Short-term prophylaxis with cefotaxime for prostatic surgery

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.

The management of acute urinary retention in France: a cross-sectional survey in 2618 men with benign prostatic hyperplasia

OBJECTIVE

To evaluate current practice in the management of acute urinary retention (AUR) in men with benign prostatic hyperplasia (BPH) in France.

PATIENTS AND METHODS

In all, 2618 men (median age 72 years) presenting with non-febrile AUR were enrolled by 658 French urologists in a prospective cross-sectional survey. The patients' demography, history of BPH, type of AUR and its management (trial without catheter, TWOC, use of alpha(1)-blockers, immediate or elective surgery, other alternatives) were collected.

RESULTS

Of the 2618 men analysed, 1875 (71.6%) had spontaneous AUR (sAUR) and 743 (28.4%) had precipitated AUR (pAUR), mainly after surgery with locoregional or general anaesthesia. BPH was revealed by AUR in 52.3% of men with pAUR and 25.9% of men with sAUR. A urethral catheter was inserted in most cases (82.7%) while only 16.7% had a suprapubic catheter. After initial catheterization, 72.8% of men had a TWOC (pAUR 89.4%, sAUR 66.2%, P < 0.001) after a median of 3 days of catheterization, 17.9% had elective surgery after a median of 8 days of catheterization (pAUR 7.1%, sAUR 22.1%, P < 0.001), 5.7% had immediate surgery after a median of 4 days of catheterization (pAUR 1.1%, sAUR 7.5%, P < 0.001), 0.4% had a urethral stent inserted and 1.1% had an indwelling catheter. Of the 1906 men who had a TWOC, 79% received an alpha(1)-blocker (mainly alfuzosin) before catheter removal. The TWOC was successful in 50.2% of men (pAUR 52.3%, sAUR, 49.0%, P = 0.17) and the success rate was significantly higher in men receiving an alpha(1)-blocker (53.0% vs 39.6%, P < 0.001) before the TWOC. If the TWOC failed, 33.4% had a second TWOC (pAUR 39.9%, sAUR 30.2%, P = 0.003) after a median of 7 days re-catheterization, 57.5% had elective surgery (pAUR 49.1%, sAUR, 61.7%, P < 0.001) after a median of 8 days re-catheterization, 1.5% had a stent inserted and 1.1% had an indwelling catheter. The overall success rate of a second TWOC was 25.9% (pAUR 32.2%, sAUR 21.9%, P = 0.04). Men catheterized for >3 days had a slightly lower success rate for TWOC, greater comorbidity and double the rate of prolonged hospitalization due to adverse events than those catheterized for < or = 3 days.

CONCLUSIONS

TWOC after a median of 3 days of catheterization has become standard practice in France for men with BPH and AUR. alpha(1)-blockade before a TWOC significantly increases the chance of a successful TWOC. If the TWOC fails, only a quarter of men will have a successful second TWOC. All efforts should be made to reduce the duration of catheterization, to reduce the comorbidity.

Alfuzosin once daily facilitates return to voiding in patients in acute urinary retention

PURPOSE

We confirmed the beneficial effect of the alpha1-blocker alfuzosin for the acute management of acute urinary retention (AUR) related to benign prostate hyperplasia (BPH), and further identified factors influencing the success of a trial without catheter (TWOC).

MATERIALS AND METHODS

A total of 360 patients presenting with a first episode of spontaneous AUR related to BPH underwent emergency catheterization and were then randomly and blindly assigned to receive 10 mg alfuzosin once daily or placebo at a ratio of 2:1 for 3 days. The primary efficacy criterion of this large study was the rate of successful TWOC within 24 hours after catheter removal. The influence of factors such as age, urine retention volume, fluid consumption, constipation and urinary tract infection on TWOC outcome was also assessed.

RESULTS

Successful TWOC was recorded in 61.9% of the 236 patients treated with alfuzosin vs 47.9% of the 121 receiving placebo (p = 0.012). Elderly patients (65 years or older) and patients with a drained volume of 1000 ml or greater had significantly greater chances of TWOC failure (success vs failure OR 0.309, 95% CI 1.182 to 0.514 and OR 0.361, 95% CI 0.225 to 0.571, respectively). Nevertheless, even in the presence of these 2 factors 10 mg alfuzosin once daily almost doubled the likelihood of successful TWOC (OR 1.98, 95% CI 1,226 to 3,217). Alfuzosin (10 mg) once daily was well tolerated.

