Antibiotic Prophylaxis

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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
Implanted prosthetic devices 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

Questions

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References