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

Antibiotic prophylaxis for transurethral urological surgeries: Systematic review

The use of antibiotic prophylaxis to prevent urinary tract infection and bacteremia (sepsis) following endoscopic urologic procedures is a controversial topic. Evidence in the literature revealed that urological instrumentation is associated with increased incidence of urinary tract infection and bacteremia. The aim of this review is to evaluate the effectiveness of antibiotic prophylaxis in reducing the risk of urinary tract infection in patients who had transurethral urological surgeries. We have selected all RCTs of adult population who underwent all different types of transurethral urological surgery, including cystoscopy, transurethral resection of prostate and transurethral resection of bladder tumor, and received prophylactic antibiotics or placebo/no treatment. At first, more than 3000 references were identified and reviewed; of which 42 studies with a total of 7496 patients were included in the final analysis. All those trials were analyzing antibiotic prophylaxis versus placebo/no treatment, and they were significantly favoring antibiotic use in reducing all outcomes, including bacteriuria (RR 0.36, 95% CI 0.29 to 0.46, P < 0.0001) with moderate heterogeneity detected (I² 48%), symptomatic UTI (RR 0.38, 95% CI 0.28 to 0.51, P < 0.0001) with no significant heterogeneity was detected (I²= 17%), bacteremia (RR 0.43, 95% CI 0.23 to 0.82, P < 0.0001) with no noted heterogeneity (I² = 0%), and fever ≥38.5 Celsius (RR 0.41, 95% CI 0.23 to 0.73, P = 0.003); also, there was no noted heterogeneity (I² = 0%). However, using antibiotic prophylaxis did not reduce the incidence of low grade temperature (RR 0.82, 95% CI 0.61 to 1.11, P = 0.20) or in moderate grade temperature (RR 1.03, 95% CI 0.71 to 1.48, P = 0.89). Antibiotic prophylaxis appears to be an effective intervention in preventing urinary tract infections and its sequels following transurethral urological surgeries in patients with preoperative sterile urine.

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.

[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.

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.

Enoxacin: a reappraisal of its clinical efficacy in the treatment of genitourinary tract infections

Enoxacin is a 6-fluoronaphthyridinone antibacterial agent with good in vitro activity against Neisseria gonorrhoeae and most Gram-negative urinary tract pathogens. It is less active in vitro against Acinetobacter spp., Pseudomonas aeruginosa, and most Gram-positive bacteria, than against Gram-negative organisms. Enoxacin is rapidly absorbed, with a high oral bioavailability (87 to 91%). Of the absorbed dose, 44 to 56% is excreted unchanged in the urine, with peak urinary concentrations (>500 mg/L within 4 hours) remaining high (>100 mg/L) for up to 24 hours, sufficient to inhibit most urinary tract pathogens. Single (400 mg) and multiple oral dose regimens (100 to 600 mg twice or 3 times daily for 5 to 14 days) of enoxacin are as effective for the treatment of patients with complicated or uncomplicated urinary tract infections as other antibacterial agents such as amoxicillin, cefuroxime axetil, cotrimoxazole (trimethoprim-sulfamethoxazole) or trimethoprim. Noncomparative data suggest that enoxacin is also an effective agent for the treatment of prostatitis. Single 400 mgoral doses of enoxacin produce >/- 95% bacteriological cure rates in gonococcal infections, comparable to those produced by single intramuscular doses of ceftriaxone 250 mg. Perioperative doses of oral enoxacin 200 mg provide effective prophylaxis against postoperative bacteriuria after transurethral resection of the prostate. Concomitant administration of enoxacin with a number of commonly used therapeutic agents (e.g. antacids, methylxanthines, warfarin) affects the pharmacokinetic properties of either enoxacin or the coadministered agents. Enoxacin is reasonably well tolerated, with the incidence of adverse experiences ranging from 0 to 24%. Adverse events are mainly gastrointestinal, neurological or dermatological and resolve with minimal intervention. Overall, although enoxacin exhibits a number of clinical characteristics that are similar to those of other agents for the treatment of genitourinary tract infections, the advantages offered by this agent generally do not outweigh those of alternative fluoroquinolone agents. Thus, it is likely to prove to be yet another addition to the list of agents available for the management of these infections.

