Antimicrobial agents in transurethral prostatic resection

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.

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.

Risk Factors for Bacteremia in Patients With Urinary Catheter-Associated Bacteriuria

BACKGROUND

Catheter-associated bacteriuria is complicated by secondary bacteremia in 0.4% to 4.0% of cases. The directly attributable mortality rate is 12.7%.

OBJECTIVE

To identify risk factors for bacteremia associated with catheter-associated bacteriuria.

METHODS

Data were acquired from a large electronic clinical and administrative database of consecutive adult inpatient admissions to 2 acute care hospitals during a 7-year period. Data on patients with catheter-associated bacteriuria and bacteremia were compared with data on control patients with catheter-associated bacteriuria and no bacteremia, matched for date of admission plus or minus 30 days. Urine and blood cultures positive for the same pathogen within 7 days were used to define catheter-associated bacteriuria and bacteremia. Multivariable conditional logistic regression was used to determine independent risk factors for bacteremia.

RESULTS

The sample consisted of 158 cases and 474 controls. Independent predictors of bacteremia were male sex (odds ratio, 2.76), treatment with immunosuppressants (odds ratio, 1.68), urinary tract procedure (odds ratio, 2.70), and catheter that remained in place after bacteriuria developed (odds ratio, 2.75). Patients with enterococcal bacteriuria were half as likely to become bacteremic as were patients with other urinary pathogens (odds ratio, 0.46). Odds of secondary bacteremia increased 2% per additional day of hospital stay (95% CI, 1.01-1.04) and decreased 1% with each additional year of age (95% CI, 0.97-0.99).

CONCLUSIONS

The results add new information about increased risk for bacteremia among patients with catheters remaining in place after catheter-associated bacteriuria and confirm evidence for previously identified risk factors.

Is Preoperative Assessment and Treatment of Asymptomatic Bacteriuria Necessary for Reducing the Risk of Postoperative Symptomatic Urinary Tract Infections After Urologic Surgical Procedures?

OBJECTIVE

To evaluate whether it is always necessary to test for the presence of asymptomatic bacteriuria (AB) in patients undergoing urologic surgical procedures, and if present, whether to treat AB with antimicrobial prophylaxis.

MATERIALS AND METHODS

All patients who underwent urologic surgical procedures from December 2008 to October 2013 in a tertiary referral urologic center were considered for this study. All patients received antimicrobial prophylaxis in line with European Association of Urology guidelines on urologic infections. AB was diagnosed if ≥10⁵ colony-forming units/mL were cultured. The population was subdivided into 2 groups: group A, patients with preoperative AB, and group B, patients without AB. Data on postoperative symptomatic urinary tract infections (UTIs) were compared for the 2 groups.

RESULTS

A total of 2201 patients were considered eligible for this study and were analyzed; 668 (30.4%) patients were found to harbor AB (group A), and 1533 (69.6%) patients did not have AB (group B). Microbiologically verified symptomatic postoperative UTIs occurred in 198 patients (8.9%). No difference in terms of overall rate of postoperative symptomatic UTI was found between the 2 groups (group A: 70 [10.4%] and group B: 128 [8.3%]; OR: 1.28 95%CI 0.94-1.74; P = .12), as well as in terms of urosepsis (group A: 2 [0.30%] and group B: 4 [0.26%]; P = 1.0).

CONCLUSION

In patients undergoing urologic surgical procedures who are receiving antimicrobial prophylaxis in accordance with European Association of Urology guidelines, the preoperative presence of AB in this study was not associated with a higher incidence of postoperative symptomatic UTI.

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.

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.

Single‐dose orally administered quinolone appears to be sufficient antibiotic prophylaxis for radical retropubic prostatectomy

OBJECTIVE

To evaluate a new prophylaxis routine, which was introduced at our clinic in December 1998, comprising a single oral dose of antibiotic given prior to radical retropubic prostatectomy (RRP).

MATERIAL AND METHODS

A total of 60 men scheduled to undergo RRP were included in a prospective study and received antibiotic prophylaxis in the form of a single oral dose of quinolone. Cultures were made from the tip of the catheter and from urine sampled at the time of extraction as well as 1 and 2 weeks post-extraction. The outcome of this prospective study of 60 men was then compared to the total numbers of patients operated on in 1998 (n = 103) and 1999 (n = 140) by means of a retrospective analysis of clinical files.

