Antibiotic Prophylaxis: Difference between revisions

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*'''See [[CUA: Antibiotic Prophylaxis (2015)|CUA Guideline Notes]]'''

=== Surgical ~~wound classification =~~==

== Surgical Wound Classification ==

* '''Clean: uninfected wound without inflammation or entry into the genital, urinary, or alimentary tract'''

* '''Clean: uninfected wound without inflammation or entry into the genital, urinary, or alimentary tract'''

* '''Clean-contaminated: uninfected wound with controlled entry into the genital, urinary, or alimentary tract'''

* '''Clean-contaminated: uninfected wound with controlled entry into the genital, urinary, or alimentary tract'''

* '''Contaminated: uninfected wound with major break in sterile technique (gross spillage from gastrointestinal tract or non-purulent inflammation)'''

* '''Contaminated: uninfected wound with major break in sterile technique (gross spillage from gastrointestinal tract or non-purulent inflammation)'''

* '''Dirty: wound with preexisting clinical infection or perforated viscera'''

* '''Dirty: wound with preexisting clinical infection or perforated viscera'''

=== Host ~~factors that increase the risk of post-operative infection~~ (10) ===

== Risk Factors for Post-Operative Infection ==

# '''Advanced age'''

=== Host Factors (10) ===

# '''Anatomic anomalies'''

# '''Advanced age'''

# '''Poor nutritional status'''

# '''Anatomic anomalies'''

# '''Smoking'''

# '''Poor nutritional status'''

# '''Chronic corticosteroid use'''

# '''Smoking'''

# '''Immunodeficiency'''

# '''Chronic corticosteroid use'''

# '''Chronic indwelling hardware'''

# '''Immunodeficiency'''

# '''Infected endogenous/exogenous material'''

# '''Chronic indwelling hardware'''

# '''Distant co-existent infection'''

# '''Infected endogenous/exogenous material'''

# '''Prolonged hospitalization'''

# '''Distant co-existent infection'''

# '''Prolonged hospitalization'''

=== ~~Special considerations~~ ===

== Recommended Prophylaxis ==

{| class="wikitable"

|+

!Procedure

!Antibiotic

!Alternative

!Duration

|-

|'''Cystoscopy with minor manipulation'''

|'''If risk-factors'''

'''TMP-SMX OR'''

==== '''~~Risk of endocarditis~~''' ====

'''Amoxicillin/Clavulanate'''

* '''~~The risk of~~ infectious ~~endocarditis (IE) after urologic procedures is low~~'''.

|'''1st/2nd generation cephalosporin OR'''

** '''~~Enterococcus faecaelis is the pathogen most likely responsible for IE following a genitorurinary~~ tract ~~bacteremia~~'''

'''Aminoglycoside +/- Ampicillin OR'''

* '''~~The current recommendation is that the use of prophylactic antibiotics solely to prevent IE is not recommended~~'''

** Previous guidelines from the American Heart Association had recommended routine prophylaxis

'''Aztreonam +/- Ampicillin'''

* '''~~The guidelines do state that for patients with certain concomitant conditions (prosthetic cardiac valve~~, ~~previous IE~~, ~~congenital heart disease, cardiac transplantation) AND an active infection~~ or ~~colonization who are to undergo GU~~ tract ~~manipulation~~, ~~including elective cystoscopy~~, ~~antibiotic therapy to sterilize the urine may be reasonable~~''' (~~Class IIb evidence~~).

|'''Single dose'''

** Amoxicillin or ampicillin is suggested as a ~~first~~-~~line agent for enterococci~~, ~~vancomycin~~ for ~~penicillin allergy~~

|-

|'''Transurethral cases with resection'''

|'''Cefazolin OR'''

'''TMP-SMX'''

|'''Amoxicillin/Clavulanate OR'''

'''Aminoglycoside +/- Ampicillin OR'''

'''Aztreonam +/- Ampicillin'''

|'''Single dose'''

|-

|'''Transrectal prostate biopsy'''

|'''Fluoroquinolone OR'''

'''1st/2nd generation cephalosporin +/- aminoglycoside OR'''

'''3rd generation cephalosporin'''

|'''Aztreonam'''

'''May need infectious disease consultation'''

|'''Single dose'''

|-

|'''Percutaneous renal surgery'''

|'''1st/2nd generation cephalosporin OR'''

'''Aminoglycoside and clindamycin OR'''

'''Aminoglycoside and metronidazole OR'''

