Essential Japanese guidelines for the prevention of perioperative infections in the urological field: 2015 edition

Real-world short-term outcomes of prostate urethral lift in Japan: A prospective cohort study

OBJECTIVES

We report the first prospective trial of prostatic urethral lift for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia in Japan.

METHODS

This prospective study was conducted at a single institution and included patients with benign prostatic hyperplasia who underwent prostatic urethral lift based on the Japanese surgical indication. The primary efficacy endpoint was reduced international prostatic symptoms score in the early postoperative period after prostatic urethral lift. To assess efficacy, international prostatic symptoms score, quality of life, sexual health inventory for men, and uroflowmetry were evaluated 2 weeks before, 2 weeks after, and 6 weeks after surgery.

RESULTS

We enrolled 120 elderly men. The patients experienced significantly reduced international prostatic symptoms scores from 15 at the baseline to 13 at 2 weeks, and to 10 at 6 weeks, respectively. The peak flow rates did not change significantly at any time point. Three patients had serious adverse events of grade 3a in the Clavien-Dindo classification. Four patients were evaluated for sexual function, and none had ejaculatory dysfunction.

CONCLUSION

In the Japanese population, prostatic urethral lift is reliably performed under local anesthesia and rapidly improves symptoms.

Lower bleeding volume contributes to decreasing surgical site infection in radical cystectomy: A propensity score-matched comparison of open versus robot-assisted radical cystectomy

OBJECTIVES

To compare the incidence of surgical site infections (SSI) between robot-assisted and open radical cystectomies and investigate the risk factors for SSI after radical cystectomies.

METHODS

Consecutive patients who underwent radical cystectomy between July 2008 and December 2022 were retrospectively reviewed. The prevalence and characteristics of SSI after open and robot-assisted radical cystectomies were compared, and the risk factors for SSI were investigated using propensity score matching.

RESULTS

This study enrolled 231 patients (open: 145, robot-assisted: 86). In the robot-assisted group, urinary diversion was performed using an intracorporeal approach. SSI occurred in 34 (open: 28, robot-assisted: 6) patients, and the incidence was significantly lower in the robot-assisted group (19.3% vs. 7.0%, p = 0.007). After propensity score matching cohort (open: 34, robot-assisted: 34), increased bleeding volume, blood transfusion, and delayed postoperative oral feeding were significantly associated with SSI. Only increased bleeding volume remained a significant risk factor in the multivariate regression analysis (odds ratio, 1.13 [per 100 mL increase]; 95% confidence interval: 1.02-1.25; p = 0.001). The cutoff bleeding volume for predicting SSI was 1630 mL with an area under the receiver operating characteristic curve, sensitivity, and specificity of 0.773, 0.73, and 0.75, respectively.

CONCLUSIONS

The incidence of SSI after robot-assisted radical cystectomy was significantly lower than that after the open procedure. However, decreased bleeding volume, which was significantly associated with robot-assisted procedures, was an independent and more significant factor for reducing SSI after radical cystectomy than the differences of the surgical procedure even after propensity score matching.

Preoperative Immunonutrition Significantly Reduced Surgical Site Infection After Urinary Diversion for Invasive Bladder Cancer: A Retrospective Cohort Study

BACKGROUND

Radical cystectomy and ileal conduit have a high incidence of surgical site infection. In this study, we evaluated the effects of preoperative immunonutrition on its incidence following these procedures.

MATERIALS AND METHODS

We retrospectively enrolled 86 patients who underwent radical cystectomy and ileal conduit at our hospital between 2014 October and 2021 July. They were sequentially divided into the Immunonutrition group (n = 43) and Control group (n = 43). Patients in the Immunonutrition group drank 4 packs of IMPACT (Nestle, Japan) per day for 5 days before surgery. IMPACT contains arginine and eicosapentaenoic acid. We compared levels of plasma arginine and eicosapentaenoic acid before and after surgery and the rate of surgical site infection between the groups. Factors related to surgical site infection were analyzed using univariate and multivariable logistic regression analysis.

