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

Host factors that increase the risk of post-operative infection (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

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

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.

References

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