Antibiotic Prophylaxis in Urologic Procedures: A ...

1 Review InfectionsAntibiotic Prophylaxis in Urologic Procedures: A Systematic Jikke Bootsmaa, M. Pilar Laguna Pesa, Suzanne E. Geerlingsb, Astrid Goossensc,*aDepartment of Urology, Academic Medical Center, University of Amsterdam, The NetherlandsbDepartment of Infectious Diseases, Tropical Medicine and AIDS, Center for Infection and Immunity Amsterdam,Academic Medical Center, University of Amsterdam, The NetherlandscDepartment of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam,The Netherlandseuropean urology 54 (2008) 1270 1286available at homepage: infoArticle history.

2 Accepted March 11, 2008 Published online ahead ofprint on March 24, 2008 Keywords: Antibiotic prophylaxisBacteriuriaInfectionPostopera tive complicationsUrologic interventionsPlease read andanswer questions EU-ACME credits willthen be : Antibiotic Prophylaxis is used to minimize infectious complicationsresulting from interventions. Side-effects and development of microbial resis-tance patterns are risks of the use of antibiotics. Therefore, the use should be wellconsidered and based on high levels of evidence.

3 In this review, all availableevidence on the use of Antibiotic Prophylaxis in urology is gathered, assessed, andpresented in order to make choices in the use of Antibiotic Prophylaxis on the bestevidence currently :A systematic literature review was conducted, searching Medline,Embase (1980 2006), the Cochrane Library, and reference lists for relevant stu-dies. All selected articles were reviewed independently by two, and, in case ofdiscordance, three, :Only the transurethral resection of prostate (TURP) and prostate biopsyare well studied and have a high and moderate to high level of evidence in favourof using Antibiotic Prophylaxis .

4 Other Urologic interventions are not well moderate to low evidence suggests no need for Antibiotic Prophylaxis incystoscopy, urodynamic investigation, transurethral resection of bladder tumor,and extracorporeal shock-wave lithotripsy, whereas for therapeutic ureterore-noscopy and percutaneous nephrolithotomy, the low evidence favours the use ofantibiotic Prophylaxis . Urologic open and laparoscopic interventions were clas-sified according to surgical wound classification, since no studies were Prophylaxis is not advised in clean surgery, but is advised in clean-contaminated and prosthetic :Except for the TURP and prostate biopsy, there is a lack of well-performed studies investigating the need for Antibiotic Prophylaxis in urologicinterventions.

5 #2008 European Association of Urology. Published by Elsevier All rights reserved.* Corresponding author. Department of Clinical Epidemiology, Biostatistics & Bioinformatics,AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The +31 20 65283; Fax: +31 20 Goossens).0302-2838/$ see back matter#2008 European Association of Urology. Published by Elsevier All rights reserved. Prophylaxis is a brief course of antibioticsadministered before or at the start of an interventionand used to minimize the infectious complicationsresulting from diagnostic and therapeutic interven-tions.

6 While the rationale for the use of antibiotics iswell accepted, possible side-effects and develop-ment of microbial resistance patterns are potentialrisks. Therefore, an Antibiotic Prophylaxis policyshould be well considered and, ideally, based onhigh levels of is a surgical speciality which has under-gone many changes in the last decade. Surgicalprocedures have mainly shifted from open toendoscopic and laparoscopic procedures , and nowa-days, a greater number of elderly patients or carriersof temporary urinary derivations are being operatedon.

7 These developments can influence the choice ofantibiotic Prophylaxis it is common practice to administerantibiotic Prophylaxis in many Urologic procedures ,there is still little evidence for the use of antibioticprophylaxis in most of these procedures . This ismainly due to the lack of well-designed studies aswell as the lack of clear definitions of favourableoutcome question remains to what extent antibioticprophylaxis is beneficial in the different urologicprocedures. Various authors have addressed thisissue in reviews in recent years[1 4].

8 Also, theEuropean Association of Urology (EAU) has recentlyupdated the guideline Management of urinary andmale genital tract infections, including a chapteron perioperative antibacterial Prophylaxis in urol-ogy[5]. However, with the exception of the transur-ethral resection of the prostate[6,7], few of therecommendations in these reviews and guidelinesare supported by evidence gathered in a structuredsystematic review. The aim of this paper is toprovide a systematic review on the value ofantibiotic Prophylaxis during different urologicprocedures in order to make choices in the use ofantibiotic Prophylaxis on the best evidence cur-rently June 2006 and March 2007, the electronic databasesMedline, Embase (1980 2006)

9 , and the Cochrane Library weresearched using the terms postoperative complications, infec-tion, bacteriuria, Antibiotic Prophylaxis , chemoprophylaxis,antibiotics, and premedication plus randomized controlledtrial (RCT). Additional search terms were added for thedifferent Urologic interventions investigated (Table 1). Refer-ence lists were screened for relevant comparing Antibiotic Prophylaxis during urologicprocedures with a placebo or no Antibiotic Prophylaxis inpatients with preoperative sterile urine were selected withlanguage restriction (English, French, Spanish, German).

10 Studies included in a pre-existent systematic review of goodquality were not separately included. In the absence of arelevant RCT on the subject, case series and expert opinionswere selected. Inclusion criteria were RCT, and, if absent,observational study, of good quality, clear definitions ofoutcome parameters, and minimal post-intervention follow-up of 30 d. All selected articles were reviewed independentlyon inclusion criteria and study design by two reviewers (AB,MPL). In case of discordance, a third reviewer was consulted(AG).