'''Aztreonam and metronidazole OR'''

'''Aztreonam and clindamycin'''

|'''Ampicillin/sublactan'''

|'''≤24 hours'''

|-

|'''Ureteroscopy'''

|'''1st/2nd generation cephalosporin OR'''

'''TMP-SMX'''

|'''Aminoglycoside +/- Ampicillin OR'''

'''Aztreonam +/- Ampicillin OR'''

'''Amoxicillin/Clavulanate'''

|'''Single dose'''

|-

|'''Open, laparoscopic, or robotic surgery without entry into urinary tract'''

|'''Cefazolin'''

|'''Clindamycin'''

|'''Single dose'''

|-

|'''Open, laparoscopic, or robotic surgery involving controlled entry into urinary tract'''

|'''Cefazolin OR'''

'''TMP-SMX'''

|'''Ampicillin/Sublactam OR'''

'''Aminoglycoside and metronidazole OR'''

'''Aztreonam and metronidazole OR'''

'''Aminoglycoside and clindamycin OR'''

'''Aztreonam and Clindamycin'''

|'''Single dose'''

|-

|'''Open, laparoscopic, or robotic surgery involving small bowel'''

|'''Cefazolin'''

|Clindamycin and aminoglycoside OR

Cefuroxime (2nd generation cephalosporin) OR

Aminopenicillin combined with a β- lactamase inhibitor and Metronidazole (optional)

|'''Single dose'''

|-

|'''Implanted prosthetic devices (AUS, IPP, sacral neuromodulators)'''

|'''Aminoglycoside and 1st/2nd gen cephalosporin OR'''

'''Aminoglycoside and Vancomycin OR'''

'''Aztreonam and 1st/2nd generation cephalosporin OR'''

'''Aztreonam and Vancomycin'''

|'''Aminopenicillin OR'''

'''B-lactamase inhibitor (including ampicillin/sublactan, ticarcillin, tazobactam)'''

|'''≤24 hours'''

|}

=== Typical doses[https://anesthesia.bidmc.harvard.edu/ADEL/Documents/uro_prophy.pdf §][https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/resources/appendix+16+urological+surgery §][https://www.med.umich.edu/asp/pdf/surgical_prophylaxis/surg-ppx_Guideline.pdf §][https://www.mdanderson.org/content/dam/mdanderson/documents/for-physicians/algorithms/clinical-management/clin-management-surgical-antibiotic-prophylaxis-adult-web-algorithm.pdf §] ===

* '''TMP/SMX: 800 mg of sulfamethoxazole and 160 mg of trimethorprim PO x 1 dose'''

*'''1st generation cephalosporin: cefazolin 2gm IV x 1 dose'''

*'''3rd generation cephalosporin: cetriaxone 2g IV x 1 dose'''

* '''Clindamycin 600mg IV x 1 dose'''

* '''Fluoroquinolone: levofloxacin 500mg PO x 1 dose OR ciprofloxacin 500 mg PO x 1 dose'''

* '''Aminoglycoside: gentamicin 2mg/kg IV x 1 dose'''

* '''Vancomycin 1mg IV x 1 dose'''

* '''Metronidazole 500mg IV x 1 dose'''

* '''Intraoperative redosing if required'''

** '''Cefazolin 2gm IV q4h'''

** '''Clindamycin 600mg IV q8h'''

** '''Gentamicin 1mg/kg q8h'''

** '''Metronidazole 500mg IV q6h'''

*

~~==== '''Indwelling orthopedic hardware''' ====~~

== Urinary Catheter Removal ==

* '''In general, antibiotic prophylaxis for urologic patients with total joint replacements, pins, plates, or screws is not indicated.'''

* '''Prophylaxis is advised for individuals at higher risk of seeding a prosthetic joint, including those with recently inserted implants (within 2 years) and/or host risk factors as delineated earlier'''

===Urinary Catheter Removal===

*'''Does not significantly reduce risk of UTIs in patients undergoing radical prostatectomy or TURP'''

**'''2021 Systematic Review and Meta-Analysis'''

Line 51:

Line 155:

*****indwelling catheters > 5 days

***[https://pubmed.ncbi.nlm.nih.gov/32763348/ Liu, Linhu, et al.] "Antibiotic prophylaxis after extraction of urinary catheter prevents urinary tract infections: A systematic review and meta-analysis." ''American Journal of Infection Control'' 49.2 (2021): 247-254.

