Controlled trial of a short and a prolonged course with ciprofloxacin in patients undergoing transurethral prostatic surgery

Impact of untreated preoperative asymptomatic bacteriuria in patients undergoing holmium laser enucleation of prostate

INTRODUCTION

Treatment of preoperative asymptomatic bacteriuria (ASB) before endoscopic surgery is recommended by European Association of Urology (EAU) guidelines. United Kingdom (UK) practice varies, however, owing to the historical nature of the evidence behind the guidelines, risk of increased antimicrobial resistance, the paradoxical view that treatment of ASB leads to increased infection and inefficiencies in rescheduling. We do not routinely treat ASB in our practice before holmium enucleation of the prostate (HoLEP). To determine the safety of this, we examined our experience focusing on the infective complications.

METHODS

Retrospective data collection was performed on consecutive patients undergoing HoLEP between 2015 and 2020. Indication, preoperative urine cultures and infective complications were recorded. No patients were pretreated with oral antibiotics. All patients received intravenous antibiotics on induction and routine postoperative oral antibiotics at the surgeon's discretion.

RESULTS

Some 443 patients were studied. No urosepsis occurred in the 125 patients with ASB compared with 2 of 318 patients (0.6%) with no growth on preoperative urine culture. Twenty-nine (7%) patients were treated with oral antibiotics for symptomatic postoperative complications (urinary tract infection without fever, epididymitis and haematuria). ASB did not predict for infective complications (urosepsis odds ratio [OR]: 0.50 p=0.66; oral antibiotics OR: 0.97 p=0.93).

CONCLUSION

Not treating ASB before a HoLEP procedure is safe. This supports the judicious use of antimicrobials preoperatively. Other modalities of endoscopic surgery should be similarly assessed.

Antibiotic prophylaxis in urologic interventions: Who, when, where?

BACKGROUND

Periprocedural prophylaxis in medicine encompasses the set of measures (physical, chemical, and pharmacological) used to reduce the risk of infection. Antibiotic prophylaxis (AP) refers to the administration of a short-term regimen of antibiotics shortly before a medical procedure to reduce the risk of infectious complications that can result from diagnostic and therapeutic interventions. The outspreading growth of multidrug-resistant bacterial species and changes in the bacterial local ecosystem have impeded the development of a unique scheme of AP in urology.

OBJECTIVES

To review the literature and current guidelines regarding AP for urological diagnostic and therapeutic procedures, and to define agents, timing, and occasions when administering pharmacological prophylaxis. Secondly, according to current literature, to open new scenarios where AP can be useful or useless.

RESULTS

Major gaps in evidence still exist in this field. AP appears useful in many invasive procedures and some sub-populations at risk of infectious complications. AP is not routinely recommended for urodynamic exams, diagnostic cystoscopy, and extracorporeal shock-wave lithotripsy. The available data regarding the use of AP during the transperineal prostate biopsy are still unclear; conversely, in the case of the transrectal approach AP is mandatory. AP is still considered the gold standard for the prevention of postoperative infective complications in the case of ureteroscopy, percutaneous nephrolithotomy, endoscopic resection of bladder tumor, endoscopic resection of the prostate, and prosthetic or major surgery.

CONCLUSION

The review highlights the complexity of determining the appropriate candidates for AP, emphasizing the importance of considering patient-specific factors such as comorbidities, immunocompetence, and the nature of the urologic intervention. The evidence suggests that a one-size-fits-all approach may not be suitable, and a tailored strategy based on the specific procedure and patient characteristics is essential.

Effectiveness of appropriate antibiotic prophylaxis for transurethral resection of the prostate in the era of antibiotic resistance

The results of this study demonstrate the lower incidence of posttransurethral resection of the prostate (TURP) urinary tract infection (UTI) among patients receiving appropriate antibiotic prophylaxis (AAP) versus inappropriate antibiotic prophylaxis (27% vs 47%; P < .001). Preoperative urine culture procurement and APP are critical for post-TURP UTI prevention in the era of antibiotic resistance.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

Risk of infection in patients undergoing urologic surgery based on the presence of asymptomatic bacteriuria: A prospective study

BACKGROUND

Treatment of asymptomatic bacteriuria (ASB) is recommended in pregnant women and prior to urologic procedures with anticipated mucosal disruption. However, there is still insufficient evidence of the usefulness of treating ASB prior to urologic procedures. Therefore, the aim of this study was to ascertain the risk of infections in patients undergoing urologic surgery based on the presence of ASB.

METHODS

We conducted a cohort study among patients undergoing urologic surgery at a single center located in Medellín, Colombia. All patients were screened for ASB prior to their procedures. Patients were evaluated for the development of any postoperative infectious complications for up to 30 days after the procedure.

RESULTS

A total of 149 patients were included in this cohort. Incidence of ASB was 14.8%. Thirteen patients (8.72%) developed infectious complications: 3 (13.64%) with ASB and 10 (7.87%) without ABS. Factors associated with postoperative infectious complications included urologic cancers (hazard ratio [HR], 5.26; 95% confidence intervals [CI], 1.24-22.37), urologic interventions in the preceding 3 months (HR, 3.72; 95% CI, 1.02-13.51), and use of antibiotics 3 months prior to surgery (HR, 3.83; 95% CI, 1.01-15.49). Presence of ASB was not associated with postsurgical infectious complications (HR, 1.02; 95% CI, 0.26-3.96).

CONCLUSIONS

There was no association between ASB and postoperative infectious complications. There were other factors associated with infectious complications, such as urologic cancer, previous history of urologic manipulation, and antibiotic use.

Asymptomatic bacteriuria, to screen or not to screen - and when to treat?

PURPOSE OF REVIEW

Asymptomatic bacteriuria (ABU) is a common clinical condition that often leads to unnecessary treatment. The purpose of this review is to outline and evaluate the most recent literature on the management of ABU.