RESULTS

No cases of sepsis occurred. Two weeks after catheter removal, 15/60 patients had persisting bacteriuria. No other signs of infection were detected. Six patients developed a stricture of the anastomotic area during follow-up (mean duration 18.9 months). When the study group was compared to all patients operated on in 1998 and 1999 no increases in the incidence of anastomotic strictures or serious infections or in the length of hospitalization could be detected.

CONCLUSION

A single dose of antibiotic given before RRP appears to be sufficient prophylaxis.

Japanese guidelines for prevention of perioperative infections in urological field

For urologists, it is very important to master surgical indications and surgical techniques. On the other hand, the knowledge of the prevention of perioperative infections and the improvement of surgical techniques should always be considered. Although the prevention of perioperative infections in each surgical field is a very important issue, the evidence and the number of guidelines are limited. Among them, the preparation of guidelines has progressed, especially in gastrointestinal surgery. The Center for Disease Control and Prevention (CDC) proposed guidelines for the prevention of surgical site infections, which have been used worldwide. In urology, the original guidelines were different from those of general surgery, due to many endourological procedures and urine exposure in the surgical field. The Japanese Society of UTI Cooperative Study Group has thus framed these guidelines supported by The Japanese Urological Association. The guidelines consist of the following nine techniques: open surgeries, laparoscopic surgeries, transurethral resection of bladder tumor, ureterorenoscope and transurethral lithotripsy, transurethral resection of the prostate, prostate biopsy, cystourethroscope, pediatric surgeries in the urological field, and extracorporeal shock wave lithotripsy and febrile neutropenia. These are the first guidelines for the prevention of perioperative infections in the urological field in Japan. Although most of these guidelines were made using reliable evidence, there are parts without enough evidence. Therefore, if new reliable data is reported, it will be necessary for these guidelines to be revised in the future.

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.

ANTIBIOTIC PROPHYLAXIS FOR TRANSURETHRAL PROSTATIC RESECTION IN MEN WITH PREOPERATIVE URINE CONTAINING LESS THAN 100,000 BACTERIA PER ML: A SYSTEMATIC REVIEW

PURPOSE

We determined whether antibiotic prophylaxis can reduce the risk of postoperative infective complications in men undergoing transurethral resection of the prostate (TURP) who have preoperative urine with less than 100,000 bacteria per ml.

MATERIALS AND METHODS

MEDLINE, EMBASE (Elsevier B.V., Amsterdam, The Netherlands) and the Cochrane Library were searched for randomized and quasi-randomized controlled trials that compared the effects of antibiotic prophylaxis with placebo or active controls for men undergoing TURP with preoperative sterile urine. Two reviewers independently extracted patient characteristic and outcomes data based on a prospectively developed protocol.

RESULTS

A total of 28 trials, 10 placebo controlled and 18 no treatment controlled, involving 4,694 patients, met the inclusion criteria. The mean age of the subjects was 69 years and the majority underwent TURP for prostatic hyperplasia (85%). Antibiotic prophylaxis was significantly more effective than placebo in reducing postoperative TURP complications. The risk differences for post-TURP bacteriuria, high degree fever, bacteremia and use of additional antibiotic treatment were -0.17 (95% CI 0.20, -0.15), -0.11 (-0.15, -0.06), -0.02 (-0.04, 0.00) and -0.20 (-0.28, -0.11), respectively. The results were observed consistently across all classes of antibiotics assessed. There was no difference in the duration of postoperative catheterization or hospitalization. Adverse events were rare, generally mild, and included allergic reactions, pyrexia and abdominal complaints.

CONCLUSIONS

Prophylactic antibiotics decrease the incidence of post-TURP bacteriuria, high fever, bacteremia and additional antibiotic treatment. Additional research should evaluate the optimal antibiotic regimen, and whether the cost and possibility of the development of resistant strains of organisms justify the routine use of prophylactic antibiotics.