CONCLUSIONS

Alfuzosin (10 mg) once daily significantly improved the rate of successful TWOC in patients with AUR related to BPH, even in elderly patients and those with a large drained volume who were at increased risk for TWOC failure. This should contribute to decrease the morbidity and mortality associated with emergency surgery and avoid the discomfort and potential morbidity associated with an in situ catheter.

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.

Prospective evaluation of antibiotic prophylaxis prior to cystometrogram and/or cystogram studies: oral versus intramuscular routes

OBJECTIVE

To compare empiric single-dose gentamicin versus culture-specific oral antibiotics as prophylaxis before cystometrogram and/or cystogram. Comparisons with regards to infection, patient preference, and cost were made.

DESIGN

Prospective randomized control trial.

SETTING

Inpatient and outpatient rehabilitation hospital.

PATIENTS

Seventy received oral antibiotics and 72 received intramuscular gentamicin.

INTERVENTION

Cystometrograms and/or cystograms were performed.

MAIN OUTCOME MEASURE

Patient interviewed and chart reviewed for infection. Convenience and comfort were rated by patient.

RESULTS

Oral antibiotics and gentamicin have similar efficacy. Patients rated the gentamicin more convenient (p < .001) and comfortable (p < .01) than oral antibiotics. Gentamicin is less expensive.

CONCLUSION

Gentamicin should be used as the method of choice for cystometrogram/cystogram prophylaxis.

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.

[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.

Randomized controlled study of chemoprophylaxis in transurethral prostatectomy

We studied 599 evaluable patients with benign prostatic hypertrophy at 7 urological units. Before transurethral prostatectomy the patients were randomized into 3 groups: group 1--197 patients given single-dose ceftriaxone (2 gm.), group 2--203 patients given 160/800 mg. trimethoprimsulfamethoxazole and group 3--199 controls given no antimicrobial prophylaxis. Patients with a preoperative indwelling catheter, positive urine culture, signs of active infection or preoperative antibiotic treatment were excluded. Postoperative infectious complications were demonstrated in 15 of 197 (7.6%), 25 of 203 (12.3%) and 43 of 199 (21.6%) patients in the study groups, respectively. The difference in infectious complications between groups 1 and 3 was statistically highly significant (p < 0.01) and between groups 2 and 3 it was significant (p < 0.05). Single-dose antibiotic prophylaxis proved to be useful in the prevention of serious infectious complications after transurethral prostatectomy.

Cefotaxime is extensively used for surgical prophylaxis

Cefotaxime, a broad-spectrum third-generation cephalosporin, has been extensively used worldwide for chemotherapy of serious infections. Based on the characteristics of its antimicrobial spectrum, low incidence of allergy, and lack of adverse effects, cefotaxime has been used successfully for prophylaxis of a number of different surgical procedures. Extensive data have been accumulated for single-dose or short-course cefotaxime prophylaxis regimens. These cefotaxime regimens have been demonstrated to be very effective and inexpensive. For this article, over 11,500 published cefotaxime prophylaxis cases are reviewed (10,500 control cases) and 98 references are cited. Single-dose cefotaxime was clearly indicated for hysterectomies, cesarean sections, upper gastrointestinal cases, bone and joint operations, biliary tract procedures, transurethral resections, open urologic surgeries, and some vascular procedures. Short-course (3-4 doses) may be required for colorectal resections, cardiac surgeries, head and neck surgeries, organ transplants, specific pediatric surgical cases, and for some patients with compromised immune function, regardless of origin. Cefotaxime has reduced wound morbidity of contaminated abdominal operations to < 10%. This change from multiple-dose regimens to the single-dose or short-course regimens, enabled by cefotaxime use, decreases the risk of inducing or selecting bacterial resistance; the change would generate a significant reduction in hospital costs. Surgeons should not hesitate to employ cefotaxime and other third-generation cephalosporins with proven limited-dose indications to greatly benefit their patients and the hospital environment.