RECENT FINDINGS

The role of ABU management has been evaluated in several patient subgroups: healthy patients without identified risk factors, pregnant women, postmenopausal women, women with recurrent UTI, patients with diabetes, elderly institutionalized patients, patients with renal transplants, patients with indwelling catheters and prior to surgery. Available evidence only supports the need for screening and treatment of ABU in pregnant women and prior to urological procedures breaching the mucosa. In all the other conditions the treatment of ABU is not only useless but also harmful. A short course treatment in pregnant women is recommended; in patients with ABU prior to urological procedures breaching the mucosa the treatment should be given in line with antibiogram and in line with the recommendations of European Association of Urology guidelines.

SUMMARY

The approach to patients with ABU has changed completely during recent years. Today, screening and treatment of ABU is recommended only in pregnant women and in all patients who are candidates for urological procedures breaching the mucosa.

Clinical Practice Guidelines for the Antibiotic Treatment of Community-Acquired Urinary Tract Infections

Urinary tract infections (UTIs) are infectious diseases that commonly occur in communities. Although several international guidelines for the management of UTIs have been available, clinical characteristics, etiology and antimicrobial susceptibility patterns may differ from country to country. This work represents an update of the 2011 Korean guideline for UTIs. The current guideline was developed by the update and adaptation method. This clinical practice guideline provides recommendations for the diagnosis and management of UTIs, including asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, complicated pyelonephritis related to urinary tract obstruction, and acute bacterial prostatitis. This guideline targets community-acquired UTIs occurring among adult patients. Healthcare-associated UTIs, catheter-associated UTIs, and infections in immunocompromised patients were not included in this guideline.

Summary of the UAA-AAUS guidelines for urinary tract infections

Urinary tract infections, genital tract infections and sexually transmitted infections are the most prevalent infectious diseases, and the establishment of locally optimized guidelines is critical to provide appropriate treatment. The Urological Association of Asia has planned to develop the Asian guidelines for all urological fields, and the present urinary tract infections, genital tract infections and sexually transmitted infections guideline was the second project of the Urological Association of Asia guideline development, which was carried out by the Asian Association of Urinary Tract Infection and Sexually Transmitted Infection. The members have meticulously reviewed relevant references, retrieved via the PubMed and MEDLINE databases, published between 2009 through 2015. The information identified through the literature review of other resources was supplemented by the author. Levels of evidence and grades of recommendation for each management were made according to the relevant strategy. If the judgment was made on the basis of insufficient or inadequate evidence, the grade of recommendation was determined on the basis of committee discussions and resultant consensus statements. Here, we present a short English version of the original guideline, and overview its key clinical issues.

Methicillin-resistant Staphylococcus aureus as a uropathogen in an Irish setting

Urinary tract infections are one of the most common infectious diseases diagnosed in the community and in the hospital setting. Their treatment is complicated by drug-resistant pathogens and the colonization by microbes of indwelling urinary catheters. This study assessed the occurrence and antimicrobial susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) uropathogens isolated for 5 consecutive years at University Hospital Waterford between 2010 and 2014. We created 4 clinically relevant subdivisions, based on urine source: hospital inpatients, patients from the Emergency Department, patients referred from their General Practitioner, and Nursing Home patients. We performed a retrospective review from the hospital's electronic microbiological system and calculated resistance rates for each of the standard antimicrobial agents. During the 5-year study period, we studied 151 urine isolates obtained from 128 patients who had an MRSA cultured in their urine sample. There was 100% resistance of all MRSA isolates to Flucloxacillin and Coamoxiclav. Ninety-eight percent of isolates were resistant to Ciprofloxacin. The resistance rate for Trimethoprim was 7.4% and there was only 2.7% resistance for Nitrofurantoin. For a clinical subset of patients, we also demonstrated 100% sensitivity for samples tested against Teicoplanin and Vancomycin. Urinary MRSA is an infrequently studied phenomenon, but with the rising trend of hospital superbugs nationally, its management is of critical importance. Suitable agents to address this within our population include Nitrofurantoin in the well patient requiring urinary MRSA eradication or Vancomycin/Teicoplanin in the unwell patient requiring intravenous therapy. In all groups, fluoroquinolones should be avoided due to significant resistance rates.

Asymptomatic Bacteriuria and Bacterial Interference

Asymptomatic bacteriuria is very common. In healthy women, asymptomatic bacteriuria increases with age, from <1% in newborns to 10% to 20% of women age 80 years, but is uncommon in men until after age 50 years. Individuals with underlying genitourinary abnormalities, including indwelling devices, may also have a high frequency of asymptomatic bacteriuria, irrespective of age or gender. The prevalence is very high in residents of long-term-care facilities, from 25% to 50% of women and 15% to 40% of men. Escherichia coli is the most frequent organism isolated, but a wide variety of other organisms may occur. Bacteriuria may be transient or persist for a prolonged period. Pregnant women with asymptomatic bacteriuria identified in early pregnancy and who are untreated have a risk of pyelonephritis later in pregnancy of 20% to 30%. Bacteremia is frequent in bacteriuric subjects following mucosal trauma with bleeding, with 5% to 10% of patients developing severe sepsis or septic shock. These two groups with clear evidence of negative outcomes should be screened for bacteriuria and appropriately treated. Asymptomatic bacteriuria in other populations is benign and screening and treatment are not indicated. Antimicrobial treatment has no benefits but is associated with negative outcomes including reinfection with antimicrobial resistant organisms and a short-term increased frequency of symptomatic infection post-treatment. The observation of increased symptomatic infection post-treatment, however, has led to active investigation of bacterial interference as a strategy to prevent symptomatic episodes in selected high risk patients.

Bacteraemia during Transurethral Resection of the Prostate: What Are the Risk Factors and Is It More Common than We Think?