Current practice of antibiotic prophylaxis for catheter procedures

The practice of giving prophylactic antibiotics to patients at the time of urinary catheter insertion, change or removal is variable since guidelines for their use have yet to be established. The use of prophylactic antibiotics to prevent urinary catheter-related infections and the possibility of bacteraemia and septicaemia, despite a lack of evidence for their efficacy, is a matter of concern in light of the reported overuse of, and increased resistance to, antibiotics. This article describes an audit of, and increased resistance to, antibiotics. This article describes an audit conducted in one trust to establish the current practice of antibiotic prophylaxis for urinary catheter procedures. The audit confirmed that in 60% of the recorded catheter procedures, patients were given antibiotics, usually gentamicin. Variations in gentamicin prophylaxis were revealed, including differences in the timing of administration relative to the catheter procedure. This audit revealed that intramuscular gentamicin was given simultaneously with the procedure or after the procedure in a number of cases, suggesting that on these occasions "prophylaxis" was suboptimal.

Controversies in antibiotic prophylaxis in urology

Antibiotic prophylaxis in urologic surgery remains controversial. However, progress has been made and some of the controversies have been answered. Firstly, it is important to underline that urologic diagnostic and therapeutic procedures can induce surgical site infections (SSIs), bacteriuria, pyelonephritis and septicaemia in a substantial number of patients, too great to be neglected. Secondly, as patients are different and have various risk factors, a careful assessment of the patient and its individual risk is crucial. Thirdly, the same procedure may be totally different from one individual to another and they can rarely be grouped as standard procedures. A floating level of invasiveness is followed by a variation of the risk of infection. Fourthly, the pathogens and their susceptibility pattern vary extensively in Europe so that no clear-cut recommendations as for the choice of antibiotics can be given. Basic principles of antibiotic prophylaxis in terms of timing, mode of administration and length of regiment apply for urologic interventions. Thus, clean operations will usually not require antimicrobial prophylaxis except for those including the implant of a prosthetic device, while clean-contaminated will benefit from preventive antimicrobials. It is the task of the urologists to carefully assess each individual patient and procedure to opt for an optimal prophylaxis.

Perioperative antibiotic prophylaxis in urology

This report reviews recent studies on infectious complications and antibiotic prophylaxis in common urological instrumentation. As a result of variations in the definitions of infectious complications and inconsistencies in study design and risk factor analysis there is presently limited clear-cut evidence for giving definite standards regarding antibiotic prophylaxis for most urological interventions. The consequences are that patients may be exposed to unnecessary hazards and the healthcare system to additional costs. Nonetheless, most authors agree that patients should have sterile urine at urological instrumentation and that any other detected risk factor should be controlled. When antibiotic prophylaxis is considered, it should be timed properly before the intervention, which varies with the type of intervention and the choice of antibiotic, and should last for a limited period of time. In most common urological manipulations, correctly administered oral prophylaxis has been shown to be as effective as intravenous prophylaxis. A series of guidelines aimed at keeping the rates of healthcare-associated infections and the level of bacterial resistance as low as possible should, in combination with the rational use of antibiotics, be one of several marks of quality of a urological centre. To achieve this goal, new well-designed studies considering different regimens, risk factor analysis and economical analysis should be encouraged.

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 in surgery: summary of a Swedish-Norwegian Consensus Conference

This consensus document sets out proposals for antibiotic prophylaxis in abdominal, urological, gynaecological, orthopaedic, vascular and thoracic surgery. As far as possible the recommendations are based on prospective controlled trials. However, for some procedures, e.g. lung surgery and implantation of pacemakers, documentation is lacking but antibiotic prophylaxis is given traditionally. The choice of antibiotics is generally conservative, emphasizing that antibiotics used for therapy should be avoided in prophylactic regimens. Most recommendations are for the use of a first- or second-generation cephalosporin or an isoxazolyl penicillin, when necessary, combined with a nitroimidazole derivative (metronidazole or tinidazole). Suggestions are given for more frequent use of orally administered antibiotics, such as co-trimoxazole, doxycycline, metronidazole or tinidazole. Emphasis is put on short-term prophylaxis. In most cases surgical antibiotic prophylaxis should be given as a single dose and in no case should the prophylaxis time exceed 24 h.