== Special considerations ==

=== Risk of endocarditis ===

* '''The risk of infectious endocarditis (IE) after urologic procedures is low'''.

** '''Enterococcus faecaelis is the pathogen most likely responsible for IE following a genitorurinary tract bacteremia'''

* '''The current recommendation is that the use of prophylactic antibiotics solely to prevent IE is not recommended'''

** Previous guidelines from the American Heart Association had recommended routine prophylaxis

* '''The guidelines do state that for patients with certain concomitant conditions (prosthetic cardiac valve, previous IE, congenital heart disease, cardiac transplantation) AND an active infection or colonization who are to undergo GU tract manipulation, including elective cystoscopy, antibiotic therapy to sterilize the urine may be reasonable''' (Class IIb evidence).

** Amoxicillin or ampicillin is suggested as a first-line agent for enterococci, vancomycin for penicillin allergy

=== Indwelling orthopedic hardware ===

* '''In general, antibiotic prophylaxis for urologic patients with total joint replacements, pins, plates, or screws is not indicated.'''

* '''Prophylaxis is advised for individuals at higher risk of seeding a prosthetic joint, including those with recently inserted implants (within 2 years) and/or host risk factors as delineated earlier'''

== Questions ==

Line 62:

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* Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, vol 2, chap 12

*[https://pubmed.ncbi.nlm.nih.gov/31441676/ Lightner, Deborah J., et al. "Best practice statement on urologic procedures and antimicrobial prophylaxis." ''The Journal of Urology'' 203.2 (2020): 351-356.]