The aim of this work was to investigate the microbial causes, incidence, duration, risk factors and clinical implications of bacteraemia occurring during transurethral resection of the prostate (TURP) surgery to better inform prophylaxis strategies. An ethically approved, prospective, cohort study of patients undergoing TURP was conducted. Clinical information and follow-up details were collected using standardized data collection sheets. Blood was obtained for culture at 6 different time points peri-procedure. Standard of care antibiotic prophylaxis was given prior to surgery. Bacteriuria was assessed in a pre-procedure urine sample. Histopathology from all prostate chips was assessed for inflammation and malignancy. 73 patients were consented and 276 blood samples obtained. No patients developed symptomatic bacteraemia during the procedure, 17 patients developed asymptomatic bacteraemia (23.2%). Enterococcus faecalis and Pseudomonas aeruginosa were the most common organisms cultured. 10 minutes after the start of the TURP, the odds ratio (OR) of developing bacteraemia was 5.38 (CI 0.97-29.87 p = 0.05), and 20 minutes after the start of the procedure, the OR was 6.46 (CI 1.12-37.24, p = 0.03), compared to before the procedure. We also found an association between the development of intra-operative bacteraemia and recent antibiotic use (OR 4.34, CI 1.14-16.62, p = 0.032), the presence of a urinary catheter (OR 4.92, CI 1.13-21.51, p = 0.034) and a malignant histology (OR 4.90, CI 1.30-18.46, p = 0.019). There was no statistical relationship between pre-operative urine culture results and blood culture results. This study shows that asymptomatic bacteraemia is commonly caused by TURP and occurs in spite of antibiotic prophylaxis. Our findings challenge the commonly held view that urine is the primary source of bacteraemia in TURP-associated sepsis and raise the possibility of occult prostatic infection as a cause of bacteraemia. More work will be needed to determine the significance of transient bacteraemia in relation to more serious complications like infective endocarditis and malignancy.

[Urinary tract infections in the elderly]

Acute infection of the urinary tract is one of the most commonly encountered bacterial infections in the frail elderly population and is responsible for substantial morbidity and recurrent infections with antibiotic resistance. Although generally considered to be self-limiting without treatment or easily treated with a short antibiotic regime, urinary tract infections (UTIs) often have a dramatic history, associated with incomplete resolution and frequent recurrence. The biological complexity of the infections combined with a dramatic rise in antibiotic-resistant pathogens highlight the need for an anticipating strategy for therapy necessary for a rapid recovery. The first crucial step is the classification in asymptomatic bacteriuria or complicated pyelonephritis, on which the decision for the intensity of treatment and diagnostic effort is based. For the selection of empiric antibiotic therapy, knowledge about the predominant uropathogens as well as local resistance patterns is important. In this manner, most urinary tract infections in the elderly can be treated without greater expense.

Clinical aspects of antimicrobial prophylaxis for invasive urological procedures

The essential value of antimicrobial prophylaxis is to defend the patient undergoing invasive diagnostic procedures or surgery against infectious complications by reducing the bacterial load. Escherichia coli remains the predominant uropathogen (70-80%) isolated in acute community-acquired uncomplicated infections, followed by Staphylococcus saprophyticus (10 to 15%). Klebsiella, Enterobacter, Proteus species, and enterococci infrequently cause uncomplicated cystitis and pyelonephritis. The pathogens traditionally associated with UTI are altering many of their features, particularly because of antimicrobial resistance. Currently, only transurethral resection of prostate and prostate biopsy has been well studied and has high and moderately high levels of evidence in favor of using antibiotic prophylaxis. Other urological interventions have not been well studied. The moderate to low evidence suggests that there is no need for antibiotic prophylaxis in cystoscopy, urodynamic investigations, and extracorporeal shock-wave lithotripsy, whereas the low evidence favors the use of antibiotic prophylaxis for therapeutic ureterorenoscopy and percutaneous nephrolithotomy. The scarce data from studies on transurethral resection of bladder tumors cannot provide a definitive indication for antibiotic prophylaxis for this intervention.

[Antibiotic prophylaxis in urology]

INTRODUCTION

Antibiotic prophylaxis (AP) is used to minimize infectious complications resulting from interventions. Due to high rates of development of bacterial resistance and side effects, the use of antibiotics must be weighed on the basis of high levels of evidence. The main endpoints of urology AP are the prevention of symptomatic urogenital infections, urosepsis and wound infections. The purpose of this review is to bring objectives, principles and recommendations on urology AP according to the latest scientific evidence.

METHODS

We carried out a systematic search of MEDLINE, EMBASE and the Cochrane Library using keywords such as AP, prophylaxis, antibiotics, urological surgery, urogenital surgery and the names of the urologic procedures. The results of studies on the AP for each procedure were classified according to the levels of evidence and grades of recommendation from the European Association of Urology.

RESULTS

There are a number of good quality studies on AP about endoscopic resection of the prostate (TURP), urodynamic studies and transrectal prostate biopsies (trPB). The majority of the studies about other procedures have several limitations (sample size, consistency of definitions, statistics and trial design). Lack of consistency in the definitions of infectious complications does not allow comparison between different studies.

CONCLUSIONS

The AP is evidence-based is indicated only for TURP and trPB. It is desirable to perform randomized, prospective and controlled trials in order to rationalize the use of antibiotics, improve the cost/benefit ratio and reduce bacterial antibiotic resistances.

A survey of resident physicians' knowledge regarding urine testing and subsequent antimicrobial treatment

BACKGROUND

Asymptomatic bacteriuria is often treated with antimicrobials despite no benefit to patients, contributing to antimicrobial resistance and costs. Identifying knowledge deficits may improve physician training and antimicrobial stewardship efforts. We surveyed internal medicine and medicine-pediatrics resident physicians about their knowledge and attitudes regarding urine testing and subsequent management.

METHODS

We surveyed 280 resident physicians at Jackson Memorial Hospital/University of Miami Miller School of Medicine and the University of Minnesota Medical School, using patient management questions based on clinical vignettes. Overall knowledge, assessed by calculating the percentage of correct answers, was assessed for correlation with demographic information, training, and experience.