Lomefloxacin prophylaxis in visual laser ablation of the prostate

OBJECTIVES

Visual laser ablation of the prostate (VLAP) is a relatively new option for relief of urinary outlet obstruction secondary to benign prostatic hyperplasia. There is currently no consensus regarding the optimum use of antibiotic prophylaxis in VLAP. This study was designed to evaluate two dosage regimens of a new difluoroquinolone, lomefloxacin, for prevention of postoperative bacteriuria following VLAP.

METHODS

Sixty men with benign prostatic hyperplasia who were scheduled for VLAP were enrolled in an open-label, randomized trial comparing groups receiving no antimicrobial prophylaxis (n = 20), a single preoperative oral dose of 400 mg lomefloxacin (n = 20), or a single preoperative oral dose of 400 mg lomefloxacin followed by 400 mg daily for 3 days (n = 20). The VLAP procedures were performed using 60 watts of energy from a neodymium:yttrium-aluminum-garnet (Nd:YAG) laser delivered via a Bard Urolase fiber or Laser Sonic fiber.

RESULTS

Ten of 20 patients (50%) in the no prophylaxis group developed bacteriuria (defined as growth of 10(4) or more colony-forming units/mL) during the 14 days following surgery, whereas 2 of 20 patients (10%) in the single-dose group and 1 of 20 in the multiple-dose group (5%) developed bacteriuria during the follow-up period. Both dosage regimens were well tolerated.

CONCLUSIONS

Lomefloxacin was successful in preventing postoperative bacteriuria in 90% (single dose) to 95% (multiple doses) of patients undergoing VLAP. There was no clinically significant difference between the two dosage regimens.

[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 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.

Antimicrobial prophylaxis for surgery

Infection of the surgical wound or deep structures violated during surgery account for a major portion of postoperative morbidity. The medical consultant should have an understanding of the principles of antimicrobial prophylaxis for postoperative infection in order to manage this complication in the postoperative period. This article assesses the risks for infection, patient preparation for surgery, and antibiotic usage in frequently performed surgeries.

Timing of antibiotic prophylaxis with cefotaxime for prostatic resection: better in the operative period or at urethral catheter removal?

There are two critical moments for the development of severe infectious complications following transurethral prostatectomy (TURP): the operative and immediate postoperative periods, and the day that the postoperative drainage catheter is removed. To optimize the timing of antibiotic prophylaxis with cefotaxime, two prospective randomized studies were conducted in patients with preoperatively sterile urine. In Study 1, all patients (n = 50) received cefotaxime 1 g intramuscular (i.m.) 1 hour preoperatively and were then randomized to receive either a second identical dose of cefotaxime 1 hour before catheter removal 24 hours later, or no further antibiotic treatment. In Study 2, patients (n = 89) were randomized to receive either cefotaxime 1 g i.m. 1 hour preoperatively or no preoperative antibiotic, after which all received cefotaxime 1 g i.m. 1 hour before catheter removal. Results were compared using identical evaluation criteria for infection in both studies: incidence of fever (temperature > 38 degrees C), bacteriuria (10(5) organisms/mL) and positive blood cultures, and duration of hospital stay (days). In Study 1, infection was significantly reduced with respect to all parameters in the group receiving two doses of cefotaxime, and total drug treatment costs were halved. In Study 2, the groups did not differ with respect to any parameter. We conclude that a single dose of cefotaxime 1 g i.m. 1 hour preoperatively provides inadequate cover for urethral catheter removal 24 hours later, and that prophylaxis with a single dose of cefotaxime 1 g i.m. 1 hour before catheter removal is just as effective as two doses given 1 hour preoperatively and 1 hour before catheter removal. Prophylactic coverage is essential during the action of removing the catheter and the time immediately following the operation. Long-term antibiotic coverage (24 hours or more) is not necessary. Thus, following TURP in patients with preoperatively sterile urine undergoing continuous bladder irrigation for 24 hours postoperatively, the optimal dose schedule for antibiotic prophylaxis with cefotaxime is a single 1-g dose given i.m. 1 hour before catheter removal.