A multicenter comparison of oral lomefloxacin versus parenteral cefotaxime as prophylactic agents in transurethral surgery

This report presents the pooled results from two randomized trials of lomefloxacin and cefotaxime used as prophylaxis in patients undergoing transurethral surgical procedures. A total of 499 patients were enrolled at seven centers in the United States. Patients received either 400 mg of lomefloxacin orally 2-6 hours prior to surgery, or 1 g of cefotaxime intravenously or intramuscularly 30-90 minutes preoperatively. Patients undergoing simple cystoscopy or retrograde pyelograms were not eligible for inclusion. Urine cultures were obtained prior to surgery, 24 hours post-surgery, prior to catheter removal, and 3-5 days post operatively. Treatment failure was defined as isolation of greater than or equal to 10(5) colony-forming units (CFU)/mL of pathogenic bacteria from any post-surgical urine culture. Lomefloxacin was successful in preventing post operative infections in 204 of 207 evaluable patients (98.6%); there were three prophylactic failures. Cefotaxime was successful in 196 of 206 (95.1%) evaluable patients; 10 were prophylactic failures. Lomefloxacin concentrations were measured simultaneously in serum and in samples of prostate tissue from 29 patients undergoing transurethral resection of the prostate. Lomefloxacin prostate concentrations were 1.0-22.3 micrograms/g, with a mean of 5.0 micrograms/g. The average tissue:plasma ratio was 2.0. The safety profile of the two study drugs was excellent, and both were well tolerated. Adverse events were reported by 12.7% of the patients treated with lomefloxacin and 13.8% of those treated with cefotaxime. The majority of events were mild and required no treatment.

Norfloxacin prophylaxis for endoscopic urological surgery

A series of 140 patients, undergoing various types of urological endoscopic procedures, was divided into 2 equal, parallel, randomised groups. The first group of 70 patients, undergoing lower urinary tract surgery, was randomised, half to receive norfloxacin prophylaxis and half no antibiotic cover; the other 70 patients, undergoing percutaneous renal surgery, were randomised, half to receive norfloxacin and half cefuroxime. It was found that 26% of patients not receiving antibiotic prophylaxis and 11% on cefuroxime prophylaxis developed post-operative bacteriuria, with a high incidence of urinary tract infection (UTI). Only 1 patient of 70 on norfloxacin prophylaxis developed post-operative bacteriuria, which quickly responded to prolongation of norfloxacin therapy. Prior to surgery, 10% of all patients were found to have previously undetected bacteriuria. This group was at high risk of developing post-operative infection. Norfloxacin effectively prevented post-operative bacteriuria and urinary tract infection in these patients. This study suggests that norfloxacin is a safe and effective prophylactic antibiotic in all forms of urological endoscopic procedures.

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.

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.

Review of cefotaxime sodium for surgical prophylaxis. A model for the evolution toward single-dose or short-course cost-effective regimens

Cefotaxime is a parenteral broad-spectrum cephalosporin, used extensively worldwide for chemotherapy of serious infections. Since its release in 1979, cefotaxime has also been studied to minimize surgery-related infections and, more than any other new compound, has been used in a volume of evaluable cases. Because of the current cost-containment medical practice environment, most cefotaxime prophylaxis studies have established single-dose or short-course regimens. Over 9000 published cefotaxime prophylaxis cases were reviewed, and 81 references were cited. Single-dose cefotaxime was clearly indicated for a wide variety of operations, including hysterectomy, cesarean sections, bone and joint procedures, upper gastrointestinal cases, biliary tract procedures, transurethral resections, open urologic procedures, and some vascular cases. Approximately 24 hr of prophylaxis (cefotaxime X 4 doses) may be required for colorectal resections, cardiac surgery, head and neck surgery, transplants, and some pediatric surgical cases. Although contaminated abdominal cases and trauma surgery were not a true prophylaxis use, cefotaxime regimens have reduced wound morbidity to less than or equal to 10%. Changing to one- to four-dose schedules will have very favorable clinical impact by reducing prophylaxis cost, pharmacy preparation time, adverse reactions, and antimicrobic-resistance pressures. Surgeons should not hesitate to employ new cephalosporins (cefotaxime and others) with proved limited dose indications that would greatly benefit their patients and the hospital environment.

Prophylactic chemotherapy with fosfomycin trometamol versus placebo during transurethral prostatic resection

A prospective randomized controlled double-blind study was performed on 61 patients undergoing transurethral resection of the prostate. The first group of 31 patients received 3 g fosfomycin trometamol p.o. each on the evening before and after the operation; the second group of 30 patients received a placebo. Urine samples were taken by catheter puncture 24 and 48 h postoperative. After removal of the catheter (day 5) the first midstream urine was collected for culture, and from that moment on all patients were treated with a nitrofurantoin derivative for two weeks. Although the same strict antiseptic measures were standard practice for both groups, the incidence of early postoperative urinary tract infections was significantly lower for the fosfomycin trometamol group (0/31 versus 6/30 in placebo recipients). None of the patients suffered from a major symptomatic or complicated infection. There were no side effects registered.

