european urology 54 (2008) 1270–1286

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Review – Infections

Antibiotic Prophylaxis in Urologic Procedures: A Systematic Review
A.M. Jikke Bootsma a, M. Pilar Laguna Pes a, Suzanne E. Geerlings b, Astrid Goossens c,*

Department of Urology, Academic Medical Center, University of Amsterdam, The Netherlands Department of Infectious Diseases, Tropical Medicine and AIDS, Center for Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, The Netherlands c Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, The Netherlands

Article info Article history: Accepted March 11, 2008 Published online ahead of print on March 24, 2008 Keywords: Antibiotic prophylaxis Bacteriuria Infection Postoperative complications Urologic interventions

Objective: Antibiotic prophylaxis is used to minimize infectious complications resulting from interventions. Side-effects and development of microbial resistance patterns are risks of the use of antibiotics. Therefore, the use should be well considered and based on high levels of evidence. In this review, all available evidence on the use of antibiotic prophylaxis in urology is gathered, assessed, and presented in order to make choices in the use of antibiotic prophylaxis on the best evidence currently available. Methods: A systematic literature review was conducted, searching Medline, Embase (1980–2006), the Cochrane Library, and reference lists for relevant studies. All selected articles were reviewed independently by two, and, in case of discordance, three, reviewers. Results: Only the transurethral resection of prostate (TURP) and prostate biopsy are well studied and have a high and moderate to high level of evidence in favour of using antibiotic prophylaxis. Other urologic interventions are not well studied. The moderate to low evidence suggests no need for antibiotic prophylaxis in cystoscopy, urodynamic investigation, transurethral resection of bladder tumor, and extracorporeal shock-wave lithotripsy, whereas for therapeutic ureterorenoscopy and percutaneous nephrolithotomy, the low evidence favours the use of antibiotic prophylaxis. Urologic open and laparoscopic interventions were classified according to surgical wound classification, since no studies were identified. Antibiotic prophylaxis is not advised in clean surgery, but is advised in cleancontaminated and prosthetic surgery. Conclusions: Except for the TURP and prostate biopsy, there is a lack of wellperformed studies investigating the need for antibiotic prophylaxis in urologic interventions.
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* Corresponding author. Department of Clinical Epidemiology, Biostatistics & Bioinformatics, AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. Tel. +31 20 65283; Fax: +31 20 6912683. E-mail address: (A. Goossens).
0302-2838/$ – see back matter # 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2008.03.033

and nowadays. Introduction Antibiotic prophylaxis is a brief course of antibiotics administered before or at the start of an intervention and used to minimize the infectious complications resulting from diagnostic and therapeutic interventions. In case of discordance. The aim of this paper is to provide a systematic review on the value of antibiotic prophylaxis during different urologic procedures in order to make choices in the use of antibiotic prophylaxis on the best evidence currently available. in which postoperative was defined as the period of 30 d after the procedure. and minimal post-intervention followup of 30 d. shock wave lithotripsy. possible side-effects and development of microbial resistance patterns are potential risks.7]. an antibiotic prophylaxis policy should be well considered and. urodynamic investigation. These developments can influence the choice of antibiotic prophylaxis policy. All selected articles were reviewed independently on inclusion criteria and study design by two reviewers (AB. of good quality. Also. Urology is a surgical speciality which has undergone many changes in the last decade. with the exception of the transurethral resection of the prostate [6. clear definitions of outcome parameters. ideally. case series and expert opinions were selected. Surgical procedures have mainly shifted from open to endoscopic and laparoscopic procedures.european urology 54 (2008) 1270–1286 1271 1. and. Although it is common practice to administer antibiotic prophylaxis in many urologic procedures. shock wave therapy. Spanish. fever. TURP TURT. Studies included in a pre-existent systematic review of good quality were not separately included. infection. based on high levels of evidence. Each included article was graded on level of evidence according to the level-of-evidence list of the Oxford Centre for Evidence-Based Medicine [8]. While the rationale for the use of antibiotics is well accepted. However. if absent. Various authors have addressed this issue in reviews in recent years [1–4]. urodynamic study Transurethral resection. In the absence of a relevant RCT on the subject. observational study. Antibiotic prophylaxis was defined as use of antibiotics around an Table 1 – Search terms per urologic intervention Intervention Cystoscopy Prostate biopsy Urodynamic investigation Transurethral resection of prostate Transurethral resection of bladder tumor Extracorporeal shock wave lithotripsy Ureterorenoscopy Percutaneous nephrolithotomy Search terms Cystoscopy Prostate biopsy Urodynamics.’’ including a chapter on perioperative antibacterial prophylaxis in urology [5]. French. Embase (1980–2006). 2. a greater number of elderly patients or carriers of temporary urinary derivations are being operated on. TURB. Inclusion criteria were RCT. the European Association of Urology (EAU) has recently updated the guideline ‘‘Management of urinary and male genital tract infections. German). antibiotics. RCTs comparing antibiotic prophylaxis during urologic procedures with a placebo or no antibiotic prophylaxis in patients with preoperative sterile urine were selected with language restriction (English. The secondary outcome parameters were postoperative symptomatic urinary tract infection. transurethral resection bladder tumor. MPL). and bacteraemia. percutaneous nephrolithotomy. few of the recommendations in these reviews and guidelines are supported by evidence gathered in a structured systematic review. Reference lists were screened for relevant trials. bacteriuria. sepsis. extracorporeal lithotripsy Ureteroscopy. and bacteriuria as ! 103 colony forming units (CFU)/ml in symptomatic urinary tract infection and ! 105 CFU/ml in asymptomatic bacteriuria [5]. The question remains to what extent antibiotic prophylaxis is beneficial in the different urologic procedures. there is still little evidence for the use of antibiotic prophylaxis in most of these procedures. ESWL. ureterorenoscopy Kidney stone surgery. urodynamic examination. prostatectomy. bladder tumor resection Lithotripsy. percutaneous nephrostomy lithotripsy . The primary outcome parameter was postoperative bacteriuria. Methods Between June 2006 and March 2007. a third reviewer was consulted (AG). Additional search terms were added for the different urologic interventions investigated (Table 1). and premedication plus randomized controlled trial (RCT). This is mainly due to the lack of well-designed studies as well as the lack of clear definitions of favourable outcome parameters. the electronic databases Medline. prostatic transurethral resection. Therefore. and the Cochrane Library were searched using the terms postoperative complications. antibiotic prophylaxis. chemoprophylaxis.