Screening for bacteriuria in urological patients using reagent strips

A rapid and accurate ward-based method of diagnosing urinary infection would be of value in determining the prescription of antibiotics in pre-operative urological patients. This study describes the sensitivity and specificity of a screening technique based on commercially available reagent strips in the diagnosis of urinary infection. A total of 222 pre-operative samples and 83 post-operative samples was studied to compare the results of formal urine culture and reagent strips. Using a definition of a positive nitrite or a positive leucocyte esterase on the reagent strips as being suggestive of infection, it was found that the strips had a sensitivity of 91% and a specificity of 85% compared with formal culture in pre-operative samples. The results from post-operative samples were less satisfactory, the strips having a sensitivity of only 71% and specificity of 55%. The strips were insensitive but specific in the identification of pyuria in pre-operative specimens. These results suggest that reagent strips can be used as a ward-based method to identify men at risk of infection before urological procedures, and may allow selectivity in the use of peri-operative antibiotics.

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.

Antibacterial prophylaxis in urology: a review

The role of antibacterial prophylaxis in urology has been debated for more than 50 years. Even though controversy remains, an increasing number of physicians now support the use of prophylactic antibacterial agents in urologic surgery. This review attempts to place in perspective the value of prophylaxis for various urologic procedures in which infection is likely to occur. Prophylactic antibacterial therapy is recommended for urethral catheterization, endoscopy of the urinary tract, prostate biopsy, transurethral surgery, and selected open urologic procedures. Broad-spectrum cephalosporins and penicillins are used most often, while fluoroquinolones are being evaluated with increasing frequency.

Urinary tract infection prophylaxis in transurethral surgery: oral lomefloxacin versus parenteral cefuroxime

The purpose of this study was to compare the efficacy and safety of single-dose oral lomefloxacin and single-dose parenteral cefuroxime for the prevention of urinary tract infection following transurethral surgery. A total of 63 patients were enrolled in this prospective, randomized open-label study, which was conducted at two medical centers in France. Patients were randomized to receive either 400 mg of oral lomefloxacin 2-6 hours before surgery or 1.5 g parenteral cefuroxime 30-90 minutes before surgery. Postoperative clinical evaluation was performed daily, and bacteriologic evaluation included urine cultures performed 24 hours after surgery, just before and 1 day after removal of the indwelling catheter, and 3-5 days after surgery. Another urine culture was optionally performed 1-3 months after surgery. Infection was defined as a urinary bacteria count greater than or equal to 10(5) colony-forming units (CFU)/mL of urine. Of the 63 patients enrolled, 54 were evaluable for efficacy, 27 in each group. The success rate of prophylaxis was 88.9% in the lomefloxacin group and 88.5% in the cefuroxime group (p = nonsignificant). None of the 16 lomefloxacin-treated patients who were re-cultured at 1-3 months was found to be infected. Adverse events were minor in both groups. A single oral dose of lomefloxacin was as efficacious and as safe as a single intravenous dose of cefuroxime for prevention of postoperative urinary tract infection in patients undergoing transurethral surgery.

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.

Antimicrobial prophylaxis in transurethral resection of the prostate. With special reference to preoperatively sterile urine

The literature on antimicrobial prophylaxis in connection with transurethral resection of the prostate (TURP) is reviewed, and it is concluded that there is no proof of clinically significant beneficial effect of prophylaxis when the urine is sterile preoperatively. Prophylaxis is indicated when bacteriuria or an indwelling urethral catheter is present at the time of operation. Other possible risk factors, such as diabetes mellitus, neurogenic bladder dysfunction, immunosuppression, earlier coronary bypass operation and the presence of prosthetic devices, need further investigation.