Prophylactic chemotherapy with fosfomycin trometamol during transurethral surgery and urological manoeuvres. Results of a multicentre study

The aim of the present open prospective study is to evaluate the efficacy and safety profile of fosfomycin trometamol in the chemoprophylaxis of urinary tract infections following transurethral diagnostic and/or therapeutic manoeuvres. 712 patients were enrolled in 72 urological surgical centres. All the enrolled patients received an initial dose of fosfomycin trometamol (Monuril sachet containing 3 g of active drug in powder) 3 h before and a second dose 24 h after the transurethral manoeuvres. Clinical and microbiological examinations were carried out before the intervention, and then on the second and seventh days after the manoeuvres. 94 patients with positive baseline tests were excluded from the microbiological follow-up for non-compliance with the main inclusion criteria. Out of 618 patients with sterile urine or with bacteriuria less than 10(5) ml on baseline screening, 20 (3.2%) developed UTI on the second day and 22 (3.6%) on the seventh day after treatment. Clinical follow-up is in agreement with these microbiological data. Overall, a total of 24 side effects were observed (3.3%), 16 of which were associated with Monuril treatment. The results of this open study agree with the preliminary observations in the controlled studies.

Biofilms, bacteria and bladder catheters. A clinical study

Biofilms were present on 16 of 33 urethral catheters examined. In 11 cases the catheter carried a different microbial flora from that of the bladder urine. The length of time the catheter was in situ did not influence biofilm formation, and all types of materials tested supported biofilm growth. Biofilms were seen on 2 of the 7 catheters where prophylactic antibiotics had been used.

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.

Single dose, oral antibiotic cover for transurethral prostatectomy

A double-blind, randomised, placebo-controlled study was carried out to determine the incidence and significance of bacteriuria in 110 patients undergoing transurethral resection of the prostate (TURP) and to assess the effect of a single pre-operative dose of Ciprofloxacin, a 4-quinolone antibiotic. Fifteen (68%) of the 22 patients in the placebo group with a positive post-operative urine culture subsequently developed a clinically apparent urinary tract infection (UTI) or received antibiotics in view of a positive urine culture. Adequate prostatic concentrations of Ciprofloxacin were achieved in all who received the drug. A significant reduction in the number of positive post-operative urine cultures and urinary tract infections requiring antibiotic therapy was achieved in this group. Six patients (5.5%) developed clinical evidence of septicaemia, 5 of whom were in the placebo group. No organisms resistant to Ciprofloxacin were encountered. Prior to surgery, 19% of all patients were found to have previously unsuspected bacteriuria. Ciprofloxacin tended to reduce the chances of this group developing a UTI or requiring antibiotics. Further, there was a highly significant reduction in post-operative infective complications in those with sterile urine at the time of resection who had received the drug. This study suggests that antibiotic cover for TURP is of clinical benefit. Ciprofloxacin may prove suited to this purpose, although further experience with the drug is still required.

A double-blind comparative trial of short-term orally administered enoxacin in the prevention of urinary infection after elective transurethral prostatectomy: a clinical and pharmacokinetic study

A double-blind randomized comparative study was done to investigate the efficacy of enoxacin in the prevention of urinary infection after elective transurethral prostatectomy, as well as its ability to penetrate the prostate. A total of 40 patients received 200 mg. enoxacin and 40 received a placebo, given orally the night before the operation, 2 to 4 hours preoperatively and every 12 hours postoperatively for 36 hours. Urine samples for bacterial culture were obtained within 1 week preoperatively, at operation and at 48 hours, 5 days, and 2 and 6 weeks postoperatively. Samples of the serum and prostate were taken at operation and assayed for enoxacin levels. Of the placebo patients 15 had a urinary infection postoperatively (38 per cent) compared to 3 enoxacin patients (8 per cent) (p less than 0.01). Enoxacin penetrated well into prostatic tissue; the mean levels in tissue and serum were 3.1 +/- 1.8 mg. per kg. (standard deviation) and 1.26 +/- 0.48 mg. per l., respectively, with a mean tissue-to-serum ratio of 2.53 +/- 1.8.

