials are needed to determine the optimal regimens to prevent UTI in patients undergoing BTX for OAB.

Evaluating the utility of routine urine culture and antibiotic treatment in children with neurogenic bladder undergoing intradetrusor OnabotulinumtoxinA injection

INTRODUCTION

OnabotulinumtoxinA is used as treatment for refractory idiopathic and neurogenic detrusor overactivity in children. Many patients perform intermittent self-catheterization and therefore have higher rates of asymptomatic bacteriuria, which may increase their risk of symptomatic urinary tract infection (UTI) following treatment. Multiple injections are often needed due to the short-term efficacy of onabotulinumtoxinA treatment, which may also increase the risk of UTI.

OBJECTIVE

We aim to evaluate whether a sterile urinary tract is necessary to decrease the risk of postoperative UTI in pediatric patients treated with onabotulinumtoxinA.

STUDY DESIGN

A retrospective review of patients undergoing intradetrusor onabotulinumtoxinA injection from 2014 to 2021 was performed. Demographic data, clinical characteristics, antibiotic treatment and culture results were collected. A positive urine culture was defined as ≥ 103 CFU/ml of uropathogenic bacteria. Our primary outcome was symptomatic UTI within 14 days of the procedure.

RESULTS

103 patients underwent 158 treatments with onabotulinumtoxinA. The incidence of postoperative UTI was 3.2%. The incidence of symptomatic postoperative UTI in patients with asymptomatic bacteriuria compared to those with sterile urine was not significantly different (3.8% vs 0%, p = 0.57). Obtaining a preoperative urinalysis or urine culture did not affect the incidence of postoperative UTI (p = 0.54). The number needed to treat with antibiotics to prevent one postoperative UTI was 27. The incidence of postoperative UTI was highest in patients with low-risk bladders (p = 0.043). Prior history of multi-drug resistant UTI was a risk factor for postoperative UTI (p = 0.048).

DISCUSSION

For children undergoing onabotulinumtoxinA injection, there are no evidence-based recommendations regarding antibiotic prophylaxis and the need to screen for and treat asymptomatic bacteruria prior to treatment. Our study addresses this important clinical question, and shows no difference in the rate of postoperative UTI between patients with asymptomatic bacteriuria and those with sterile urine. Patients with a history of multi-drug resistant UTI are at increased risk of symptomatic postoperative UTI and may benefit from preoperative urine testing and treatment. Limitations of our retrospective study include its small sample size in the face of such a low incidence of our primary outcome.

CONCLUSIONS

The risk of UTI following onabotulinumtoxinA injection in children is low. The presence of sterile urine at the time of surgery does not significantly decrease the risk of postoperative UTI. Routine treatment of asymptomatic bacteriuria prior to surgery results in a large number of patients receiving unnecessary antibiotics. As a result, we recommend against preoperative urine testing for most asymptomatic patients.

Indwelling catheter vs intermittent catheterization: is there a difference in UTI susceptibility?

BACKGROUND

Patients with neurogenic lower urinary tract dysfunction (NLUTD) often rely on some type of catheterization for bladder emptying. Intermittent catheterization (IC) is considered the gold standard and is preferred over continuous catheterization, since it is considered to cause fewer urinary tract infections (UTIs) than indwelling catheterization. The main objective of our study was to describe UTI prevalence (at visit) and incidence (within the last 12 months) and urine culture characteristics between patients using an indwelling catheter versus (vs) those performing IC.

METHODS

In this cross-sectional study, we prospectively evaluated from 02/2020 to 01/2021 patients with NLUTD undergoing urine cultures for prophylactic reasons or due to UTI symptoms. At visit, all patients underwent a standardized interview on current UTI symptoms as well as UTI history and antibiotic consumption within the past year. Patients using an indwelling catheter (n = 206) or IC (n = 299) were included in the analysis. The main outcome was between-group differences regarding UTI characteristics.

RESULTS

Patients using an indwelling catheter were older (indwelling catheter vs IC: median 66 (Q1-Q3: 55-77) vs 55 (42-67) years of age) and showed a higher Charlson comorbidity index (indwelling catheter vs IC: median 4 (Q1-Q3: 2-6) vs 2 (1-4) (both p < 0·001). A total of 40 patients from both groups were diagnosed with a UTI at visit (indwelling catheters vs IC: 8% (16/206) vs 8% (24/299); p = 0·782), and the number of UTIs within the past 12 months was not significantly different between groups. Overall, Escherichia coli (21%), Enterococcus faecalis (17%), and Klebsiella spp. (12%) were the most frequently detected bacteria.