Intraprostatic distribution of lomefloxacin following multiple-dose administration

The ability of lomefloxacin to penetrate and distribute within the human prostate was assessed in 20 patients undergoing elective prostate surgery (18 transurethral prostatic resections and 2 prostatectomies). Subjects were middle-aged to elderly (mean age +/- standard deviation, 69.8 +/- 8.2 years) with normal hepatic function and with creatinine clearances ranging from 35.8 to 141 ml/min/1.73 m2. Lomefloxacin was administered in 400-mg doses orally every 24 h. Its disposition was characterized following the third dose by obtaining multiple serum samples and intraoperative paired central zone and peripheral zone prostate tissue samples. Lomefloxacin concentrations were determined by a validated high-performance liquid chromatography method with fluorescence detection. Concentrations in serum during the perioperative period declined from 3.1 +/- 1.0 mg/liter (mean +/- standard deviation) at 1 h postdose to 2.3 +/- 0.7 mg/liter at 6 h postdose. The time of tissue extraction ranged from 0.1 to 7.1 h postdose. Intraoperative serum lomefloxacin concentrations ranged from 0.5 to 4.8 (median, 2.4) mg/liter, while prostate tissue concentrations ranged from 1.1 to 10.1 (median, 5.4) mg/kg of tissue for the central zone and 0.9 to 6.5 (median, 5.2) mg/kg for the peripheral zone. Intraindividual paired prostate concentrations (central zone versus peripheral zone) were not statistically different. The partition coefficient (ratio of concentration in prostate to concentration in serum) for the central zone was 2.2 +/- 0.6 (range, 1.2 to 3.1), and for the peripheral zone it was 2.1 +/- 0.7 (range, 1.2 to 4.2). Lomefloxacin exhibited good penetration into the human prostate with homogeneous intraprostatic distribution following multiple-dose administration.

Antibiotic compared with antiseptic prophylaxis for prostatic surgery

Two different regimens of cephalosporin antibiotic prophylaxis were compared with antiseptic lubricating jelly to try to prevent infection and complications in 196 men after prostatic surgery. Pre-operative urine was cultured and prostatic chips (170 cases) were also cultured to define the source of any infection. The use of antibiotics was associated with a reduced risk of postoperative bacteriuria. No serious complications occurred, although 1 patient in the antiseptic treated group developed rigors; 79 of 170 patients (46%) had positive prostatic chip cultures, of whom 74 had sterile pre-operative urine. There was no association between the result of chip culture and the presence of a pre-operative catheter. Culture positive patients had an increased risk of post-operative urine infection, although the same organism was found in the prostate and urine in only 36% of cases of post-operative bacteriuria and in 43 (54%) the organism cultured from the prostate was Staphylococcus albus. This study provides further evidence of the benefit of true prophylactic antibiotic therapy for transurethral prostatic surgery and the prostatic chip data suggest that some of the risk is due to pre-operative contamination of the prostate in the absence of per-operative urinary infection or catheterisation.

Extracorporeal shock wave lithotripsy of kidney stones does not induce transient bacteremia. A prospective study. The Copenhagen Extracorporeal Shock Wave Lithotripsy Study Group

During 58 extracorporeal shock wave lithotripsies 161 blood cultures were drawn to evaluate the incidence of bacteremia during the procedure. Only 3 blood cultures drawn during the procedure yielded bacteria, in all cases probably skin flora contaminants. Post-lithotripsy fever was noted in 29% of the patients, and could not be associated with transient bacteremia and was not influenced by antimicrobial prophylaxis. Patients with a positive urine culture after extracoporeal shock wave lithotripsy may have an increased risk of septicemia.

Study of appropriate antibiotic therapy in transurethral prostatectomy

Septicaemia is the commonest cause of morbidity and mortality following transurethral prostatectomy. Routine blind antibiotic prophylaxis is not always effective and there is a tendency to over-use potent new and expensive antimicrobials. Attempts to "sterilise" the urine preoperatively are also expensive and disruptive. However, appropriate treatment/prophylaxis can be administered economically using rapidly obtained laboratory results. We describe here a technique of routine direct antibiotic sensitivity testing (DST) of the patient's urine pre-operatively and before catheter removal. Such testing can be performed by junior medical staff in a ward side-room. An appropriate antibiotic may then be administered parenterally 1 h before surgery or catheter removal. A total of 102 consecutive patients underwent TURP and only 1 of those with infected urine became septicaemic. In this instance, an appropriate antibiotic had been incorrectly given orally before removal of the catheter. If the antibiotic sensitivities of a patient's urine are known, and an appropriate antibiotic is given parenterally 1 h pre-operatively or before catheter removal, the incidence of septicaemia following transurethral surgery may be significantly reduced.

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.