3. preferably for a duration of less than 24 hr.14]. the results and level of evidence of the non-RCTs are described in the corresponding paragraph below. No significant difference in bacteraemia was found between placebo or control and antibiotic prophylaxis in four RCTs [27–29. investigating the effect of antibiotic treatment instead of prophylaxis [15]. used inadequate randomization methods [22–25]. Almallah et al [18] found a bacteriuria incidence of 4. two useful case series were identified describing the post-cystoscopy infection incidence without use of antibiotic prophylaxis [18.2. No significant differences were found between the frequency of bacteriuria after use of prophylaxis (7. 3. Results The included RCTs are presented in Tables 2–8. Consequently. Seven were excluded because they investigated prophylaxis methods other than antibiotic prophylaxis [20. it can be concluded that there is low to moderate evidence for the use of antibiotic prophylaxis in cystoscopy. Six RCTs comparing antibiotic prophylaxis with the use of a placebo or no antibiotic prophylaxis were included [27–32] (Table 3). Jimenez Cruz et al [9] and MacDermott et al [10]. Two studies with high level of evidence showed opposite results regarding the incidence of post-procedural symptomatic UTI [27.9% (n = 103) within 48 hr post-cystoscopy.8%.1272 european urology 54 (2008) 1270–1286 intervention. A low incidence of bacteriuria and symptomatic UTIs is seen after cystoscopy. Two studies. However. When no RCT was included. although no conclusive evidence was found on the effect of antibiotic prophylaxis on symptomatic UTIs and other infectious complications. Prostate biopsy 3.19] (level of evidence (LOE) 4). In summary. 3. Fever was not significantly reduced after use of antibiotic prophylaxis in four RCTs [27. since no separate analyses of both interventions were given. For uniformity of outcomes. Of the included studies. Several RCTs also reported secondary outcome parameters. irrespective of the use of antibiotic Thirteen RCTs were identified concerning prostate biopsy.28. A history of symptomatic UTI and additional procedures performed during cystoscopy were identified as risk factors for developing post-cystoscopy bacteriuria. of which four were included in this review (Table 2) [9–12]. The other studies were excluded because of lack of description of randomization method and group composition [13. These results indicate a need for antibiotic prophylaxis in prostate biopsy. These results suggest that antibiotic prophylaxis is not needed for cystoscopy in the absence of risk factors for developing UTI.1.9%. or use of outdated investigation techniques [33– 37]. Wilson et al [12] and Tsugawa et al [11] did not find a decrease in either bacteriuria or in symptomatic UTIs after use of antibiotic prophylaxis.32].5% incidence of postcystoscopy bacteriuria. the incidence dropped to 0. .31]. Cundiff et al investigated the effect of prophylaxis on combined cystoscopy and urodynamics in a well-designed study in women with stress incontinence (LOE 1B) [16]. Cystoscopy A total of nine RCTs was found. Although 14% of all patients reported irritative symptoms within 48 hr. and studying more interventions than cystoscopy alone. resulting in a symptomatic UTI incidence of 1. use of incorrect randomisation methods. there is moderate to high evidence that the use of antibiotic prophylaxis in prostate biopsy reduces the incidence of postprostate biopsy bacteriuria.7%) at 1 wk follow up. only a small portion developed bacteriuria as well. but was significantly reduced in another RCT of lower quality [29]. along with the reasons for exclusion of the corresponding RCTs. prophylaxis. However. the study was excluded. Clark et al [19] described a 7. respectively.32]. asymptomatic bacteriuria and asymptomatic urinary tract infection are both referred to as bacteriuria and symptomatic urinary tract infection (UTI) and symptomatic bacteriuria is referred to as symptomatic UTI. without possibility of a separate analysis [16.3.1%) and placebo (4. They show a significant decrease of bacteriuria after prostate biopsy with the use of antibiotic prophylaxis compared with no use of antibiotics. Urodynamic investigation A total of five RCTs evaluated the effect of antibiotic prophylaxis on bacteriuria after urodynamic investigation. After identifying and excluding patients with risk factors. or investigated the effect of antibiotic treatment instead of prophylaxis [26]. but rather administration of antibiotics after the intervention.17]. none were included in this review because no ‘‘true’’ antibiotic prophylaxis was used.21].31. with the first dose given before or at the start of the intervention. along with their level of evidence. Additionally. found a significant decrease of symptomatic UTIs and bacteriuria.