@@ Line 4: / Line 4: @@
 *'''See [[CUA: Antibiotic Prophylaxis (2015)|CUA Guideline Notes]]'''
-=== Surgical wound classification ===
+== Surgical Wound Classification ==
-* '''Clean: uninfected wound without inflammation or entry into the genital, urinary, or alimentary tract'''
+* '''<span style="color:#ff0000">Clean: uninfected wound without inflammation or entry into the genital, urinary, or alimentary tract'''
-* '''Clean-contaminated: uninfected wound with controlled entry into the genital, urinary, or alimentary tract'''
+* '''<span style="color:#ff0000">Clean-contaminated: uninfected wound with controlled entry into the genital, urinary, or alimentary tract'''
-* '''Contaminated: uninfected wound with major break in sterile technique (gross spillage from gastrointestinal tract or non-purulent inflammation)'''
+* '''<span style="color:#ff0000">Contaminated: uninfected wound with major break in sterile technique (gross spillage from gastrointestinal tract or non-purulent inflammation)'''
-* '''Dirty: wound with preexisting clinical infection or perforated viscera'''
+* '''<span style="color:#ff0000">Dirty: wound with preexisting clinical infection or perforated viscera'''
-=== Host factors that increase the risk of post-operative infection (10) ===
+== Risk Factors for Post-Operative Infection ==
-# '''Advanced age'''
+=== Host Factors (10) ===
-# '''Anatomic anomalies'''
+# '''<span style="color:#ff0000">Advanced age'''
-# '''Poor nutritional status'''
+# '''<span style="color:#ff0000">Anatomic anomalies'''
-# '''Smoking'''
+# '''<span style="color:#ff0000">Poor nutritional status'''
-# '''Chronic corticosteroid use'''
+# '''<span style="color:#ff0000">Smoking'''
-# '''Immunodeficiency'''
+# '''<span style="color:#ff0000">Chronic corticosteroid use'''
-# '''Chronic indwelling hardware'''
+# '''<span style="color:#ff0000">Immunodeficiency'''
-# '''Infected endogenous/exogenous material'''
+# '''<span style="color:#ff0000">Chronic indwelling hardware'''
-# '''Distant co-existent infection'''
+# '''<span style="color:#ff0000">Infected endogenous/exogenous material'''
-# '''Prolonged hospitalization'''
+# '''<span style="color:#ff0000">Distant co-existent infection'''
+# '''<span style="color:#ff0000">Prolonged hospitalization'''
-=== Special considerations ===
+== Recommended Prophylaxis ==
+{| class="wikitable"
+|+
+!Procedure
+!Antibiotic
+!Alternative
+!Duration
+|-
+|'''<span style="color:#ff0000">Cystoscopy with minor manipulation'''
+|'''<span style="color:#ff0000">If risk-factors'''
+'''<span style="color:#ff0000">TMP-SMX OR'''
-==== '''Risk of endocarditis''' ====
+'''<span style="color:#ff0000">Amoxicillin/Clavulanate'''
-* '''The risk of infectious endocarditis (IE) after urologic procedures is low'''.
+|'''1st/2nd generation cephalosporin OR'''
-** '''Enterococcus faecaelis is the pathogen most likely responsible for IE following a genitorurinary tract bacteremia'''
+'''Aminoglycoside +/- Ampicillin OR'''
-* '''The current recommendation is that the use of prophylactic antibiotics solely to prevent IE is not recommended'''
-** Previous guidelines from the American Heart Association had recommended routine prophylaxis
+'''Aztreonam +/- Ampicillin'''
-* '''The guidelines do state that for patients with certain concomitant conditions (prosthetic cardiac valve, previous IE, congenital heart disease, cardiac transplantation) AND an active infection or colonization who are to undergo GU tract manipulation, including elective cystoscopy, antibiotic therapy to sterilize the urine may be reasonable''' (Class IIb evidence).
+|'''Single dose'''
-** Amoxicillin or ampicillin is suggested as a first-line agent for enterococci, vancomycin for penicillin allergy
+|-
+|'''<span style="color:#ff0000">Transurethral cases with resection'''
+|'''<span style="color:#ff0000">Cefazolin OR'''
+'''<span style="color:#ff0000">TMP-SMX'''
+|'''Amoxicillin/Clavulanate OR'''
+'''Aminoglycoside +/- Ampicillin OR'''
+'''Aztreonam +/- Ampicillin'''
+|'''Single dose'''
+|-
+|'''<span style="color:#ff0000">Transrectal prostate biopsy'''
+|'''<span style="color:#ff0000">Fluoroquinolone OR'''
+'''<span style="color:#ff0000">1st/2nd generation cephalosporin +/- aminoglycoside OR'''
+'''<span style="color:#ff0000">3rd generation cephalosporin'''
+|'''Aztreonam'''
+'''May need infectious disease consultation'''
+|'''Single dose'''
+|-
+|'''<span style="color:#ff0000">Percutaneous renal surgery'''
+|'''<span style="color:#ff0000">1st/2nd generation cephalosporin OR'''
+'''<span style="color:#ff0000">Aminoglycoside and clindamycin OR'''
+'''Aminoglycoside and metronidazole OR'''
+'''Aztreonam and metronidazole OR'''
+'''Aztreonam and clindamycin'''
+|'''Ampicillin/sublactan'''
+|'''≤24 hours'''
+|-
+|'''<span style="color:#ff0000">Ureteroscopy'''
+|'''<span style="color:#ff0000">1st/2nd generation cephalosporin OR'''
+'''<span style="color:#ff0000">TMP-SMX'''
+|'''Aminoglycoside +/- Ampicillin OR'''
+'''Aztreonam +/- Ampicillin OR'''
+'''Amoxicillin/Clavulanate'''
+|'''Single dose'''
+|-
+|'''<span style="color:#ff0000">Open, laparoscopic, or robotic surgery without entry into urinary tract'''