Relative value of antibiotics and catheter care in the prevention of urinary tract infection after transurethral prostatic resection

One hundred patients were prospectively randomised into two groups to receive either a single dose of 1 g ampicillin and 80 mg gentamicin pre-operatively or no antibiotic prophylaxis. The incidence of breakage in the continuity of the closed drainage system was documented. All patients with urinary tract infection (UTI), catheterisation, clinical prostatic carcinoma, neurogenic bladder and bladder tumours were excluded. UTIs, bacteraemia and fever were noted. There were 7 late exclusions. The incidence of UTI in the control and antibiotic groups was 16 and 17% respectively. No blood cultures were positive. There were no significant differences in the incidence of fever between the two groups. A break in the closed drainage system occurred in 13 patients. Fifteen of the 93 developed UTI. A break in the closed drainage system occurred in 7 of the 15 patients (40%) with UTI. Of the 78 patients without UTI, 8 had a break (10%). This difference was highly significant. We recommend that less emphasis be placed on prophylactic antibiotics and more on avoiding breakage of the closed system in the prevention of UTI after transurethral resection of the prostate (TURP) in the low risk situation.

Short-term cephradine prophylaxis in elective transurethral prostatectomy

A prospective randomized trial was conducted to assess the value of short-term antibiotic prophylaxis in elective transurethral resection of the prostate. Two hundred patients were randomized to receive 1.5g cephradine intramuscularly preoperatively and 1g cephradine orally before removal of the urethral catheter or to receive no antibiotic prophylaxis. Fifty-eight patients were excluded because of occult neoplasm or protocol violation. There was no difference in time to removal of catheter, incidence of pyrexial episodes, length of hospital stay or minor complication rate between the two groups. We conclude that a short-term antibiotic regime is of no value in the elective patient with sterile urine.

Double-blind study comparing aztreonam with placebo for prophylaxis of infection following prostatic surgery

In a prospective, randomised, double-blind study, 179 patients undergoing retropubic or transurethral prostatectomy were given pre-operatively either 1 g aztreonam or a placebo. In patients treated with aztreonam there was a significant reduction in the number with post-operative bacteriuria and in the number requiring treatment of post-operative bacteriuria. Other differences were not significant. The mean duration of post-operative hospital stay for patients receiving aztreonam was 7.1 days compared with 6.9 days for those receiving placebo. In patients treated with aztreonam there was no increase in the frequency of infections due to Gram-positive bacterial species.

Oral ciprofloxacin as prophylaxis for optical urethrotomy

It is known that urethral strictures predispose to bacteriuria. We studied a series of patients undergoing optical urethrotomy to see if antibiotic prophylaxis was justified. Twenty-three patients were randomised to receive either no prophylaxis or a short peri-operative course of oral ciprofloxacin. Two patients with sterile pre-operative urine and two patients with pre-operative bacteriuria given no prophylaxis had post-operative bacteriuria, whereas all patients given ciprofloxacin had sterile urine after operation. Antibiotic prophylaxis may be indicated in patients undergoing optical urethrotomy.

Oral ciprofloxacin as prophylaxis in transurethral resection of the prostate

A new quinolone antibacterial, ciprofloxacin, was evaluated as oral prophylaxis for transurethral resection of the prostate in a randomised controlled trial. A 3-day course of perioperative ciprofloxacin 250 mg twice daily reduced the post-operative infection rate, the post-operative hospital stay and the frequency of infective complications. Ciprofloxacin was well tolerated and no significant haematological or biochemical side effects were detected.

Bacteremia in connection with transurethral resection of the prostate

A bacteriological survey of 50 consecutive patients undergoing transurethral resection of the prostate was performed. Preoperatively, 28% of the patients had asymptomatic bacteriuria. In the postoperative period, 46% of all the patients developed transient bacteremia. A significantly higher rate of bacteremia was found in patients with hypertrophy of the prostate than in those with cancer of the prostate and in patients undergoing long-lasting surgical intervention. Patients who developed bacteremia due to pathogenic bacteria were hospitalized for a significantly longer period of time.

Antibiotic prophylaxis for prostatic surgery. Single-dose cephradine compared with single-dose cefotaxime

Several previous studies have attested to the value of antibiotic prophylaxis for prostatic surgery. We report a prospective randomised study which compared a single dose of cefotaxime with a single dose of cephradine given with the induction of anaesthesia. There was little difference between these regimens and it was concluded that either may be used, depending on availability and cost of the antibiotic. We have now completed a 5-year study of antibiotic prophylaxis for prostatic surgery and we also report the results of a long-term survey of the ward flora. There has been no significant change and there is no evidence for the emergence of resistant strains.

