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: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.

2 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. 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 . 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 .

3 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.#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.

4 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. 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.

5 Various authors have addressed thisissue in reviews in recent years[1 4]. 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), and the Cochrane Library weresearched using the terms postoperative complications, infec-tion, bacteriuria, Antibiotic Prophylaxis , chemoprophylaxis,antibiotics, and premedication plus randomized controlledtrial (RCT).

6 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).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). Each included article was graded on level of evidenceaccording to the level-of-evidence list of the Oxford Centre forEvidence-Based Medicine[8].

7 The primary outcome parameter was postoperative bac-teriuria, in which postoperative was defined as the period of30 d after the procedure, and bacteriuria as 103colony formingunits (CFU)/ml in symptomatic urinary tract infection and 105 CFU/ml in asymptomatic bacteriuria[5]. The secondaryoutcome parameters were postoperative symptomatic urinarytract infection, fever, sepsis, and bacteraemia. Antibioticprophylaxis was defined as use of antibiotics around anTable 1 Search terms per Urologic interventionInterventionSearch termsCystoscopyCystoscopyProstate biopsyProstate biopsyUrodynamic investigationUrodynamics, urodynamic investigation, urodynamic examination,urodynamic studyTransurethral resection of prostateTransurethral resection, prostatic transurethral resection,prostatectomy, TURPT ransurethral resection of bladder tumorTURT, TURB, transurethral resection bladder tumor, bladder tumorresectionExtracorporeal shock wave lithotripsyLithotripsy, ESWL, shock wave therapy, shock wave lithotripsy,extracorporeal lithotripsyUreterorenoscopyUreteroscopy, ureterorenoscopyPercutaneous nephrolithotomyKidney stone surgery, percutaneous nephrolithotomy, percutaneousnephrostomy lithotripsyeuropean urology 54 (2008)

8 1270 12861271intervention, preferably for a duration of less than 24 hr, withthe first dose given before or at the start of the included RCTs are presented inTables 2 8,along with their level of evidence. When no RCT wasincluded, the results and level of evidence of thenon-RCTs are described in the corresponding para-graph below, along with the reasons for exclusion ofthe corresponding RCTs. For uniformity of out-comes, asymptomatic bacteriuria and asympto-matic urinary tract infection are both referred toas bacteriuria and symptomatic urinary tract infec-tion (UTI) and symptomatic bacteriuria is referred toas symptomatic CystoscopyA total of nine RCTs was found, of which four wereincluded in this review (Table 2)[9 12]. The otherstudies were excluded because of lack of descrip-tion of randomization method and group composi-tion[13,14], investigating the effect of antibiotictreatment instead of Prophylaxis [15], and studyingmore interventions than cystoscopy alone, withoutpossibility of a separate analysis[16,17].

9 Oftheincluded studies, Wilson et al[12]and Tsugawaet al[11]did not find a decrease in eitherbacteriuria or in symptomatic UTIs after use ofantibiotic Prophylaxis . Two studies, Jimenez Cruzet al[9]and MacDermott et al[10], found asignificant decrease of symptomatic UTIs andbacteriuria, , two useful case series were identi-fied describing the post-cystoscopy infection inci-dence without use of Antibiotic Prophylaxis [18,19](level of evidence (LOE) 4). Almallah et al[18]found abacteriuria incidence of (n= 103) within 48 hrpost-cystoscopy. Although 14% of all patientsreported irritative symptoms within 48 hr, only asmall portion developed bacteriuria as well, result-ing in a symptomatic UTI incidence of Clarket al[19]described a incidence of post-cystoscopy bacteriuria. After identifying and exclud-ing patients with risk factors, the incidence droppedto A history of symptomatic UTI and additionalprocedures performed during cystoscopy wereidentified as risk factors for developing post-cysto-scopy summary, it can be concluded that there is lowto moderate evidence for the use of antibioticprophylaxis in cystoscopy.

10 A low incidence ofbacteriuria and symptomatic UTIs is seen aftercystoscopy, irrespective of the use of antibioticprophylaxis. These results suggest that antibioticprophylaxis is not needed for cystoscopy in theabsence of risk factors for developing Prostate biopsyThirteen RCTs were identified concerning prostatebiopsy. Seven were excluded because they investi-gated Prophylaxis methods other than antibioticprophylaxis[20,21], used inadequate randomizationmethods[22 25], or investigated the effect ofantibiotic treatment instead of Prophylaxis [26].Six RCTs comparing Antibiotic Prophylaxis with theuse of a placebo or no Antibiotic Prophylaxis wereincluded[27 32](Table 3). They show a significantdecrease of bacteriuria after prostate biopsy with theuse of Antibiotic Prophylaxis compared with no useof antibiotics. Several RCTs also reported secondaryoutcome parameters. Fever was not significantlyreduced after use of Antibiotic Prophylaxis in fourRCTs[27,28,31,32], but was significantly reduced inanother RCT of lower quality[29].