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9. PERI-OPERATIVE ANTIBACTERIAL PROPHYLAXIS IN UROLOGY

SUMMARY

The main aim of antimicrobial prophylaxis in urology is to prevent symptomatic/febrile genito-urinary infections, such as acute pyelonephritis, prostatitis, epididymitis and urosepsis, as well as serious wound infections.

The need for prophylaxis depends on the type of intervention and the individual risk for each individual patient. General antibiotic prophylaxis is not required in open operations without bowel segments. The same is true for reconstructive operations in the genital area, with the exception of long or secondary interventions, or implant surgery. For diagnostic interventions, peri-operative antibacterial prophylaxis is generally recommended only in transrectal prostate biopsy with a thick needle. Prophylaxis should always be considered in patients who have an increased risk of infection, and especially before a transurethral resection of the prostate (TURP) if there is a history of a UTI.

Generally, a single full dose of a suitable antibiotic, preferably administered parenterally (alternatively with oral drugs with excellent bioavailability, e.g. fluoroquinolones), is appropriate for prophylaxis. Only in the case of a prolonged intervention (> 3 hours) may additional doses be required, the size and timing of which are dictated by the pharmacokinetics of the antibiotic. Antibiotic prophylaxis should not be continued for > 24 hours. When continuous urinary drainage, e.g. indwelling catheter, stent, nephrostomy, etc., is left in place after an operation, prolongation of peri-operative antibacterial prophylaxis is contra-indicated.

Many antibiotics meet the criteria for use in prophylaxis (Appendix 4), e.g. second-generation cephalosporins, fluoroquinolones and aminopenicillins plus a BLI. Aminoglycosides should be reserved for high-risk patients and those who are allergic to (3-lactams. Broad-spectrum antibiotics, such as third-generation cephalosporins, acylaminopenicillins plus a BLI, or carbapenems, should be used only sparingly, e.g. if the site of the operation is contaminated with multi-resistant nosocomial bacteria. This applies also to the use of vancomycin.

9.2 Introduction

Almost 50 years after its introduction, peri-operative prophylaxis is still controversial. Whereas a clear benefit has been established for certain surgical operations (e.g. elective colonic surgery), there is no general consensus on the use of antibacterial prophylaxis in urology. The traditional classification of surgical procedures according to Cruse and Foord (1) into clean, clean-contaminated, contaminated and dirty does not adequately describe the risk of infection in endo-urology. The overall risk is influenced by the patient's condition, the surgical procedure and environmental factors. However, the significance of each factor has not yet been quantified (2).

At present, most studies are poorly designed or lack statistical power. The differentiation between therapy and prophylaxis is not clear. Evaluation of risk factors is unsatisfactory and the terms bacteriuria and infection are used uncritically. In addition, many of these studies lack knowledge of pharmacokinetics and pharmacodynamics, bacterial pathogenicity and the role of nosocomial infections (3,4). Thus, it is not surprising that the literature is inconclusive with regard to prophylaxis, showing negative as well as positive results for every kind of urological intervention.

A recent survey of 320 German urologists revealed controversial opinions about peri-operative antibiotic prophylaxis (5). It was administered in only 51 % of procedures involving the urinary tract and 9% of the responding urologists did not even use prophylaxis when opening the intestine. There was little agreement on the choice of antibiotics (35.3% used co-trimoxazole, 26.6% cephalosporins and 8.7% fluoroquinolones) and the duration of prophylaxis (only 10% used a single pre-operative dosing regimen). There are also variations between countries (6-8). Consequently, guidelines for the indication of peri-operative prophylaxis in urology are certainly necessary to improve the quality of patient care.

Presented are practical recommendations covering patients with normal and increased susceptibility, as well as different types of surgical procedures. These recommendations are based on clinical studies, expert opinion and professional consensus. They also consider the recommendations of societies, such as the Paul Ehrlich Society for Chemotherapy (9), the Working Group "Infectiology" of the German Society for Urology (10), Association Frangais d'Urologie (11) and the Swedish-Norwegian Consensus Group (12).

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