ABP 0.Symptomatic UTI: 10. CFU = colony forming units. fever 1 mo post-cystoscopy .Incidence control/intervention group: . 1998 [11] 2B RCT N = 45 (24/21) Jimenez Cruz et al.89% .No AB prior Intervention/ Control . double blind Population control/ intervention N = 234 (122/112) Inclusion criteria .o. coli RCT = Randomized Controlled Trial. HPF = high power field.Single dose ceftriaxon 1 gram i. bacteriuria.m. i.2%/2.7% ! ABP 2% (significant) .82%.Single dose norfloxacin 400 mg p.Placebo Outcome parameter .No AB .Trial discontinued at interim analysis (low infection rate + no differences between 2 groups) european urology 54 (2008) 1270–1286 .Single dose sparfloxacin 200 mg p. symptomatic UTI 2–3 d + 1 mo post-cystoscopy Outcome Remarks Wilson et al. .o. no pyuria (> 5 white blood cells/HPF) . UTI = urinary tract infection.Post-cystoscopy incidence bacteriuria no ABP 15. ASB = asymptomatic bacteriuria. When no blinding took place. 1273 .None of patients in control or intervention group developed pyuria.Symptomatic UTI: bacteriuria > 102 CFU/ml + symptoms 7 d postcystoscopy .Pre-cystoscopy sterile urine . 2005 [12] Tsugawa et al.No definition of bacteriuria (count) . or fever . investigator-blinded.ASB. a It is mentioned if the study was performed in a double-blind. = per os (orally). or patient-blinded manner.Most cultured organism: E.Post-cystoscopy incidence symptomatic UTI: placebo 0. 1988 [10] 2B RCT N = 98 (51/47) .52% (not significant) .Pyuria.02%/1. = intramuscular. p. ABP = antibiotic prophylaxis.Bacteriuria > 105 CFU/ml 5 d postcystoscopy .m.Pre-cystoscopy sterile urine .o. .No AB < 7 d prior .5% (significant) .No AB MacDermott et al.3 doses cephradine 1 g <24 h around cystoscopy .Table 2 – Included studies on cystoscopy Author Level of evidence 1B Study typea RCT. bacteriuria. AB = antibiotics. nothing is mentioned.No AB .ASB: 3.No need therapeutic intervention . .No bacteriuria (> 104. 1993 [9] 2B RCT N = 2172 (1057/1115) .

Incidence postprostate biopsy fever placebo 6.5%–2.Fever (> 38.No UTI .Incidence postprostate biopsy symptomatic UTI placebo 5% ! ABP 3% (not significant) .Bacteraemia Crawford et al. + placebo until 3 d . patient blinded N = 48 (25/23) .6%–10.Incidence postprostate biopsy bacteraemia placebo 16% ! ABP 22% .Placebo Outcome parameter . 2000 [27] 1B RCT.Incidence postprostate biopsy bacteriuria day 2 placebo 36% ! ABP 8.8% (significant difference) .1274 Table 3 – Included studies on prostate biopsy Author Level of evidence 1B Study typea RCT.Bacteriuria > 104 CFU/ml 15 d postprostate biopsy .3% ! ABP 7.6% .o.7% ! ABP 0%–1.Fever (> 38 8C) .6%.Incidence postprostate biopsy overall infective complications placebo 25.No significant differences between single dose and 3 d of antibiotics.Placebo 3 d .Carbenicillin 1 d prior + 1 d post biopsy . day 14 placebo 20% ! ABP 8. .Incidence postprostate biopsy bacteriuria placebo 18. patient blinded N = 231 (75/79/77) . 1982 [29] 2B RCT.Incidence postprostate biopsy bacteriuria placebo 8% ! ABP 3% (significant difference) .Bacteriuria (48 h post-biopsy) .o.No AB or endoscopic manipulation 1 wk prior .6% ! ABP 5%–7.Incidence postprostate biopsy fever placebo 48% ! ABP 17% european urology 54 (2008) 1270–1286 . double blind Population control/ intervention N = 457 (230/227) Inclusion criteria Intervention/ Control .Placebo . .No UTI .Incidence postprostate biopsy bacteraemia placebo 2.5 8C) .No indwelling catheter Aron et al.Single dose ciprofloxacin 500 mg p.Bacteriuria (> 105 CFU/ml) 2 + 14 d post biopsy .7% ! ABP 2.6% .Ciprofloxacin 500 mg + tinidazole 600 mg p.3% . twice daily for 3 d .Single dose ciprofloxacin 500 mg + tinidazole 600 mg p.No indwelling catheter .Bacteraemia .o.No AB 2 wk prior .No VHD or prothesis . 1998 [31] .4% (significant difference) .No bacteriuria .Symptomatic UTI Outcome Remarks Kapoor et al.

No AB or endoscopic manipulation 24 h prior .v.biopsy infectious complications was studied. DM = diabetes mellitus.Incidence postprostate biopsy fever no AB 22% ! ABP 50% RCT = Randomized controlled trial.o.v.No significant differences.o. VHD = valvular heart disease. i.No AB .Incidence postprostate biopsy bacteraemia no AB 37.Negative urine and blood cultures prior .No AB or endoscopic manipulation 24 h prior .No AB . ABP = antibiotic prophylaxis TMP/SMX = trimethoprim/ sulfamethoxazole. ABP TMP/SMX 6.Bacteriuria 7–10 d post biopsy . .Bacteraemia . prostatitis Melekos et al. . effect of povidoneiodine enema on post biopsy infectious complications was studied. 30 min before biopsy . 1990 [32] 2B RCT N = 38 (16/22) . UTI = urinary tract infection.Bacteriuria (> 105 CFU/ml) 1 d post biopsy .No significant differences. DM.In the same study.No AB 3 d prior . . effect of povidoneiodine enema on post.Bacteriuria 1 d post biopsy .No AB .Incidence postprostate biopsy bacteriuria no AB 26. When no blinding took place.No VHD. nothing is mentioned. CFU = colony forming units.Single dose TMP/SMX 160/800 mg p. . = per os (orally).Gentamicin 80 mg i.Negative urine and blood cultures prior .Incidence postprostate biopsy bacteriuria no AB 44% ! ABP 20% . or patient-blinded manner.No VHD .Isen et al. . No significant difference between 2 antibiotic schemes.Piperacillin 2 g i. p.Fever (> 101 8F) . steroid use. .1% ! ABP ofloxacin 4.8%. investigator-blinded.Difference significant between no-AB group and ABP-group.7% .Incidence postprostate biopsy bacteriuria no AB 31% ! ABP 9% .5% ! ABP 14% european urology 54 (2008) 1270–1286 Brown et al. 1275 . .Bacteraemia 1 d post biopsy .o. = intravenously. 1981 [28] 2B RCT N = 19 (9/10) . indwelling catheter. a It is mentioned if the study was performed in a double-blind.In the same study. 1999 [30] 1B RCT N = 110 (23/42/45) . AB = antibiotics.Single dose ofloxacin 400 mg p. 2 h prior + 2 h post biopsy .Incidence postprostate biopsy bacteraemia no AB 33% ! ABP 40% .No VHD .v.

