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Ivan SJ et al, 2018: Comparison of guideline recommendations for antimicrobial prophylaxis in urologic procedures: variability, lack of consensus, and contradictions.

Ivan SJ, Sindhwani P.
Department of Urology, University of Toledo College of Medicine and Life Sciences, 3000 Arlington Avenue, Toledo, OH, 43614, USA.

Abstract

PURPOSE: This review assesses guideline discrepancies for urologic surgery antimicrobial prophylaxis and identifies opportunities for improvement of antimicrobial prophylaxis and stewardship. METHODS: Literature search using PubMed, Embase, Cochrane, and association websites identified guidelines for review from the American Urological Association, Canadian Urological Association, European Association of Urology, Japanese Urological Association, and Association of Health-System Pharmacists/Infectious Disease Society of America/Surgical Infection Society/Society for Healthcare Epidemiology of America.
RESULTS: The greatest variability between guidelines was found in prophylaxis recommendations for prostate brachytherapy, transurethral resection of bladder tumor, extracorporeal shock wave lithotripsy (ESWL), and ureteroscopy with manipulation. Variability was also present in recommended duration of prophylaxis and recommended antibiotic. Contradictions between guidelines existed regarding prophylaxis for patients with indwelling stents undergoing ESWL, as well as for patients at risk of endocarditis undergoing urologic procedures. Procedures with the least variability in prophylaxis recommendation included diagnostic procedures (cystourethroscopy, urodynamic studies, and diagnostic ureteroscopy), transurethral resection of prostate, transrectal prostate biopsy, percutaneous nephrolithotomy, procedures involving prosthesis placement or intestine, and open or laparoscopic procedures.
CONCLUSIONS: Consensus recommendations are present for several procedures, many of which still rely on non-urologic data. Several other procedures have variability in recommendations, generally due to a lack of strong data. The use of risk factors as indication for prophylaxis in many procedures is at times ambiguous and confusing. Together, these observations indicate a need for further research to provide more robust and consistent guidelines for antimicrobial prophylaxis and stewardship in the field of urology.

Int Urol Nephrol. 2018 Aug 25. doi: 10.1007/s11255-018-1971-1. [Epub ahead of print] Review.

 

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Comments 1

Hans-Göran Tiselius on Wednesday, 21 November 2018 07:20

This chapter deals with antibiotic prophylactic treatment in urological procedures in general. I shall only comment on SWL and to some extent also on auxiliary procedures associated with SWL. I agree completely with the authors that there is a lack of consensus on how and when prophylactic treatment with antibiotics should be used. The comments I give are not necessarily based on strong scientific evidence, but rather on extensive personal experience of SWL.

It is recommended by AUA, CUA and JAU that prophylactic treatment with antibiotic should be given for patients at “high risk”, but the definition of “high risk “ is subject to a considerable diversity. Whereas antibiotics is recommended for high risk patients defined as those with “large stone burden, associated pyuria, history of pyelonephritis, and adjunctive operative procedures including stents, nephrostomy insertion, percutaneous nephrolithotomy (PCNL), or ureteroscopy, EAU restricts the recommendation to patients with stents or nephrostomy tubes.

It is absolutely clear that antibiotics always should be given to patients with nephrostomy tubes. Urine in these patients always contains bacteria and the development of infection complications is the rule rather than the exception. For patients with stents it is my personal opinion that antibiotics are not necessary provided stent insertion has been carried out in a straightforward and sterile way. Another prerequisite is of course that there is no bacteriuria and that the stent is not calcified!

It has not been my own strategy to treat patients with antibiotics only because of a large stone if there is no indication that the stone contains infection components, there is no bacteriuria or no infection history. But apart from that it might be indicated to treat patients with antibiotics if any kind of infectious complication would jeopardize patients’ general health or result in life-threatening complications.

In addition to what has been mentioned above general recommendations might be helpful, but an individualized approach might be even better.

This chapter deals with antibiotic prophylactic treatment in urological procedures in general. I shall only comment on SWL and to some extent also on auxiliary procedures associated with SWL. I agree completely with the authors that there is a lack of consensus on how and when prophylactic treatment with antibiotics should be used. The comments I give are not necessarily based on strong scientific evidence, but rather on extensive personal experience of SWL. It is recommended by AUA, CUA and JAU that prophylactic treatment with antibiotic should be given for patients at “high risk”, but the definition of “high risk “ is subject to a considerable diversity. Whereas antibiotics is recommended for high risk patients defined as those with “large stone burden, associated pyuria, history of pyelonephritis, and adjunctive operative procedures including stents, nephrostomy insertion, percutaneous nephrolithotomy (PCNL), or ureteroscopy, EAU restricts the recommendation to patients with stents or nephrostomy tubes. It is absolutely clear that antibiotics always should be given to patients with nephrostomy tubes. Urine in these patients always contains bacteria and the development of infection complications is the rule rather than the exception. For patients with stents it is my personal opinion that antibiotics are not necessary provided stent insertion has been carried out in a straightforward and sterile way. Another prerequisite is of course that there is no bacteriuria and that the stent is not calcified! It has not been my own strategy to treat patients with antibiotics only because of a large stone if there is no indication that the stone contains infection components, there is no bacteriuria or no infection history. But apart from that it might be indicated to treat patients with antibiotics if any kind of infectious complication would jeopardize patients’ general health or result in life-threatening complications. In addition to what has been mentioned above general recommendations might be helpful, but an individualized approach might be even better.
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