RESULTS

Of 100 responses (36% response rate), the mean percentage of correct answers was 48% (range for individual questions, 19%-85%). Experience and demographic factors demonstrated no association with overall knowledge. Training appeared to be associated with overall knowledge, with third-year residents having significantly higher percentages of correct answers compared with first-year residents (53% vs 40%; P = .03), but this was nonsignificant when adjusted for multiple comparisons (P = .18). Knowledge was significantly better for questions regarding surgical versus nonsurgical scenarios (63% vs 37%; P < .001), and for questions for which the correct answer was to start antimicrobials, versus withholding antimicrobials/limiting further testing (83% vs 39%; P < .001).

CONCLUSIONS

Knowledge deficits may contribute to unnecessary detection and treatment of asymptomatic bacteriuria.

Urinary tract infections in the elderly population

BACKGROUND

Urinary tract infections (UTIs) are a common problem in the elderly population. The spectrum of disease varies from a relatively benign cystitis to potentially life-threatening pyelonephritis.

OBJECTIVE

This review covers the management of asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, antibiotic resistance, catheter-associated bacteriuria/symptomatic UTIs, and antibiotic prophylaxis for recurrent infections in elderly men and women.

METHODS

Literature was obtained from English-language searches of MEDLINE (1966-April 2011), Cochrane Library, BIOSIS (1993-April 2011), and EMBASE (1970-April 2011). Further publications were identified from citations of resulting articles. Search terms included, but were not limited to, urinary tract infections, asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, antibiotic resistance, catheter associated urinary tract infections, recurrent urinary tract infections, and elderly.

RESULTS

The prevalence of UTIs in elderly women depends on the location in which these women are living. For elderly women living in the community, UTIs compromise the second most common infection, whereas in residents of long-term care facilities (LTCFs) and hospitalized subjects, it is the number one cause of infection. The spectrum of patient presentation varies from classic signs and symptoms in the independent elderly population to atypical presentations, including increased lethargy, delirium, blunted fever response, and anorexia. Although there are few guidelines specifically directed toward the management of UTIs in the elderly population, therapy generally mirrors the recommendations for the younger adult age groups. When choosing a treatment regimen, special attention must be given to the severity of illness, living conditions, existing comorbidities, presence of external devices, local antibiotic resistance patterns, and the ability of the patient to comply with therapy.

CONCLUSIONS

Improved guidelines for the diagnosis and management of UTIs in the elderly population are needed. Better techniques to evaluate and prevent catheter-associated bacteriuria and UTIs await improved diagnostic modalities and catheter technologies. Alternative methods for prophylaxis of patients who suffer from recurrent infections must be found while minimizing the risk of developing or propagating antibiotic resistance.

Asymptomatic bacteriuria: review and discussion of the IDSA guidelines

Asymptomatic bacteriuria is a common finding, but is usually benign. Screening and treatment of asymptomatic bacteriuria is only recommended for pregnant women, or for patients prior to selected invasive genitourinary procedures. Healthy women identified with asymptomatic bacteriuria on population screening subsequently experience more frequent episodes of symptomatic infection, but antimicrobial treatment of asymptomatic bacteriuria does not decrease the occurrence of these episodes. Clinical trials in spinal-cord injury patients, diabetic women, patients with indwelling urethral catheters, and elderly nursing home residents have consistently found no benefits with treatment of asymptomatic bacteriuria. Negative outcomes with antimicrobial treatment do occur, including adverse drug effects and re-infection with organisms of increasing resistance. Optimal management of asymptomatic bacteriuria requires appropriate implementation of screening strategies to promote timely identification of the selected patients for whom treatment is beneficial, and avoidance of antimicrobial therapy where no benefit has been shown.

[Urinary bacteriologic study prior to endoscopic urologic surgery]

OBJECTIVE

The objectives of this study are to know the incidence of preoperative bacteriuria in patients undergoing endoscopic urologic surgery, to analyze the most frequent microorganisms appearing in the cultures and their resistance to antibiotics in order to select the most appropriate prophylactic one for our population, and to determine the risk factors related to postoperative bacteriuria or sepsis of urologic origin.

MATERIAL AND METHODS

449 patients undergoing endoscopic urologic surgery were included in the study. Urinary samples were collected for culture prior to prophylactic antibiotic administration and again a week after bladder catheter removal once the antibiotic treatment was finished. Variables related to an increase in infectious complications were analyzed. Special attention was paid to postoperatory incidences, mainly those of infectious nature.

RESULTS

Preoperative bacteriuria was found in 66 out of 428 patients (15.4%). It was found to be related to age, sex, previous infection episodes, diabetes mellitus, indwelling catheter and to the pathology for which operation was indicated. The most frequently found microorganism was Escherichia Coli. Resistance to prophylactic antibiotic was found in 37.9% of patients with preoperatory bacteriuria. Postoperatory bacteriuria, observed in 22.0% of the patients was exclusively related to preoperatory bacteriuria. 2.9% of patients showed sepsis of urinary origin criteria during hospital staying, and it was found to be exclusively related to length of surgery and neither to preoperatory bacteriuria nor to indwelling catheter time or the "inappropriate" prophylactic antibiotic use in these cases.

CONCLUSIONS

A good part of patients who underwent endoscopic surgery showed preoperatory bacteriuria, responsible for postoperative bacteriuria in less than 25% of the cases. The length of surgery seemed to be the only related cause whit sepsis of urinary origin.

The catheterized patient undergoing transurethral resection of the prostate: a survey of the current practice of British urologists

OBJECTIVE

To determine, using a postal questionnaire survey of practising British consultant urologists, the duration and type of antibiotic deemed most effective in patients with an existing indwelling catheter before transurethral resection of the prostate (TURP), as the value of prophylactic antibiotics before TURP is well recognized, but no data are available.

METHODS

A questionnaire was posted to each of the 321 practising consultant urologists listed in the handbook of the British Association of Urological Surgeons (1998). A hypothetical situation in the opening statement proposed 'a patient with an indwelling catheter is to undergo TURP'. The type, timing and duration of prophylactic antibiotic usage were elicited by circling the appropriate response from a choice of several possibilities.