CONCLUSIONS

In this cohort of patients with NLUTD, we did not find relevant differences in UTI frequency between groups. These results suggest that UTI-related concerns should not be given undue emphasis when counseling patients for catheter-related bladder emptying methods.

[Onabotulium toxin A detrusor injection: The "real world" of users, the "real world" of patients - Update BOTUROLOGY 2022]

BACKGROUND

OnabotulinumtoxinA (Botox) has been approved in Germany since 2013 for the second-line treatment of idiopathic overactive bladder in the form of a detrusor injection (OnabotA DI) after failure of anticholinergic therapy. Until 2018, however, its application lagged far behind the demand due to billing hurdles. Since the beginning of 2018, there has been an EBM (German Uniform Evaluation Standard) approval number in Germany for the transurethral application of Botox in urology.

QUESTION

The aim of a survey performed in 2019 among course participants of regular injection workshops (WS-P) in our institution was to evaluate whether billability has changed user behaviour in Germany in line with the demand. A similar survey was carried out in 2021 to show the developments over the past two years.

MATERIAL AND METHODS

In 2019, 88 consecutive participants in a user workshop that had been held regularly since 2013 were asked about their OnabotA DI practice anonymously via questionnaire. The survey was repeated in 2021 in an anonymous online survey of 55 course participants in order to evaluate changes in user behaviour over the past two years.

RESULTS

Evaluation 2019: Response rate 35/88 of the questionnaires (39.8%); a large majority (82%) of the WS-P attended the workshop AFTER the establishment of the EBM code. Only 54.5% of the WS-P performed two or more (12% more than 10) OnabotA DIs per quarter after the workshop. Most users (85%) always or predominantly performed the procedure on an outpatient basis, 63% always or predominantly under local anesthesia. The majority (84%) administered no or only a perioperative antibiotic treatment, 13% for one week. 89% stated that at least 70% of their patients had no or only mild symptoms under the LA. In the 2021 evaluation, the users tended to perform the procedure more often on an outpatient basis and in LA, and more often without any antibiotics.

CONCLUSIONS

The results of our user survey indicate that the implementation of the OnabotA DI has gained significant impetus since the EBM approval in Germany in January 2018. In most cases, the procedure can be performed easily on an outpatient basis under local anesthesia.

Definitions of Urinary Tract Infection Used in Interventional Studies Involving Neurourological Patients-A Systematic Review

CONTEXT

Neurourological patients often encounter bacteriuria without any symptoms or may experience symptoms suspicious of urinary tract infections (UTIs). However, there is a lack of guidelines that unequivocally state the definition of UTIs in this specific patient group.

OBJECTIVE

To present all used definitions of UTIs in neurourological patients.

EVIDENCE ACQUISITION

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies were identified by electronic search of Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov without a time limitation (last search September 2020) and by screening of reference lists and reviews. The occurrences of the various UTI definitions were counted and the frequencies calculated.

EVIDENCE SYNTHESIS

After screening 7164 abstracts, we included 32 studies enrolling a total of 8488 patients with a neurourological disorder who took part in an interventional clinical study. UTI definitions were heterogeneous. The concordance to predefined definitions was low.

CONCLUSIONS

Interventional clinical studies rarely report specific definitions for UTIs, and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed.

PATIENT SUMMARY

Patients suffering from neurological disorders often experience symptoms in their lower urinary tract that resemble urinary tract infections. Furthermore, they can have positive urine cultures without symptoms (the so-called asymptomatic bacteriuria). However, clinical studies rarely report specific definitions for urinary tract infections, and when it is done, they are heterogeneous. A generally accepted urinary tract infection definition for neurourological patients is urgently needed. TAKE  HOME MESSAGE: Interventional clinical studies on neurourological patients rarely report specific definitions for urinary tract infections (UTIs), and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed.