Postoperative bacteriuria significant decrease 26% ! 9.Different ABP schemes . TMP/SMX.20.RCT Intervention/ Control .Postoperative bacteriuria 1 wk post-TURP .Postoperative bacteriuria (104–107 CFU/ml) 2–5 d after surgery .1276 Table 4 – Included studies on TURP Author Level of Study typea evidence 1A Meta-analysis Population control/ intervention .Postoperative sepsis significant decrease 4. .Pre-TURP sterile urine (< 104 CFU/ml) .02. 2005 [7] 1A Systematic review .Different AB and schemes effective . 2002 [6] . additional antibiotic treatment needed.5 8C.Sepsis: 8 RCTs N = 1979 Inclusion criteria .Single dose: 57% decrease.Postoperative fever RD À0.11. elevated CRP) Qiang et al.No significant reduction in post-TURP catheterization or hospitalization . . b-penicillin european urology 54 (2008) 1270–1286 . hospital duration ABP gives: . quinolone .Postoperative fever.4% ! 0. coli.Significant decrease by different AB: aminoglycosides. bacteraemia.Single dose seems less effective than short-term dose prophylaxis . .All treatment duration protocols significant decrease bacteriuria: .RCT . short course (< 72 h) 68% decrease.Bacteriuria: 32 RCTs N = 4260 (1914/2346) . extended course (> 72 h) 72% decrease ABP gives significant reduction in postoperative complications: . 1st/2nd/3rd generation cephalosporin.28 RCTs N = 4694 .Postoperative bacteriuria incidence decrease 26% ! 9%. .bacteraemia RD À0. urethral stricture. sepsis.No significant decrease: nitrofurantoin.use additional antibiotics RD À0.Most common organisms cultured: E.Different ABP schemes Outcome parameters Outcome Remarks Berry et al. . rigors.1% .7% . penicillin.Pre-TURP sterile urine .Postoperative sepsis (> 38. catheterization. enterococcus. Staphylococcus. Streptococcus.

investigator-blinded.Pre-TURT sterile urine . .9% (B) .v. RD = risk difference. AB = antibiotics. a It is mentioned if the study was performed in a double-blind.1% ! ABP 9. ABP = antibiotic prophylaxis.Incidence bacteriuria 3–5 d post-TURP decrease 29.1% (B) . significance 5.4% (not significant) . CFU = colony forming units.o.Symptomatic UTI Outcome . (A) . 1988 [10] 2B RCT N = 91 (47/44) . i.Wagenlehner et al.Pre-TURT sterile urine . or patient-blinded manner.Single dose pefloxacine 800 mg i.Bacteriuria > 105 CFU/ml 5 d post-TURT TURT = Transurethral resection of bladder tumor. 1993 [53] Level of evidence 2B Study typea RCT.Postoperative complications . CRP = C reactive protein. = per os (orally).No AB < 4 d prior .v.Postoperative bacteriuria (> 104 CFU/ml) 3–5 d and 3–5 wk post-TURP .Bacteriuria > 104 CFU/ml 2 wk post-TURT .No AB < 14 d prior Intervention/Control .7% (C) ! 21. = intravenously.Higher additional AB consumption no-ABP group.2% (A)/19. (B) . european urology 54 (2008) 1270–1286 Table 5 – Included studies on TURT Author Delavierre et al.No AB (C) .9 doses/ patient (C) .5% (not significant) Remarks MacDermott et al. nothing is mentioned. CFU = colony forming units. When no blinding took place.Post-TURT incidence bacteriuria no ABP 17% ! ABP 4. When no blinding took place. but correlation present TURP = Transurethral resection of the prostate. nothing is mentioned.No AB < 7 d prior .9% (A)/26.Pre-TURP sterile urine (< 104 CFU/ml) .Post-TURT incidence bacteriuria placebo 24. 2005 [49] 1B RCT N = 376 . TMP/ SMX = trimethoprim/sulfamethoxazole. RCT = Randomized controlled trial.Symptomatic UTI 0% in both groups .Single dose levofloxacin 500 mg p. double blind Population control/intervention N = 61 (29/32) Inclusion criteria . p.No AB .o. investigator-blinded. 1277 . or patient-blinded manner. AB = antibiotics.o.Placebo Outcome parameter . ABP = antibiotic prophylaxis.Single dose 320/1600 mg TMP/SMX p. a It is mentioned if the study was performed in a double-blind.Incidence bacteriuria 3–5 wk post-TURP decrease 36.0 (A+B) ! 6.Not all patients with bacteriuria postoperative complication. RCT = Randomized controlled trial.3 doses cephradine 1 g < 24 h around TURT . UTI = urinary tract infection.3% (C) ! 25.

