Schnabel MJ et al., 2019: Perioperative antibiotic prophylaxis for stone therapy
Schnabel MJ, Wagenlehner FME, Schneidewind L.
Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg.
Department of Urology, Paediatric Urology and Andrology, University Hospital Giessen, Giessen.
Department of Haematology/Oncology, University Medicine Greifswald, Greifswald, Germany.
PURPOSE OF REVIEW: To give an overview about state-of-the-art antibiotic prophylaxis in urolithasis therapy and focus on recent publications in this field. RECENT FINDINGS: The number of high-quality publications within the recent time is limited. Preoperative inflammatory blood parameters like C-reactive protein and erythrocyte-sedimentation rate might help in prediction of postoperative systemic inflammatory response syndrome (SIRS) after percutaneous nephrolithotomy (PCNL). White blood cell count is nonpredictive for urinary tract infection (UTI) in patients with acute renal colic. In patients with low risk for infectious complications, antibiotic prophylaxis during shock-wave lithotripsy (SWL) is unnecessary and single-dose antibiotics are comparably effective as prolonged antibiotic usage during PCNL and ureterorenoscopy (URS). SUMMARY: Current findings support the American Urological Association (AUA) and European Association of Urology (EAU) guideline recommendations for a risk-adapted minimal antibiotic usage. Single-dose antibiotic prophylaxis is sufficient for low-risk PCNL and URS. For SWL no antibiotic prophylaxis is needed.
Curr Opin Urol. 2019 Mar;29(2):89-95. doi: 10.1097/MOU.0000000000000576.
The authors have reviewed the literature regarding the need of antibiotics in patients treated with SWL, URS and PCNL.
Generally it is important to avoid unnecessary treatment with antibiotics as far as possible in order to avoid development of resistant bacterial strains. In patients treated with SWL the conclusion was that antibiotics are not necessary provided absence of pre-operative risk factors. Based on almost 35 years of experience with SWL I can fully support that statement. But it is also highly desirable to avoid infection complications as a result of non- or least invasive stone removal when infection risk cannot be excluded.
The following rules were followed for patients treated with SWL in my own unit.
When a percutaneous nephrostomy catheter had been inserted: always give antibiotics!
In patients with a medical history of urinary tract infections but with negative bacteria test (urine culture, dip-stick): give a single dose of an antibiotic agent, either according to any known sensitivity pattern or a broad-spectrum alternative such as aminoglycoside or ceftazidime. That regimen has been very rewarding over the years.
In patients with recent infection history, pre-treatment with antibiotics one or two weeks was usually applied.
In patients without a history of urinary tract infection but with a positive bacterial test: give a single dose of aminoglycoside or ceftazidime.
For one-shot antibiotic prophylactic treatment, the administration should be made not later than one hour before SWL in order to get sufficient tissue concentrations of the antibiotic.
One important lesson from the review is that decompression should be made when necessary and it previously has been recommended in case of stent insertion that antibiotics should be given. It is my personal experience, however, that routine administration of antibiotics is not necessary only because of a stent, provided stent insertion has been made under strictly sterile conditions.