In Patients with Neurogenic Detrusor Overactivity and Hinman's Syndrome: Would Intravesical Botox Injections Decrease the Incidence of Symptomatic Urinary Tract Infections

Purpose

To study the effect of intravesical Botox injection on the incidence of recurrent symptomatic UTI in neurogenic bladder patients with detrusor overactivity.

Patients and Methods

This was a prospective cohort study for patients who received Botox intravesical injection. We included patients with neurogenic bladder with detrusor overactivity and symptomatic recurrent UTI. We compared the number of symptomatic UTIs at six months pre- and post-intravesical Botox injection. Patient files were reviewed for diagnosis, vesico-uretric reflux, hydronephrosis, urodynamic findings pre- and post-injection, and dose of Botox used. Patients were followed for the number of symptomatic UTIs post-Botox injection.

Results

There were 93 patients diagnosed with neurogenic detrusor overactivity and symptomatic recurrent UTI. Patients were categorized into three categories: Group 1 – adults, Group 2 – pediatrics, Group 3 – non-neurogenic neurogenic bladder (Hinman’s syndrome). Spina bifida was diagnosed in 22 adults (Group 1) and 32 pediatric patients (Group 2). After receiving Botox injection, 75% of all patients (70) had a significant decrease in number of symptomatic UTIs. Urodynamic tests post-injection showed an improvement in bladder capacity, compliance, and detrusor pressure versus baseline in all three groups. Correlation analysis showed significant correlation between decreased symptomatic UTI post-Botox injection and detrusor pressure post-injection as well as bladder compliance; p-value=0.01 and p=0.021, respectively.

Conclusion

Intravesical Botox injection may decrease incidence of symptomatic UTI in neurogenic detrusor overactivity. This effect seemed to be related to better bladder management.

Antibiotic regimen and route of administration do not alter rates of urinary tract infection after intravesical botulinum toxin injection for overactive bladder

INTRODUCTION AND HYPOTHESIS

Guidelines vary on antibiotic prophylaxis for onabotulinumtoxinA (Botox) treatment for overactive bladder (OAB). Our primary objective was to determine whether any prophylactic regimen is more effective in preventing urinary tract infection (UTI) after Botox. The secondary objective was to identify prophylactic practice patterns among female pelvic medicine and reconstructive surgery (FPMRS) providers of different training backgrounds as well as general urologists.

METHODS

This was a secondary analysis of a retrospective cohort study on urinary retention after Botox injection in women with and without diabetes mellitus and OAB. Women > 18 years old who underwent Botox injection for OAB between January 2013 and September 2018 were included. Exclusion criteria were history of urinary retention and neuromuscular bladder dysfunction.

RESULTS

A total of 565 patients were included. Two hundred eighty (49.6%) were treated by OB-GYN FPMRS, 209 (37.0%) by urology FPMRS and 76 (13.5%) by general urologists. The majority (92.9%) received antibiotic prophylaxis: 44.4% received intravenous (IV) only, 8.9% received oral (PO) only, and 39.7% received combination IV and PO prophylaxis. Urology FPMRS used antibiotic prophylaxis less frequently (p = 0.003). Within 3 months, 171 patients developed UTI (30.4%). There was no difference in post-procedural UTI for any antibiotic regimen compared to no prophylaxis. No route of antibiotic administration was superior at preventing UTI.

CONCLUSIONS

In this cohort, no route of antibiotic administration was more effective in the prevention of UTI. Antibiotic prophylaxis did not lower the rate of post-procedural UTI compared to no antibiotics.

Does a Recent Urinary Tract Infection Increase the Risk of Postprocedure Urinary Tract Infection After Onabotulinum Toxin A?

OBJECTIVES

The objective of this study was to evaluate the risk of postprocedure urinary tract infection (UTI) after injection of onabotulinum toxin A (BTX-A) in women who had a UTI within 30 days before procedure.

METHODS

This was a retrospective cohort study of women who underwent their first injection of BTX-A from 2010 to 2016. Two cohorts were identified: (1) recent UTI (within 30 days before injection) and (2) no recent UTI. Our primary outcome was UTI within 90 days after BTX-A. Continuous variables were analyzed using the Wilcoxon rank sum test, and categorical variables were analyzed using Fisher exact or χ2 tests.