9% ! ABP 24.Placebo Claes et al.2% 7 d post-ESWL . .Symptomatic UTI placebo 3% ! ABP 2% Incidence 6 wk post-ESWL: .Single dose ciprofloxacin 200 mg iv (A) .No symptomatic UTI in both groups .Control 0.3% .No AB .Symptomatic UTI 1 d.Ciprofloxacin 200 mg once daily 7 d (C) .7% ! ABP 1. UTI) . = per os (orally).No risk factors (manipulation pre-ESWL.Fever 1 + 5 + 24h post-ESWL . CFU = colony forming units.No AB 7 d prior . bacteremia and fever in both groups Remarks Study ended after interim analysis because of no differences between placebo-ABP groups european urology 54 (2008) 1270–1286 Ilker et al.68% ! ABP 1.Symptomatic UTI in presence of risk factor (indwelling catheter) 2+ 6 wk post. investigator-blinded.Pre-ESWL sterile urine .1278 Table 6 – Included studies on ESWL Author Bierkens et al. When no blinding took place.Single dose cefuroxime 750 mg iv (B) .Bacteriuria (> 105 CFU/ml) .No risk factors (staghorn stone.Incidence symptomatic UTI 7.0% bacteriuria 1 d + 4 wk follow-up . a It is mentioned if the study was performed in a double-blind.Pre-ESWL sterile urine .Bacteriuria (> 104 CFU/ml) . UTI = urinary tract infection. nothing is mentioned. 1995 [60] 1B RCT N = 311 (148/163) .o.Single dose amoxycillin/ clavulanate 2 g/0.6% in no AB-group. 1989 [58] 2B RCT N = 181 (92/89) .Single dose ceftriaxon 1 g iv .ESWL Outcome Incidence 2 wk post-ESWL: .Placebo Outcome parameter .Bacteriuria (> 105 CFU/ml) 1 + 7 d post-ESWL . staghorn stone) .Symptomatic UTI (bacteriuria + pyuria + symptoms) . 1997 [57] Population Level of Study typea control/intervention evidence 1B RCT.Bacteriuria placebo 18. RCT = Randomized controlled trial.Bacteriuria .Cefuroxime 750 mg day 1 + 250 mg day 2–7 (D) .Symptomatic UTI placebo 2.Bacteremia 1 + 5h post-ESWL . patient blinded N = 50 (25/25) . 7 d. 4 wk post-ESWL Gattegno et al. p.Pre-ESWL sterile urine (< 104 CFU/ml) Intervention/ Control . 1988 [59] 2B RCT.Symptomatic UTI (bacteriuria + fever) 1 d post-ESWL . iv = intravenously. JJ.Single dose ofloxacin 200 mg p.0% bacteriuria.o. patient blinded N = 177 (30/41/ 39/29/38) Inclusion criteria . . ABP = antibiotic prophylaxis.4% .Bacteriuria overall 20% .No AB .Pre-ESWL sterile urine .2 g iv . AB = antibiotic. 0% in ABP group 1 d post-ESWL (significant) ESWL = Extracorporeal shock-wave lithotripsy. or patient-blinded manner.Presence of indwelling catheter no different outcome Incidence bacteriuria: .

5% ! ABP 1. 1990 [68] Level of evidence 2B Study typea RCT.No clinical/laboratory signs of infection .Bacteriuria: placebo 12% ! ABP 5% 3 d post-URS (not significant) . CFU = colony forming units.5% 3 d post-URS (not significant) .Placebo .Bacteriuria (> 105 CFU/ml) . european urology 54 (2008) 1270–1286 URS = Ureterorenoscopy. or patient-blinded manner.o.Pre-intervention sterile urine . It is mentioned if the study was performed in a double-blind.Bacteriuria (> 105 CFU/ml) .Table 7 – Included studies on therapeutic URS Author Knopf et al. . 1279 . a PNL = Percutaneous nephrolithotomy.No AB for 1 wk prior Intervention/ Control .Bacteriuria: placebo 13% ! ABP 3. iv = intravenously.No AB Outcome parameter . When no blinding took place. nothing is mentioned.Symptomatic UTI 1 wk post-URS Outcome . or patient-blinded manner.Bacteriuria (> 105 CFU/ml) . Group numbers of interventions separate too small for significance. p.Placebo Outcome parameter . AB = antibiotics.No AB 1 mo prior . RCT = Randomized controlled trial. RCT = Randomized controlled trial. nothing is mentioned.Fever not separately reported Remarks Study reports on both URS and PNL. Table 8 – Included studies on PNL Author Fourcade et al.Single dose cefotaxim 1 gram iv . URS = Ureterorenoscopy. When no blinding took place. double blind N = 71 (38/33) . = per os (orally). 2003 [69] Level of evidence 2B Study typea RCT Population control/intervention N = 113 (56/57) Inclusion criteria .Bacteriuria: control 12.Fever not separately reported Remarks Fourcade et al.Symptomatic UTI 0% both groups .Fever (> 38 8C) 3 + 30 d post-PNL Outcome . UTI = urinary tract infection. CFU = colony forming units. 1990 [68] 2B RCT. PNL = Percutaneous nephrolithotomy. a It is mentioned if the study was performed in a double-blind.o. investigator-blinded. Group numbers of interventions separate too small for significance. ABP = antibiotic prophylaxis.Single dose cefotaxim 1 gram iv .Fever (> 38 8C) 3 + 30 d post-URS Study reports on both URS and PNL.Pre-intervention sterile urine .Single dose levofloxacin 250 mg p. iv = intravenously. AB = antibiotics.8% (significant difference) . ABP = antibiotic prophylaxis. investigator-blinded. double blind Population control/intervention N = 49 (22/27) Inclusion criteria .No AB 1 mo prior Intervention/ Control .