RESULTS

In all, 250 questionnaires were returned; 98% of respondents recognized the importance of the prophylactic use of antibiotics in catheterized patients undergoing TURP, and routinely use them. Most urologists (53%) use more than one dose, with most of these preferring a second dose on catheter removal (60%).

CONCLUSION

The magnitude and diversity of response suggests uncertainty about the appropriate prophylaxis in such patients, and the need for further studies to clarify this situation.

Ceftriaxone (1 g intravenously) penetration into abdominal tissues when administered as antibiotic prophylaxis during nephrectomy

A pharmacokinetics study was conducted to determine the effects of ceftriaxone administered before nephrectomy on the occurrence of postoperative wound infection. Ceftriaxone was administered as antibiotic prophylaxis in 11 consecutive patients undergoing nephrectomy who received 1,000 mg intravenously 30 min before surgery. Simultaneous blood and tissue samples were collected at three stages of the surgical procedure: opening of the abdominal cavity, nephrectomy, and closure of the abdominal cavity. Samples of following tissues were assayed: abdominal-wall fat, perirenal fat, kidney cortex and medulla, and urine. During the different stages of surgical procedures, ceftriaxone concentrations remained higher than the MIC90 of the potential pathogens (Staphylococcus aureus, Escherichia coli, and Enterobacteriaceae). In selected patients undergoing nephrectomy and requiring antimicrobial prophylaxis such as malnourished, debilitated, diabetic or immunosuppressed patients, the use of a single dose of ceftriaxone (1,000 mg) makes it possible to offer an optimal bacterial coverage for the prevention of postoperative infection. According to our kinetic evaluation, ceftriaxone is potentially a good antibiotic for prophylaxis in urological surgery.

Comparison of local povidone-iodine antisepsis with parenteral antibacterial prophylaxis for prevention of infective complications of TURP: a prospective randomized controlled study

OBJECTIVE

To determine whether antisepsis with povidone-iodine solution applied at the external urethral meatus confers protection against infective complications following transurethral resection of the prostate (TURP) and compare that with antibacterial prophylaxis.

METHODS

A total of 167 patients with sterile urine undergoing TURP for benign prostatic hyperplasia (BPH) were prospectively randomized into three groups. Group A, had gauze soaked in saline applied at the urethral meatus (control group). In group B, the gauze was soaked in povidone-iodine instead of saline and group C had a single 1 g i.v. injection of cephradine at induction of anaesthesia with no treatment for the meatus. Bacteraemia, post-operative bacteriuria and other infective complications were compared in the three groups. Associations of bacteriuria at catheter removal and intra-operative bacteraemia with infective complications and with long term bacteriuria were also studied.

RESULTS

Bacteriuria rate at catheter removal was not significantly different in the three groups. However, intraoperative bacteraemia and bacterial growth at the external urethral meatus was significantly lower in group C. Bacteriuria at catheter removal was significantly associated with bacterial growth at the meatus but not with long term bacteriuria at 3 months. Bacteriuria at catheter removal could not accurately predict infective complications.

CONCLUSION

Post-TURP bacteriuria appears to be preceded by bacterial growth at the external urethral meatus. Antisepsis with povidone-iodine solution application at the meatus does not confer adequate protection against meatal bacterial growth as that obtained by prophylactic antibacterials. Nonetheless, neither antibacterial prophylaxis nor local antisepsis could reduce bacteriuria rate in this study.

Do antimicrobials have a role in preventing septicaemia following instrumentation of the urinary tract?

Urinary tract instrumentation is a significant cause of septicaemia. Review of the literature suggests that selective use of antimicrobials would reduce the risk of septicaemia as this varies between patients and with procedures. Antimicrobial prophylaxis is indicated for patients at high risk of endocarditis, or who are neutropenic. For patients without these risk factors, it is indicated for open, transurethral, or certain forms of laser prostatectomy or trans-rectal prostate biopsy. For cystoscopy, antimicrobials are indicated for patients with preoperative bacteriuria or a preoperative indwelling catheter. Single dose aminoglycosides or oral fluoroquinolones are the agents of choice with the exception of the prevention of endocarditis, where combinations active against streptococci are recommended. For other instrumentations, the risk of antimicrobial toxicity probably outweighs the benefits and a risk-reduction strategy is recommended. Further studies are required to provide definitive answers in many of these areas.

An economic analysis of antimicrobial prophylaxis against urinary tract infection in patients undergoing transurethral resection of the prostate

Despite the high level of safety and low incidence of mortality associated with transurethral resection of the prostate (TURP), urinary tract infections (UTIs)-the most common complication associated with this procedure-continue to be an important source of postoperative morbidity and costs. However, there is controversy about whether antimicrobial agents should be used as UTI prophylaxis in patients undergoing TURP and, if so, which agents should be used and for what duration. This retrospective study used multivariate regression analysis to evaluate the different types and durations of antibiotic prophylaxis in 222 patients who underwent TURP at a Veterans Affairs hospital between January 1, 1995, and March 30, 1998. The primary outcome measures were total medical costs (ie, medication use, clinic office visits, and hospital care in the 4 weeks after the procedure), length of hospital stay (total days in hospital due to the procedure), and probability of UTI (incidence of infection in the 4 weeks after the procedure). Results showed that there was no difference in the length of hospital stay regardless of the regimen or duration of pre-TURP antibiotic therapy. Patients who received pre-TURP ampicillin plus ceftizoxime incurred moderately higher total medical costs than did patients who received the least costly drug, cefazolin (P = 0.10). Similarly, patients who received post-TURP quinolones incurred a significantly higher total medical cost than did patients who received co-trimoxazole (P = 0.06). We found no evidence of a relationship between use of specific parenteral or oral antibiotic prophylaxis for UTI in patients undergoing TURP and the rate of UTI in such patients. Thus there is no justification for the use of more expensive antibiotic regimens. At our institution, the preferred pre-TURP prophylactic regimen would be cefazolin, whereas co-trimoxazole would be the most cost-effective post-TURP prophylactic regimen. Because duration of post-TURP prophylaxis does not appear to influence the rate of UTI, 24 hours would seem adequate.