+|'''<span style="color:#ff0000">Cefazolin'''
+|'''Clindamycin'''
+|'''Single dose'''
+|-
+|'''<span style="color:#ff0000">Open, laparoscopic, or robotic surgery involving controlled entry into urinary tract'''
+|'''<span style="color:#ff0000">Cefazolin OR'''
+'''<span style="color:#ff0000">TMP-SMX'''
+|'''Ampicillin/Sublactam OR'''
+'''Aminoglycoside and metronidazole OR'''
+'''Aztreonam and metronidazole OR'''
+'''Aminoglycoside and clindamycin OR'''
+'''Aztreonam and Clindamycin'''
+|'''Single dose'''
+|-
+|'''<span style="color:#ff0000">Open, laparoscopic, or robotic surgery involving small bowel'''
+|'''<span style="color:#ff0000">Cefazolin'''
+|Clindamycin and aminoglycoside OR
+Cefuroxime (2nd generation cephalosporin) OR
+Aminopenicillin combined with a β- lactamase inhibitor and Metronidazole (optional)
+|'''Single dose'''
+|-
+|'''<span style="color:#ff0000">Implanted prosthetic devices (AUS, IPP, sacral neuromodulators)'''
+|'''<span style="color:#ff0000">Aminoglycoside and 1st/2nd gen cephalosporin OR'''
+'''<span style="color:#ff0000">Aminoglycoside and Vancomycin OR'''
+'''Aztreonam and 1st/2nd generation cephalosporin OR'''
+'''Aztreonam and Vancomycin'''
+|'''Aminopenicillin OR'''
+'''B-lactamase inhibitor (including ampicillin/sublactan, ticarcillin, tazobactam)'''
+|'''≤24 hours'''
+|}
+=== Typical doses[https://anesthesia.bidmc.harvard.edu/ADEL/Documents/uro_prophy.pdf §][https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/resources/appendix+16+urological+surgery §][https://www.med.umich.edu/asp/pdf/surgical_prophylaxis/surg-ppx_Guideline.pdf §][https://www.mdanderson.org/content/dam/mdanderson/documents/for-physicians/algorithms/clinical-management/clin-management-surgical-antibiotic-prophylaxis-adult-web-algorithm.pdf §] ===
+* '''TMP/SMX: 800 mg of sulfamethoxazole and 160 mg of trimethorprim PO x 1 dose'''
+*'''1st generation cephalosporin: cefazolin 2gm IV x 1 dose'''
+*'''3rd generation cephalosporin: cetriaxone 2g IV x 1 dose'''
+* '''Clindamycin 600mg IV x 1 dose'''
+* '''Fluoroquinolone: levofloxacin 500mg PO x 1 dose OR ciprofloxacin 500 mg PO x 1 dose'''
+* '''Aminoglycoside: gentamicin 2mg/kg IV x 1 dose'''
+* '''Vancomycin 1mg IV x 1 dose'''
+* '''Metronidazole 500mg IV x 1 dose'''
+* '''Intraoperative redosing if required'''
+** '''Cefazolin 2gm IV q4h'''
+** '''Clindamycin 600mg IV q8h'''
+** '''Gentamicin 1mg/kg q8h'''
+** '''Metronidazole 500mg IV q6h'''
+*
-==== '''Indwelling orthopedic hardware''' ====
+== Urinary Catheter Removal ==
-* '''In general, antibiotic prophylaxis for urologic patients with total joint replacements, pins, plates, or screws is not indicated.'''
-* '''Prophylaxis is advised for individuals at higher risk of seeding a prosthetic joint, including those with recently inserted implants (within 2 years) and/or host risk factors as delineated earlier'''
-===Urinary Catheter Removal===
 *'''Does not significantly reduce risk of UTIs in patients undergoing radical prostatectomy or TURP'''
 **'''2021 Systematic Review and Meta-Analysis'''
@@ Line 51: / Line 155: @@
 *****indwelling catheters > 5 days
 ***[https://pubmed.ncbi.nlm.nih.gov/32763348/ Liu, Linhu, et al.] "Antibiotic prophylaxis after extraction of urinary catheter prevents urinary tract infections: A systematic review and meta-analysis." ''American Journal of Infection Control'' 49.2 (2021): 247-254.
+== Special considerations ==
+=== Risk of endocarditis ===
+* '''The risk of infectious endocarditis (IE) after urologic procedures is low'''.
+** '''Enterococcus faecaelis is the pathogen most likely responsible for IE following a genitorurinary tract bacteremia'''
+* '''The current recommendation is that the use of prophylactic antibiotics solely to prevent IE is not recommended'''
+** Previous guidelines from the American Heart Association had recommended routine prophylaxis
+* '''The guidelines do state that for patients with certain concomitant conditions (prosthetic cardiac valve, previous IE, congenital heart disease, cardiac transplantation) AND an active infection or colonization who are to undergo GU tract manipulation, including elective cystoscopy, antibiotic therapy to sterilize the urine may be reasonable''' (Class IIb evidence).
+** Amoxicillin or ampicillin is suggested as a first-line agent for enterococci, vancomycin for penicillin allergy
+=== Indwelling orthopedic hardware ===
+* '''In general, antibiotic prophylaxis for urologic patients with total joint replacements, pins, plates, or screws is not indicated.'''
+* '''Prophylaxis is advised for individuals at higher risk of seeding a prosthetic joint, including those with recently inserted implants (within 2 years) and/or host risk factors as delineated earlier'''
 == Questions ==
@@ Line 62: / Line 179: @@
 * Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, vol 2, chap 12
+*[https://pubmed.ncbi.nlm.nih.gov/31441676/ Lightner, Deborah J., et al. "Best practice statement on urologic procedures and antimicrobial prophylaxis." ''The Journal of Urology'' 203.2 (2020): 351-356.]