4. Consequently. neurogenic bladder.1%–19. whereas with use of antibiotics.56].8%–4. but since those RCTs were already included in the highquality systematic reviews of Berry and Qiang.48]. 3.9%–10. None of the other included RCTs with a higher level of evidence reproduced those data. although the findings did not reach statistical significance. Reference lists were screened and RCTs meeting our inclusion criteria were added to the already identified ones and assessed. Only one of the included studies showed a significant decrease in the incidence of postESWL symptomatic UTIs after use of antibiotic prophylaxis [58]. 3. and another was excluded [50] because no univocal antibiotics regimen was followed. However. transplant patients. since several of the evaluated studies in their review did not meet the selected inclusion criteria of the present systematic review. with 21 RCTs reviewed in both studies. they were not included separately in this review.43. However.41–46]. favouring the use of antibiotic prophylaxis in TURP. with a small increase in bacteriuria when no antibiotic prophylaxis is given.1280 european urology 54 (2008) 1270–1286 Case series (LOE 4) report a pre-urodynamics bacteriuria incidence of 1. immunodepressed patients. and the need for additional antibiotics post-TURP. The overall incidence of post-ESWL .45].6. There was a trend suggesting higher efficacy for a short course (< 72 hours) of antibiotic prophylaxis than for a single-dose regimen [6]. whereas no information on posturodynamics symptomatic UTI is available. Pearle et al [54] concluded in a meta-analysis of eight RCTs that the use of antibiotic prophylaxis in patients with preESWL sterile urine is beneficial and reduces the post-ESWL complication rate. complemented by several additional outcome parameters.9% after 1 wk followup [38. ie. In conclusion. several studies have been performed questioning the need for antibiotic prophylaxis in this intervention. sepsis. Without use of antibiotic prophylaxis. increasing age was identified as a risk factor for developing posturodynamics bacteriuria [41. the reported incidence was 1. Both studies found a nonsignificant decrease in incidence of post-TURT bacteriuria with the use of antibiotic prophylaxis. 3. or carriers of vesicoureteral reflux).0% for women and 3. Two were excluded from the present review due to a lack of proper randomisation [51] and questionable statistical analysis [52].1%–13. Their conclusions were similar. A good number of RCTs published before 2005 was identified. Next to the systematic reviews of Berry [6] and Qiang [7].39.5. Both reviews used postoperative bacteriuria as their main outcome parameter.3% [38–41].6%–6. The two included studies of Delavierre et al [53] and MacDermott et al [10] are relatively outdated and included small numbers of subjects (Table 5). and the 0% incidence of symptomatic UTIs in both groups precludes any conclusion in the study of Delavierre et al [53]. this review was excluded. Two RCTs were excluded because of incomplete description of methodology and results [61] and inconsistency between results and conclusions [62]. evaluation of the effect of antibiotic prophylaxis instead of treatment [55.2% for men [47. Four RCTs met the inclusion criteria and were included in this review [57–60] (Table 6). Since then. the same low level of evidence may support the use of antibiotic prophylaxis in those patients with known increased risk for infections (eg. In summary. post-TURP fever. Furthermore. the evidence for use of antibiotic prophylaxis in urodynamic investigation is low and can only be gained from case series. a relatively low incidence of posturodynamics bacteriuria is seen. it can be concluded that there is high evidence that the use of prophylactic antibiotics in TURP decreases bacteriuria and clinical infectious complications. Transurethral resection of the prostate ner et al [49] are comparable. there is moderate to low-grade evidence suggesting that antibiotic prophylaxis is not necessary in TURT. respectively. Transurethral resection of bladder tumor Four studies of transurethral resection of bladder tumor (TURT) met the inclusion criteria.6% after 2–3 d follow-up and 4. The systematic reviews by Berry et al [6] and Qiang et al [7] included 32 and 28 RCTs. Additionally. one study was included [49]. These results suggest there is no need for antibiotic prophylaxis in urodynamic investigations. The average enrollment was 4474 patients (Table 4). They concluded that antibiotic prophylaxis gives a significant decrease in post-TURP bacteriuria. The findings of Wagenleh- Extracorporeal shock-wave lithotripsy (ESWL) originated in the 1980s as a treatment for renal and ureter stones. the post-urodynamics bacteriuria frequency was 1. Extracorporeal shock-wave lithotripsy Transurethral resection of the prostate (TURP) is the most extensively studied subject in urology regarding the use of antibiotic prophylaxis.

In clean-contaminated surgery. No studies were found examining the diagnostic option. no studies were found and reference to expert opinion may be advocated. the relevant surgical literature was screened. needing treatment with antibiotics [71] (LOE 4). The presence of a nontreated infection. with consequent low evidence (LOE 5). Unfortunately.1% in patients with pre-ESWL sterile urine (LOE 4) [63–67]. Clean surgery involves uninfected tissues without opening of the urinary tract and with primary closure of the wound. by assessing the pre-intervention surgical wound class. In a number of case series. 3. Two small RCTs concerning the use of antibiotic prophylaxis in endoscopic stone removal were identified and included [68. including UTI. Percutaneous nephrolithotomy Only one RCT was found comparing placebo with antibiotic prophylaxis in both percutaneous nephrolithotomy (PNL) and URS. Charton et al found a postPNL bacteriuria of 35% while using no antibiotic prophylaxis and 10% of patients presenting with post-PNL fever without sepsis or bacteraemia [70] (LOE 4). This finding is consistent with the results from the RCTs. there is a fair amount of evidence available for this intervention showing that the post-ESWL rate of bacteriuria and symptomatic UTIs is low and use of antibiotic prophylaxis does not decrease this incidence. Whereas Osman et al describe a post-PNL An extensive search was performed addressing urologic open and laparoscopic interventions.69] (Table 7). Altogether. 3. The results suggest no need for prophylaxis in diagnostic URS in uncomplicated patients and moderate to low evidence for prophylaxis in therapeutic URS [2. Only moderate to low-level evidence advocates the use of antibiotic prophylaxis in therapeutic URS with respect to postoperative bacteriuria. without the presence of infected tissues or bacteriuria.7. the reported incidence of post-ESWL bacteriuria is 0%–5. the urinary tract is entered under controlled conditions. Therefore.9. Presence of a struvite stone was identified as a risk factor for developing post-ESWL bacteriuria [65]. Subsequently. Discussion In this systematic review. Derived from the surgical literature and not supported by urologic evidence. the surgery is labelled dirty [74]. there is no indication for antibiotic prophylaxis in clean surgery. should be considered as contaminated urologic surgery. the individual group size was too small to reach statistically significant differences in both PNL and therapeutic URS.5]. an estimate can be made of the need for antibiotic prophylaxis during surgery. Ureterorenoscopy transient fever and symptomatic UTI in 32. Contaminated and dirty surgery should be covered by therapeutic antibiotics instead of prophylactic dosages. When pus is present. Since infectious complications are potentially serious when involving prosthesis material.5% of 315 patients. This implies there is no need for antibiotic prophylaxis in uncomplicated patients undergoing ESWL when preoperative cultures are negative. Surgery with use of bowel tissue is also classified as clean-contaminated. 4. Low evidence supports the nonbeneficial effect of prophylactic antibiotics regarding post-URS symptomatic UTI. with separate analyses possible for both interventions [68] (Table 8). and dirty seems just as relevant for urologic surgery as for general surgery [74]. when the preoperative urine culture is negative. Several case studies were identified [70.1% and 3. but no relevant urologic studies could be identified. contaminated. clean-contaminated. all currently available RCTs addressing the use of antibiotic prophylaxis in .73]. whereas there is an indication in clean-contaminated and prosthetic surgery.european urology 54 (2008) 1270–1286 1281 symptomatic UTIs was low both with and without use of antibiotics. Surgical wound classification in the categories clean. 3. For diagnostic URS. When comparing different antibiotic prophylaxis regimens in a RCT.8. Following 107 patients with preoperative sterile urine. without an evident advantage for any specific antimicrobial regimen. In this way. Open/laparoscopic urologic interventions Ureterorenoscopy (URS) can be used for diagnostic and therapeutic measures. there is low evidence suggesting a more favourable outcome after PNL when using prophylactic antibiotics. Post-URS symptomatic UTI was 0% in both groups in a study by Knopf et al [69]. They both describe a positive effect of antibiotic prophylaxis on post-URS bacteriuria.71]. antibiotic coverage is advocated irrespective of surgical class [74]. Implantation of prosthesis material is not classified as above. it showed that a single dose was as effective in preventing postoperative infections as multiple doses when using ofloxacin or cefuroxim in combination with norfloxacin [72.