Antibiotic prophylaxis for patients undergoing transurethral resection of the prostate

OBJECTIVES

To evaluate the prevention of urinary tract infections (UTIs) after transurethral resection of the prostate (TURP) in a prospective randomized study using a quinolone antibiotic (fleroxacin) to compare the efficacy of: (1) a single oral dose, (2) a single intravenous (IV) dose, and (3) an extended regimen consisting of an initial IV dose followed by oral therapy until removal of the urinary catheter, but for less than 6 days.

METHODS

We excluded from study patients who received antimicrobial agents within 48 hours of surgery. Single-dose prophylaxis consisted of 400 mg of fleroxacin given either orally or intravenously. The extended regimen consisted of an initial 400 mg IV dose followed by 400 mg oral each day (patients older than 75 years, or with a creatinine clearance less than 40 mL/min, received 200 mg/day). UTI was defined as clinical evidence of infection plus the presence of more than 10 white blood cells (WBC)/mm3 in any urine specimen plus the presence of more than 10(4) cfu/mL in midstream urine specimens or more than 10(2) cfu/mL in catheter specimens.

RESULTS

Prior to TURP, 30% (25/84) of the patients had a urethral catheter in situ and 12% (3/25) of these patients had bacteriuria. Only 1 patient developed a UTI and that was 22 days after a TURP (intergroup comparisons, Fisher's exact test greater than 0.05). There were no instances of urosepsis.

CONCLUSIONS

A single oral dose of a fluoroquinolone agent provided optimum prophylaxis for patients undergoing TURP.

Prospective randomized open study between ciprofloxacin and a combination of sulfadiazine and trimethoprim in antibiotic prophylaxis in connection with transurethral prostatectomy

A randomized open prospective study with antibodies was conducted on 398 cases of TURP to compare the efficacy of either 250 mg of ciprofloxacin twice daily (CF) or 500 mg/160mg of sulfadiazine-trimethroprim twice daily (ST) in the prevention of urinary and other infection complications. The medication was started on the evening preceding the operation and continued up to the day following the removal of an indwelling catheter. The preoperative risk factors were similar in both groups. The groups did not differ in terms of the duration of the operation, the volume of irrigation fluid or the weight of the resected chips. The incidence of immediate complications was 26% in the CF group and 20% in the ST group. All the complications were minor. There were three serious late complications, one intertervertebral discitis and one coxitis in the CF group and one endocarditis in the ST group. The patient with endocarditis died. One the removal of the indwelling catheter on the third postoperative day, bacteriuria was detected in 3% of the patients in the CF group and in 9% in the ST group. The difference was statistically significant (p < 0.05). One month after TURP, bacteriuria was detected in 7% in both study groups. It is concluded that ciprofloxacin may be more effective to preventing immediate urinary tract infections after TURP than a combination of sulfadiazine and trimethoprim. There were three serious late complications. As late as one month after TURP, bacteriuria was still diagnosed in about 7% of all patients, which is post-TURP monitoring of urinary values is important.

Ciprofloxacin. A review of its pharmacological profile and therapeutic use in the elderly

Ciprofloxacin belongs to the fluoroquinolone class of antimicrobial agents which primarily inhibit bacterial DNA gyrase. It is effective after oral or intravenous administration, demonstrating potent antibacterial activity against most Gram-negative, and many Gram-positive bacteria. Although most bacterial strains have remained susceptible to the drug, low rates of resistance have been observed in some strains of Pseudomonas aeruginosa and enterococci and higher rates in methicillin-resistant Staphylococcus aureus. Ciprofloxacin attains concentrations in most tissues and body fluids sufficient to inhibit the majority of susceptible pathogens. Its pharmacokinetic profile in the elderly (> or = 65 years) is broadly similar to that reported in younger persons, although plasma concentrations are higher, and renal clearance is decreased in elderly persons. Ciprofloxacin is an effective treatment for those infections most common in elderly patients, including infections of the urinary tract, lower respiratory tract, skin and soft-tissues, and bone and joints, and is an effective agent for prophylaxis in transurethral surgery. Orally administered ciprofloxacin appeared to be at least as effective as alternative orally administered antimicrobial agents (trimethoprim, cotrimoxazole [trimethoprim/sulfamethoxazole], amoxicillin, amoxicillin/clavulanic acid) and also as effective as various parenteral agents (ceftriaxone, cefamandole, ceftazidime, cefotaxime) in a small number of comparative clinical trials. However, further studies are needed to clarify the comparative efficacy of ciprofloxacin with that of other oral and parenteral agents in the elderly. Initial trials have also indicated therapeutic efficacy of oral ciprofloxacin in malignant external otitis and bacterial prostatitis. Nevertheless, with its good tolerability profile and potent antimicrobial activity following oral administration, ciprofloxacin appears to offer a valuable alternative for treating various acute and chronic infections in elderly patients. Causative pathogens are frequently multiresistant in this patient group, and ciprofloxacin avoids or minimises the need for parenteral therapy.

[Antibiotic prophylaxis in urology. Surgical and endoscopic surgery. Lithotripsy. Transplantation]

The opening of the urinary tract switches surgical and endoscopic urology to the clean contaminated category and therefore for each of them antibiotic prophylaxis has to be considered. Prophylactic antibiotics are only recommended before surgery in patients with sterile urine. Those with infected urine should have curative antibiotics. Prophylactic antibiotics are commonly recommended for transurethral resection of the prostate, transrectal biopsy of the prostate, renal transplant and radical cystectomy with ileal or colonic pouch for urinary diversion. It is worthless in diagnostic cystoscopy. ESWL and scrotal surgery. For other procedures more data are required to conclude.

