Antibiotic Prophylaxis

• See Original AUA Guidelines on Antibiotic Prophylaxis
  • See Table for Recommended antimicrobial prophylaxis for urologic procedures
• See Original CUA Guidelines on Antibiotic Prophylaxis
• See CUA Guideline Notes

Surgical Wound Classification

• 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
• 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

Risk Factors for Post-Operative Infection

Host Factors (10)

1. Advanced age
2. Anatomic anomalies
3. Poor nutritional status
4. Smoking
5. Chronic corticosteroid use
6. Immunodeficiency
7. Chronic indwelling hardware
8. Infected endogenous/exogenous material
9. Distant co-existent infection
10. Prolonged hospitalization

Recommended Prophylaxis

Procedure	Antibiotic	Alternative	Duration
Cystoscopy with minor manipulation	If risk-factors TMP-SMX OR Amoxicillin/Clavulanate	1st/2nd generation cephalosporin OR Aminoglycoside +/- Ampicillin OR Aztreonam +/- Ampicillin	Single dose
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§§§§

• 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

Urinary Catheter Removal

• Does not significantly reduce risk of UTIs in patients undergoing radical prostatectomy or TURP
  • 2021 Systematic Review and Meta-Analysis
    • 8 randomized trials evaluating antibiotic prophylaxis for UTIs after extraction of a temporary (≤14 days) urinary catheter.
      • 2 trials were laparoscopic radical prostatectomy patients
      • 1 trial was TURP patients
    • Results
      • Only 2 studies showed that antibiotic prophylaxis can significantly reduce the consequent UTIs after extraction of urinary catheters while 6 did not.
        • None of the 3 urological trials found a significant benefit of antibiotic prophylaxis
        • 2 trials that found benefit were in patients undergoing abdominal surgery or women on medical and surgical wards with bacteriuria
      • Overall, antibiotic prophylaxis was associated with reduced UTIs (RR, 0.47, 95% confidence interval [CI] 0.28-0.72, P< .01, I2 = 31%).
      • Subgroup analysis suggested that patients who could get more benefit from antibiotic prophylaxis included
        • Are > 60
        • Received Trimethoprim/sulfamethoxazole (TMP/SMX
        • indwelling catheters > 5 days
    • 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

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, vol 2, chap 12
• Lightner, Deborah J., et al. "Best practice statement on urologic procedures and antimicrobial prophylaxis." The Journal of Urology 203.2 (2020): 351-356.