Still. Statistical analysis: Goossens.69] contemplated UTI. or symptoms as an outcome. Acquisition of data: Bootsma. and low to moderate for cystoscopy [9. there is only moderate to low evidence for the use of antibiotic prophylaxis. Laguna.12. Bootsma. lithiasic obstruction. oncologic) or urologic risk factors (eg. not enough evidence supports the systematic use of antibiotic prophylaxis to prevent UTIs in the rest of the procedures.58. The evidence was moderate to high for prostate biopsy [27. there is a lack of well-performed studies. we realized not only that variations in duration. the evidence presented in this review can be used to establish local antibiotic prophylaxis guidelines. those patients with increased risk for infectious complications should receive antibiotic prophylaxis. fever.74] increases the risk of a postoperative infectious complication and. Is it decrease of postintervention bacteriuria. few of them [6. our secondary outcome parameters were symptomatic UTI. Conclusions Ideally. except for TURP and prostate biopsy. Altogether. The presence of general risk factors (eg. While all the studies included in our review had bacteriuria as primary parameters. Administrative. Obtaining funding: None. antibiotic prophylaxis in urologic procedures should only be administered when wellperformed studies demonstrate its beneficial effect on post-intervention infectious complications.31]. Goossens. simple interventions in immunodepresed patients) were insufficiently explored. In our review. Author contributions: Astrid Goossens had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.7. and bacteraemia. we could not find high evidence supporting the use of antibiotic prophylaxis in urologic interventions to prevent UTI except for TURP [6]. . However. Study concept and design: Goossens.53.1% and 0.9.79]. comorbidity). neither UTI as such nor the relation between infection rate and type of laparoscopic procedure were described in any of those series [75–77]. technical.60. therefore. the reader should keep in mind that antibiotic prophylaxis is only one of the various measures to prevent post-intervention infectious complications. good clinical practice should drive the decision in those circumstances.12]. with the exception of TURP and prostate biopsy. the need for an adequate antibiotic prophylaxis even in cases of low evidence for benefit. In fact. Asymptomatic bacteriuria is often of no clinical importance and resolves spontaneously in many cases. Goossens. the presence of risk factors for infection was an exclusion criterion in all the RCTs analyzed. 5. Some observational series illustrate the direct correlation between complication rate and complexity of the laparoscopic surgery.27. sepsis. and this evidence is moderate to high for prostate biopsy. between 0. therefore. Laguna. Antibiotic prophylaxis cannot compensate for inadequate operative care. but the urologic case series report an extremely low rate. Laguna. Such guidelines will increase the quality of care and at the same time reduce both costs and the development of microbial resistance [78. or the decrease of symptomatic UTIs or other infectious complications? While the aim of preventing symptomatic UTIs and other serious infectious complications seems evident. Strong evidence supports the use of short-term prophylaxis for TURP. Goossens. when performing the present systematic review. Geerlings. the need to prevent asymptomatic bacteriuria remains questionable. Finally. The inclusion of laparoscopic intervention under the same classification as for open surgery is justified by the lack of RCTs examining antibiotic prophylaxis.31. high irrigation pressure during endoscopy or infected stone) [5. Laguna. antibiotic agent.11. we chose it as the primary outcome parameter for our review purposes. Currently. Since ‘‘postoperative bacteriuria’’ is the best-assessed outcome parameter. Drafting of the manuscript: Bootsma. Because of the current lack of evidence. fever.57. Geerlings.11. risk factors related to the type of intervention (eg.1282 european urology 54 (2008) 1270–1286 urologic interventions were identified and assessed and the results grouped and presented. For most urologic interventions. Geerlings. or material support: Bootsma. Further research is needed because. general recommendations for prevention of surgical site infections should be followed [74]. The main point of consideration when assessing the benefit of antibiotic prophylaxis is what to consider as a favourable outcome. However. or dose of what was considered ‘‘antibiotic prophylaxis’’ existed. and. Because we were aware of the possible lack of clinical significance of bacteriuria. It is possible that infective outcomes increase with laparoscopic complexity. but also that variables of importance in some complicated conditions as can be the presence of indwelling upper urinary tract drainages (eg. Analysis and interpretation of data: Laguna. Critical revision of the manuscript for important intellectual content: Laguna.8% of infective complications.