[The role of new molecules in surgical antibiotic prophylaxis]

The preoperative administration of a new antibiotic for antimicrobial prophylaxis is questionable because of the methodological difficulties to demonstrate its efficiency and benefits in decreasing the postoperative infectious complications. As their rate is very low, especially in clean surgery, the number of patients to be included in a comparative trial is very high. Most studies assessed only small groups and therefore any extrapolation for clinical practice is of limited value. Because of their therapeutic efficiency the fluoroquinolones are often recommended for antimicrobial prophylaxis. However, the rapid occurrence of resistances, directly related to their prescription should invite the prescribers to be cautions. They should be contra-indicated as long as an alternative of similar efficiency is existing, in case of bacteraemia, when an administration of more than 48 hours in required or when the intra-hospital resistance rate exceeds 10 p. 100.

The source of organisms in the post-prostatectomy bacteriuria of patients with pre-operative sterile urine

Ninety patients undergoing prostatectomy for benign prostatic hyperplasia (BPH) with sterile urine pre-operatively were prospectively studied for post-prostatectomy bacteriuria; 26 of 90 patients (29%) developed bacteriuria (18 of 64 after transurethral resection (TUR) and 8 of 26 after open prostatectomy), of whom 15 had pre-operative indwelling urethral catheters. The correlation of bacteriuria with several factors was studied, namely the presence of a histological inflammatory reaction within the prostatic adenoma, prostatic culture, intra-operative outgoing irrigation fluid culture, intra-operative blood culture and post-operative external meatal swab culture. The only significant correlation was between bacteriuria and meatal cultures. It was concluded that post-prostatectomy bacteriuria is probably caused by post-operative ascending infection along urethral catheters. There was not enough evidence to ascribe bacteriuria to pre-existing septic foci within the adenoma. Intra-operative contamination and infection from distant foci were also unlikely causes.

Timing, dosing and duration of antimicrobial prophylaxis in urology: a study in guinea pigs with special reference to high-risk conditions

A study in guinea pigs was performed to investigate the importance of timing, dosage and duration of antimicrobial prophylaxis in urologic surgery. To simulate high-risk conditions, in one group a foreign body was implanted subcutaneously. The prostate and one kidney were cauterized and bacteremia was induced by intravenous injection of an Escherichia coli suspension. Various ciprofloxacin regimens were tested. The results indicate that antimicrobial prophylaxis is beneficial only if administered before or shortly after surgery. Full therapeutic dosage may not be necessary for prophylactic efficacy. Single-dose prophylaxis was as effective as multiple doses. Foreign body infection could be prevented by single-dose prophylaxis.

Prophylaxis in urological surgery

Prophylaxis in urological surgery is usually taken to mean antibacterial agents. However, in this study, other factors such as the environment, patient risk and surgical risk factors are also taken into account. Because patients have a wide variety of possible risk factors, individual variations must be possible. In standard transurethral resection in non-risk patients, single-dose preoperative prophylaxis may be sufficient. In open surgery prophylactic measures should be varied according to the extent of the procedure.

Prophylactic ciprofloxacin for catheter-associated urinary-tract infection

Patients receiving antibiotics during bladder drainage have a lower incidence of urinary-tract infections compared with similar patients not on antibiotics. However, antibiotic prophylaxis in patients with a urinary catheter is opposed because of the fear of inducing resistant bacterial strains. We have done a double-blind, placebo-controlled trial of prophylactic ciprofloxacin in selected groups of surgical patients who had postoperative bladder drainage scheduled to last for 3 to 14 days. Patients were randomly assigned to receive placebo (n = 61), 250 mg ciprofloxacin per day (n = 59), or 500 mg ciprofloxacin twice daily (n = 64) from postoperative day 2 until catheter removal. 75% of placebo patients were bacteriuric at catheter removal compared with 16% of ciprofloxacin-treated patients (relative risk [RR] [95% CI] 4.7 [3.0-7.4]). The prevalence of pyuria among placebo patients increased from 11% to 42% while the catheter was in place; by contrast, the rate of pyuria was 11% or less in patients receiving ciprofloxacin (RR 4.0 [2.1-7.3]). 20% of placebo patients had symptomatic urinary-tract infections, including 3 with septicaemia, compared with 5% of the ciprofloxacin groups (RR 4.0 [1.6-10.2]). Bacteria isolated from urines of placebo patients at catheter removal were mostly species of enterobacteriaceae (37%), staphylococci (26%), and Enterococcus faecalis (20%), whereas species isolated from urines of ciprofloxacin patients were virtually all gram-positive. Ciprofloxacin-resistant mutants of normally sensitive gram-negative bacteria were not observed. Ciprofloxacin prophylaxis is effective and safe in the prevention of catheter-associated urinary tract infection and related morbidity in selected groups of patients requiring 3 to 14 days of bladder drainage.

Impact of concurrent antimicrobial therapy on catheter-associated urinary tract infection

Results of a survey in two Dutch district hospitals which investigated the impact of concurrent administration of antibiotics on the incidence of catheter-associated urinary tract infection (UTI), showed that 61% of catheterized patients received antibiotics at some stage during bladder drainage. The use of antibiotics within 48 hours prior to catheter removal reduced the risk of bacteriuria fivefold. Multivariate analysis of patients who were catheterized for 3-14 days indicated that, apart from the duration of catheter employment, the use of antibiotics was the only variable significantly and independently associated with the development of bacteriuria. The power of this association varied inversely with increasing duration of catheterization but remained significant throughout the 3-14-day interval. Patients with bacteriuria at the time of catheter removal were more likely to have a febrile illness compared to those who remained free of catheter-associated UTI.

Long term survival after transurethral resection of the prostate. Influence of preoperative bacteriuria and indwelling catheter treatment on late mortality

In this report we have analysed the long term survival after transurethral resection of the prostate in patients with cancer and benign hyperplasia, with special reference to the effect of bacteriuria. One hundred and eighty-nine men were followed for seven years after operation. Life tables according to the Kaplan-Meier method indicated a decreased survival rate for patients with preoperative catheter treatment and/or bacteriuria (p = 0.004 and p = 0.013, respectively). In order to evaluate the influence on the long-term survival of each of these factors alone as well as of other factors like diagnosis, age at operation and perioperative antibiotic treatment, a multivariate analysis, according to Cox proportional hazards method was made. This displayed a two-fold increase of mortality in the patients attributed to the catheter treatment per se, whereas bacteriuria alone was not associated with an increased risk of earlier death.