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

The efficacy of a short (Group I) and a prolonged (Group II) course with ciprofloxacin was assessed in patients undergoing transurethral prostatic resection for benign hyperplasia or cancer of the prostate and compared with that of controls without antibiotic (Group III). Both regiments significantly reduced the frequency of postoperative bacteriuria (p less than 0.01) and of severe infectious complications (p = 0.004) as compared to the controls. Both regimens were equally effective in preventing perioperative and postoperative acquisition of bacteriuria in patients without bacteriuria at surgery. In patients with bacteriuria before surgery, bacteriuria was found postoperatively in 35% in Group I and 10% in Group II (p = 0.012), but in 82% of the patients in Group III. Ciprofloxacin inhibited all but 7 of 176 bacterial strains at an MIC of less than or equal to 1 microgram/ml. Given orally ciprofloxacin is a valuable alternative antimicrobial for use in conjunction with transurethral prostatic resection. A short course is sufficient for prophylaxis, and adequate therapy is achieved with a prolonged regimen.

The effectiveness of a short perioperative course with pivampicillin/pivmecillinam in transurethral prostatic resection: clinical results

In a randomized control study comprising 261 patients undergoing transurethral prostatic resection (TUR), the effect of a short perioperative course with the oral combination of pivampicillin/pivmecillinam (PAPM) was analysed in 129 patients. The study was divided in 2 parts: the first 60 patients received 450 mg and the following 69 patients, 900 mg every 12 h until removal of catheter but not longer than for 1 week. 132 controls received parenterally 1 g of cefotaxime (CFT) daily throughout the study. During the first part of the study the frequency of bacteriuria in the PAPM group was 43% preoperatively and 30% 10 days postoperatively, during the second part 47% and 12%, respectively (p less than 0.025). In the CFT group the frequency of bacteriuria was reduced from 52% preoperatively to 28% postoperatively. The prophylactic effect (i.e. the protection against acquired bacteriuria) was 96% and 92% in the PAPM and the CFT groups, respectively. Preoperative bacteriuria was eliminated in 40% of the patients during first part and 69% during second part in the PAPM group, while corresponding figures were 48% and 46% in the cefotaxime group. There were 2 cases of septicemia and 5 of upper urinary tract infections throughout the study evenly distributed between the two groups. Oral pivampicillin/pivmecillinam 900 mg every 12 h was found to be a good alternative for perioperative antibiotic prophylaxis at TUR.

Short-term prophylactic antibiotics in patients undergoing prostatectomy: report of a double-blind randomized trial with 2 intravenous doses of cefotaxime

The effect of short-term antibiotic prophylaxis on postoperative infection with 2 injections of cefotaxime begun preoperatively was evaluated in a double-blind, randomized, placebo-controlled trial at 1 center on 181 patients with preoperative sterile urine undergoing transurethral resection (90) or open prostatectomy (91). Antibiotic prophylaxis reduced the number of urinary infections significantly in both groups without altering the level of resistant pathogens. Cefotaxime lowered the incidence of postoperative infection in the early postoperative period from 30 to 4 per cent in the transurethral resection group and from 46 to 4.5 per cent in the open prostatectomy group. A significant difference was found between the 2 treatment groups in the incidence of perioperative bacteremia and postoperative fever. Among the patients undergoing an open prostatectomy a reduced rate of wound infection and a shorter duration of hospital stay were witnessed in the treated group. Thus, short-term chemoprophylaxis by cefotaxime is of benefit in reducing morbidity and hospital cost for prostatectomy by either procedure.

Long-term follow-up after transurethral prostatic resection with or without a short peri-operative antibiotic course

This study was undertaken to analyse the results in 192 patients who 3 to 4 years earlier had undergone transurethral resection (TUR) in a controlled clinical trial on the value of a short peri-operative course of antibiotics. The survival rate was comparable in both groups. Most deaths were due to cardiovascular disease and/or cancer of the prostate and the gastrointestinal tract. Infectious events predominated in the control group and more antibiotics were prescribed for these patients during follow-up than for the patients in the peri-operative antibiotic group. Bacteriuria was found in 24% of patients, evenly distributed between the groups. Eighty-three per cent were satisfied with the results of prostatectomy but 38% complained of symptoms from the lower urinary tract. The maximum urinary flow rate was not influenced by the presence of bacteriuria and/or symptoms. There was no difference between the groups regarding mortality or morbidity except for the frequency of post-operative urethral stricture formation, which was significantly higher in the controls. It was concluded that prospective long-term follow-up is indicated to assess the effect of short peri-operative antibiotic courses.