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Torres A.european urology 54 (2008) 1270–1286 1285 [63] Charton M. Prapotnich D. simple ureteroscopy (diagnostic or for distal uncomplicated stones). the present review outlines no advantage of short-course over single-shot prophylaxis for prostate biopsy in RCTs. Schulze H. J Urol 1998. University of Foggia. Colombo Jr JR. Veillon B. Jarvis WR. Am J Med 2006. Ozden E. Zoabi A. Perioperative antibiotic prophylaxis in ureteroscopic stone removal. Incidence of bacteremia and bacteriuria in patients with non-infection-related urinary stones undergoing extracorporeal shock wave lithotripsy. [70] Charton M. Am J Infect Control 1999. Guideline for Prevention of Surgical Site Infection. as potential advantages of antibiotic administration should be carefully weighed against potential side effects. 160:18–21.151:329–30. J Antimicrob Chemother 1990. Giftopoulos A. Kostakopoulos A.172:757–62. 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Guidelines for the treatment of community-acquired pneumonia: predictors of adherence and outcome. Br J Urol 1992. et al. Eur Urol 2003. Michel MS.16:649–53.135:15–7. Italy luigicormio@libero. Dogan HS. providing absence of risk factors. Complication of laparoscopic procedures in urology: experience with 2. and health care costs. J Endourol 1998. Eur Urol 1990. [69] Knopf H-J. Tazici N. Pearson ML. J Urol Antimicrobial prophylaxis for urologic procedures is a major issue. and clean (urinary tract not opened) open or laparoscopic surgery. Both reviews recommend no prophylaxis for cystoscopy.17: 134–8. but while EAU guidelines suggest it can be omitted for lowrisk patients with small prostates. Rassweiler J. which currently exist in the form of a nonstructured review [2].44:115–8.96:875–8. Koutsokalis G. and that issue is far from having been solved or even adequately addressed for the other procedures. Husain I.7:449–51. [71] Osman M. The present systematic literature review [1] adds further information to available European Association of Eurology (EAU) recommendations for antibiotic prophylaxis in urologic surgery. Mortensen EM. Akdogan B. Burgess DS. Zalacain R. Complications of laparoscopic surgery for urological cancer: a single institution analysis. Atassi R. percutaneous nephrolithotomy. Cetinkaya Y. Both reviews recommend prophylaxis for prostate biopsy. Graff H-J. Ozdiler E. 1999. Jelovsek JE.178:786–91.29:517–21.12:1–3. Norfloxacin prophylaxis for endoscopic urological surgery. Knoll T. Antibiotic prophylaxis with cefotaxime in endoscopic extraction of upper urinary tract stones: a randomized study. Brisset JM. Veillon B. [65] Dincel C. Horan TC. et al. Antibiotic prophylaxis in percutaneous nephrolithotomy: prospective study in 81 patients. Vallancien G. Sahin A. Fahlenkamp D.162:765–70. Foggia. Laparoscopic nephrectomy: the experience of the laparoscopy working group of the German Urologic Association.26(suppl A):77–83. el-Faqih SR.69:421–4. While for endourologic procedures such lack of information may be justified by the great number of clinical . [66] Kattan S. urodynamics.119: 865–71. Again. Mangram AJ. Rassweiler J. et al. J Urol 1994. extracorporeal shock wave lithotripsy (ESWL). Frei CR. The necessity of prophylactic antibiotics during extracorporeal shock wave lithotripsy. Both recommend prophylaxis for transurethral resection of the prostate (TURP). Vallancien G. Weber M. complicated (proximal or impacted stone) ureteroscopy. microbial resistance. Use of antibiotics in the conjunction with extracorporeal lithotripsy. Loening SA. and clean/ contaminated (urinary tract opened) surgery (either open or laparoscopic). Heger K. [64] Deliveliotis C. Shental J. Fornara P. but EAU guidelines favour short-course prophylaxis over single-shot prophylaxis. Impact of guideline-concordant empiric antibiotic therapy in community-acquired pneumonia.27:97–132. Silver LC. BJU Int 2005. [68] Fourcade RO. Kosar A. J Endourol 1993. Sudarsky M. transurethral resection of bladder tumours. the present review outlines the higher efficacy of short-course (<72 h) over single-shot prophylaxis found in randomised controlled trials (RCTs). Kendi S. J Endourol 2002. Restrepo MI. Fornara P. J Urol 1986. Am J Respir Crit Care Med 2005. Menendez R.

Antibiotic prophylaxis in urological procedures: a systematic review.uroweb. as in the era of evidence-based medicine rational use of antibiotics should be a marker of quality in a urologic centre.1016/j. quite impressive is the absence of RCTs testing antibiotic prophylaxis in open and laparoscopic urological procedures. Laguna Pes MP.034 DOI of original article: 10. Goossens A.54:1270–86. http://www. Well-designed RCTs are therefore eagerly awaited. obstruction.033 .org/nc/ professional-resources/guidelines/online/?no_cache= 1&view=archive.1286 european urology 54 (2008) 1270–1286 variables (infection. Geerlings SE.2008.1016/j.eururo. [2] Naber KG. DOI: 10. patient conditions. Bjerklund-Johansen TE. It is noteworthy that EAU recommendations on open procedures are based on general surgery. surgical technique.eururo. Eur Urol 2008.03. and comorbidities) to be taken into account.03.2008. Guidelines on the management of urinary and male genital tract infections. References [1] Bootsma AMJ. et al. whereas laparoscopic procedures are just assumed to require the same prophylactic regimen used for the corresponding open procedures. Bishop MC.

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