Quinolone antibacterial agents for the treatment of genitourinary tract infections

The fluoroquinolones have expanded the therapeutic options available for the treatment of genitourinary tract infections. Their ease of oral administration, favourable pharmacokinetics, low incidence of adverse reactions, and broad spectrum of in vitro activity against aerobic and facultative organisms make them especially suitable for treating bacteriuria, particularly when pathogens are resistant to other available oral agents. Their efficacy has also been established in the treatment of prostatis, gonorrhea and chancroid. They have lower in vitro activity against chlamydia, ureaplasma and anaerobes, and their role in the treatment of non-gonococcal urethritis, vaginitis and acute pelvic inflammatory disease is less well established.

Fluoroquinolone antimicrobial agents

The fluoroquinolones, a new class of potent orally absorbed antimicrobial agents, are reviewed, considering structure, mechanisms of action and resistance, spectrum, variables affecting activity in vitro, pharmacokinetic properties, clinical efficacy, emergence of resistance, and tolerability. The primary bacterial target is the enzyme deoxyribonucleic acid gyrase. Bacterial resistance occurs by chromosomal mutations altering deoxyribonucleic acid gyrase and decreasing drug permeation. The drugs are bactericidal and potent in vitro against members of the family Enterobacteriaceae, Haemophilus spp., and Neisseria spp., have good activity against Pseudomonas aeruginosa and staphylococci, and (with several exceptions) are less potent against streptococci and have fair to poor activity against anaerobic species. Potency in vitro decreases in the presence of low pH, magnesium ions, or urine but is little affected by different media, increased inoculum, or serum. The effects of the drugs in combination with a beta-lactam or aminoglycoside are often additive, occasionally synergistic, and rarely antagonistic. The agents are orally absorbed, require at most twice-daily dosing, and achieve high concentrations in urine, feces, and kidney and good concentrations in lung, bone, prostate, and other tissues. The drugs are efficacious in treatment of a variety of bacterial infections, including uncomplicated and complicated urinary tract infections, bacterial gastroenteritis, and gonorrhea, and show promise for therapy of prostatitis, respiratory tract infections, osteomyelitis, and cutaneous infections, particularly when caused by aerobic gram-negative bacilli. Fluoroquinolones have also proved to be efficacious for prophylaxis against travelers' diarrhea and infection with gram-negative bacilli in neutropenic patients. The drugs are effective in eliminating carriage of Neisseria meningitidis. Patient tolerability appears acceptable, with gastrointestinal or central nervous system toxicities occurring most commonly, but only rarely necessitating discontinuance of therapy. In 17 of 18 prospective, randomized, double-blind comparisons with another agent or placebo, fluoroquinolones were tolerated as well as or better than the comparison regimen. Bacterial resistance has been uncommonly documented but occurs, most notably with P. aeruginosa and Staphylococcus aureus and occasionally other species for which the therapeutic ratio is less favorable. Fluoroquinolones offer an efficacious, well-tolerated, and cost-effective alternative to parenteral therapies of selected infections.

Quinolones in urology

The new quinolones have broad antimicrobial spectra covering all aerobic gram-negative and gram-positive bacteria encountered in urinary tract infections. All are administered orally, some also parenterally, low degree of resistance, few side effects and bacteriological and clinical cure rates similar to or higher than traditional antimicrobials make them especially suitable for treatment of complicated urinary tract infections including bacterial prostatitis. Non-critical use of quinolones in simple infections where standard drugs may be equally effective and safe should be discouraged.

Norfloxacin versus trimethoprim-sulfamethoxazole. A study in patients with known bacteriuria undergoing transurethral resection of the prostate

Three hundred and forty-three patients with suspected bacteriuria undergoing transurethral resection of the prostate (TUR-P) were randomized to treatment with either trimethoprim-sulfamethoxazole (TMP-SMX) or norfloxacin (NF) for 5 1/2 days beginning the evening prior to operation. It was possible to analyse 165 patients for efficacy. Elimination of bacteria on days 10 to 20 was achieved in 78.1% and 78.3% in the TMP-SMX and NF group, respectively. The accumulated elimination rates for the follow up period (days 10-42) were 68.5% for the TMP-SMX group and 76.2% for the NF group. The differences were not statistically significant. No patient had any clinical signs of upper urinary tract infection or septicemia. Three hundred and twelve patients were analysed for safety. Twenty-six patients reported 32 adverse drug events (ADEs). Four reactions in the TMP-SMX group were considered severe while in the NF group all the ADEs were of mild or moderate intensity. In this study NF seems to be at least as effective and safe as TMP-SMX.

Postoperative prophylaxis with norfloxacin in patients requiring bladder catheters

The effect of once daily doses of 200 mg oral norfloxacin on the occurrence of catheter-associated bacteriuria (greater than 1000 CFU/ml) and pyuria was studied in 105 post-operative gynaecologic patients. Norfloxacin was given from the second day after surgery until catheter removal. Bacteriuria developed in 32 of 51 (63%) control patients compared to 8 of 54 (15%) patients receiving norfloxacin (p less than 0.001). Pyuria was present in 22 of 51 (43%) control subjects versus only 3 of 54 (5%) patients treated with norfloxacin (p less than 0.001). Bacteria isolated from control patients comprised species of Enterobacteriaceae (40%), Staphylococcus (35%), and Streptococcus (17%); seven isolates were resistant to multiple antibiotics reflecting their nosocomial origin. In contrast, strains isolated from norfloxacin-treated patients comprised non-fermenting gram-negative rods (79%, usually Alcaligenes or Acinetobacter spp.) and faecal streptococci (12%). It is concluded that once daily doses of 200 mg oral norfloxacin are effective in reducing the rate of catheter-associated bacteriuria and pyuria following reconstructive gynaecologic surgery.