Comparison of single-dose antibiotic prophylaxis in uncomplicated transurethral resection of the prostate

We evaluated the necessity for antibiotic prophylaxis in uncomplicated transurethral resection of the prostate. A total of 107 patients was entered into a double-blind, prospective, placebo-controlled, randomized trial. Only 7 patients were excluded because they had positive preoperative urine cultures. All patients received a single dose of either 1 gm. cefonicid or saline placebo intramuscularly before surgery. No further antibiotics were administered. Urine cultures were obtained intraoperatively, daily while hospitalized, and at 2 and 4 weeks postoperatively. A growth of 10(4) organisms constituted a positive urine culture. Postoperative infection rates were statistically significant with 12% (6 of 51) in the cefonicid group and 37% (18 of 49) in the placebo group (p = 0.003). During the initial 2 days postoperatively there were no infections in the cefonicid treated patients as opposed to 8 in the placebo group (p = 0.003). Our study demonstrated the need for antibiotic prophylaxis to prevent infection after uncomplicated transurethral resection of the prostate. This can be accomplished by using a single dose, broad-spectrum cephalosporin (cefonicid). This procedure simplifies the implementation and decreases the cost of prophylaxis for transurethral resection of the prostate.

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.

Prevention of urinary tract infection and bacteremia following transurethral surgery: oral lomefloxacin compared to parenteral cefotaxime

A multicenter, randomized, open label study compared the safety and efficacy of a single dose of oral lomefloxacin, a broad-spectrum antimicrobial agent of the quinolone class, to a single parenteral dose of cefotaxime, a third generation cephalosporin, for prophylaxis in transurethral surgery. Of the 230 patients initially recruited 182 were considered evaluable: 92 in the lomefloxacin group and 90 in the cefotaxime group. Both study groups were well balanced with respect to demographics and transurethral procedures. Efficacy and safety were evaluated with urine cultures, clinical laboratory evaluations and monitoring of adverse events. The success rate among the lomefloxacin patients was 98% versus 94% in the cefotaxime patients. The difference was not statistically significant. Adverse events, regardless of attributability, were reported by 16% of the lomefloxacin patients and 17% of the cefotaxime patients, respectively. Our results indicate efficacy and safety profiles of lomefloxacin equivalent to cefotaxime. Lomefloxacin has the economic advantage of an oral route of administration compared to the parenteral route of cefotaxime for prophylaxis in transurethral genitourinary procedures.

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.

[Enoxacin concentration in seminal fluid, in prostate secretions and in prostatic adenoma tissue following oral administration or intravenous infusion]

In eleven volunteers and 39 patients undergoing transurethral resection of the prostate or bladder tumor, concentrations of enoxacin were measured in seminal fluid (volunteers), in prostatic fluid (volunteers, patients) and in prostatic adenoma tissue (patients) after oral (400 mg) administration and intravenous (428 mg) infusion (60 min) of enoxacin. Simultaneously 2.534 g of iothalamic acid was i.v. injected to identify possible urinary contamination. The concentrations of enoxacin in seminal fluid after 2-4 h and in prostatic tissue after about 1-4 h and 14-16 h exceeded plasma concentrations more than two-fold. The concentrations in prostatic fluid after 1-4 h were about half the plasma concentrations. Venous blood samples were taken after intravenous infusion at intervals of up to 24 h in a total of 14 patients. The mean plasma concentration of enoxacin decreased from its maximum of 6.9 mg/l at the end of infusion to 0.5 mg/l at 12 h after administration. A terminal half life of 6.65 h was calculated according to an open two-compartment model.