RESULTS

One hundred sixty-six women underwent their first BTX-A injection. Twenty-five (15%) had a recent UTI and 141 (85%) did not. Women with a recent UTI were more likely to have a subsequent infection (52% vs 26%, P < 0.01). However, in a logistic regression model, controlling for history of recurrent UTI, age, history of diabetes mellitus, periprocedural antibiotics, and urinary retention requiring catheterization, the association between having a recent UTI, and a subsequent UTI was no longer significant (adjusted odds ratio, 1.98; 95% confidence interval, 0.60-6.50; P = 0.26).

CONCLUSIONS

Performing a first injection of BTX-A within 30 days of a UTI does not increase the odds of postprocedure UTI. Therefore, BTX-A therapy does not need to be delayed after a recent UTI.

A comparison of antibiotic prophylaxis regimens to decrease the risk of post-procedure urinary tract infection after onabotulinum toxin A injection

INTRODUCTION AND HYPOTHESIS

To evaluate the risk of post-injection urinary tract infection (UTI) after onabotulinumtoxin A (BTX-A) treatment based on the timing of when antibiotic prophylaxis is started.

METHODS

This is a retrospective cohort study of 111 women with refractory idiopathic overactive bladder who underwent intradetrusor injection of BTX-A. Two cohorts were identified: (1) 67 women who started antibiotic prophylaxis with ciprofloxacin 1 day prior to injection; (2) 44 women who received antibiotic prophylaxis with ciprofloxacin after injection only. We assessed for post-injection UTI within 90 days after BTX-A. Multivariable logistic regression was performed to adjust for potential confounders.

RESULTS

One hundred eleven women underwent BTX-A. In total, 30 (27%) had a UTI within 90 days; these included 15/67 (22%) of those who started antibiotics 1 day prior to injection and 15/44 (34%) of those receiving antibiotics after injection. While the unadjusted analysis showed no significant associations between timing of antibiotic administration and UTI (OR = 0.56; 95% CI = 0.24, 1.30; p = 0.18), an adjusted analysis showed the pre-procedure antibiotic group had a significant reduction in post-procedure UTI after controlling for age, history of UTI, diabetes, and urinary retention requiring catheterization (OR = 0.23; 95% CI = 0.07, 0.73; p = 0.01).

CONCLUSIONS

Starting antibiotics 1 day prior to BTX-A injection decreases the odds of post-injection UTI compared with women who use post-procedure antibiotic prophylaxis over shorter duration. Consideration should be given to beginning antibiotic prophylaxis prior to the procedure and continuing it for 4 total days to decrease the risk of UTI.

Safety of Intradetrusor OnabotulinumtoxinA (BTX-A) Injection in the Asymptomatic Patient With a Positive Urine Dip

OBJECTIVE

To evaluate differences in adverse events (AE) in asymptomatic patients with a positive urine dip (UD) at time of intradetrusor onabotulinumtoxinA (BTX-A) injection vsthose with a defined negative UD.

MATERIALS AND METHODS

All intradetrusor BTX-A injections were retrospectively reviewed at a single institution between 2016 and 2018. Exclusion criteria included an indwelling catheter, recent positive urine culture, recent antibiotic course, or absence of UD on the day of injection. A positive UD was defined using 7 different definitions with varying combinations of any level of positive blood, leukocyte esterase, or nitrite. Negative UDs were defined those excluded from the positive UD group. We compared multiple positive UD-defined groups to their respective negative UD cohorts with regards to outcomes and demographics.

RESULTS

A total of 212 patients underwent 335 cycles of BTX-A injections over a 2-year period. The average age was 65 years (range: 21-90). The majority received 100 units (73%) of BTX-A for a non-neurogenic diagnosis (73%). The overall rate of AEs, urinary tract infection, and urinary retention was 14.6%, 9%, and 3%, respectively. In all groups, the most common AE was urinary tract infection followed by urinary retention. There were no major Clavien-Dindo-defined complications. There was no statistically significant difference in the total or categorical AE rates between positive and negative UD groups using all 7 definitions of a positive UD (P = .05-1.0).

CONCLUSION

These data do not support the practice of obtaining a preprocedure UD in asymptomatic patients undergoing intradetrusor BTX-A injection for any indication; test results are unable to predict outcomes or AEs.