Shafi H et al, 2018: Antibiotic prophylaxis in the prevention of urinary tract infection in patients with sterile urine before extracorporeal shock wave lithotripsy.
Shafi H, Ilkhani M, Darabi Ahangar Z, Bayani M.
Infertility and Reproductive Health Research Center, Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran.
Student Research Committee, Babol University of Medical Sciences, Babol, Iran.
Background: One of the lithotripsy complications is urinary tract infection (UTI) and sepsis after extracorporeal shock wave lithotripsy (ESWL). The aim was to study the prophylactic effect of antibiotics on UTI after ESWL.
Methods: This randomized double-blind clinical trial was carried out on 600 patients admitted to Babol Clinic hospital in 2014-2015. Patients were randomly divided into treatment group (receiving 200 mg ofloxacin and control group (receiving placebo. The effect of prophylactic antibiotics on the incidence of bacteriuria after ESWL and the impact of variables such as gender, age, urolithiasis size and location and underlying diseases in the incidence of UTI after ESWL were evaluated.
Results: Totally, 67 of the population had positive urine cultures. Twenty-nine (10.13%) of them were in the treatment group (n=286) and 38 (13.01%) of them were in the control group (n=292). All 67 patients had asymptomatic bacteriuria. Escherichia coli and proteus were the grown microorganisms in most samples. The mean age of sample population was 44.8±23, and 67.16% of patients with positive urine culture were older than 45 years.
Conclusions: The results indicated that prophylactic antibiotics prior to ESWL in patients with urinary calculi and negative urine culture had no significant decrease in urinary tract infection after lithotripsy. It is better that the use of prophylactic antibiotics is limited to patients with risk factors.
Caspian J Intern Med. 2018 Summer;9(3):296-298. doi: 10.22088/cjim.9.3.296.
This report confirms what has been evident from more than 30 years of clinical experience with SWL.
It is of fundamental importance to counteract infection complications with sepsis as the ultimate and life-threatening end point.
In this study patients planned for SWL were randomized to two groups. One group of patients was given antibiotics and the other not. Bacteriuria after SWL was demonstrated in 10-13% of the patients. There was no significant difference between the groups and the conclusion was that prophylactic treatment with antibiotics was without value.
Interestingly the authors found that presence of bacteriuria was most common in stones with a large size and without knowing anything about stone composition it is reasonable to assume that such stones either had a history of infection with inclusion of bacteria or infection stone material. It has also been suggested that bacteria in some cases might have initiated stone formation, but if this is something that occurs it is probably not a common situation.
Another important observation was that bacteriuria was more common in patients who previously had passed invasive surgery of the urinary tract. This is an observation that strongly emphasizes the value of using primary non-invasive methods for stone removal.
With this background it is nevertheless important to take steps to avoid serious infection complications and administer antibiotics when such a step is necessary. My personal routine has been to give antibiotics when there had been recent or previous episodes of urinary tract infection, or when a test for bacteriuria immediately before SWL was positive. In the latter case I have given a single dose of a broad spectrum antibiotic agent (for instance an aminoglycoside or ceftazidime) one hour before SWL. When results of a urine culture are available the sensitivity pattern should of course determine the choice of antibiotic regimen.
There are some conditions in which antibiotic treatment should be the rule. It is thus absolutely necessary to treat patients with nephrostomy catheters with antibiotics. In the reviewer’s opinion and based on a large number of cases it is not necessary to give antibiotics to patients with stents provided bacteria not have been demonstrated.
In addition to what has been mentioned it is also wise to treat patients with high age or concomitant diseases in whom infection complications might be particularly demanding or dangerous. But from my own experience it has not been necessary to give antibiotics only because of large stone burden when infection stone components are unlikely.