RESULTS

No statistically significant differences were observed in patient characteristics between the groups except for surgical operative method (P < .001) and transfusion (P = .009). Levels of plasma arginine and eicosapentaenoic acid were significantly increased the day before surgery in the immunonutrition group (P < .001). However, the levels of plasma arginine on the day after surgery did not vary significantly between the groups. The incidence of surgical site infection was significantly lower in the immunonutrition group (P = .014). Multivariate analyses showed a significant association of surgical site infection with immunonutrition (OR = 0.14, CI 0.03-0.72, P = .019) and with ASA classification (OR = 4.76, CI 1.23-18.40, P = .024).

CONCLUSIONS

Preoperative immunonutrition significantly reduced the incidence of surgical site infection following radical cystectomy and ileal conduit.

The antibiotic strategies during percutaneous nephrolithotomy in China revealed the gap between the reality and the urological guidelines

Background

Correct perioperative antibiotic strategies are crucial to prevent postoperative infections during percutaneous nephrolithotomy (PCNL). We aimed to compare the realistic antibiotic strategies applied in China with current urological guidelines.

Methods

Between April and May 2020, urologists from China were invited to finish an online cross-sectional survey. The questionnaire was designed according to the current urological guidelines and literatures.

Results

3393 completed responses were received. 61.1% (2073/3393) respondents had urological experience of more than 10 years. 72.4% urologists chose multiple-dose antibiotics for patients with both negative urine culture (UC-) and negative urine microscopy (UM-) preoperatively. Respondents in central China (OR = 1.518; 95% CI 1.102–2.092; P = 0.011), east China (OR = 1.528; 95% CI 1.179–1.979; P = 0.001) and northeast China (OR = 1.904; 95% CI 1.298–2.792; P = 0.001) were more likely to prescribe multiple-dose antibiotic for UC-UM- patients. Notably, the respondents who finished PCNL exceeded 100 cases per year were in favor of single-dose administration (OR = 0.674; 95% CI 0.519–0.875; P = 0.003). There are only 8.3% urologists chose single-dose antibiotic for UC-UM+ patients, whereas 65.5% administered antibiotics for 1–3 days. Meanwhile, for UC+ patients, 59.0% of the urologists applied antibiotics shorter than 1 week, and only 26.3% of the urologists carried out routine re-examination of UC. Moreover, postoperative antibiotics were frequently prescribed for 3–6 days (1815; 53.5%). Finally, although 88.2% urologists considered stone culture important for management of postoperative antibiotics as the guideline recommended, only 18.5% performed it routinely.

Conclusions

The antibiotic strategies are different between current practice in China and the urological guidelines. The dissimilarities suggested that further studies should be conducted to investigate the reasons of the differences and standardize the application of antibiotics.

Bacterial susceptibility change post national shortage of first cephalosporin in Japan; a longitudinal retrospective database study using interrupted time series analysis

OBJECTIVES

The clinical evidence for the impact of narrow-spectrum antimicrobial shortages on bacterial susceptibility is limited. Our purposes were to determine the impacts of the disruption of most of the Cefazolin (CEZ) supply in Japan on the susceptibility of pathogens and to analyze how long these changes persisted after the shortage of CEZ.

METHODS

We performed an interrupted time series analysis using the Japanese Infectious Disease Nationwide database. We analyzed each pathogen before and after CEZ shortage in 52 university hospitals from 2018 to 2020. May to November 2019 was designated as the implementation term for CEZ shortage. The primary outcome was the susceptibility to CEZ and other antimicrobial agents. Among all pathogens isolated from facilities, we identified pathogens that were tested for susceptibility to CEZ.

RESULTS

Of the 26 pathogens identified, analysis was performed on a total of 36346 isolates of five pathogens (E.coli, K.pneumoniae, K.oxytoca, P.mirabillis, S.aureus). Among four gram negative pathogens with low susceptibility, there were no significant immediate changes after the CEZ shortage, however, the slope change significantly increased by 1.29-2.69% per month and continued to improve 1 year after the shortage. Regarding S. aureus, which was highly susceptible at the baseline, neither immediate change nor slope was significant.

CONCLUSIONS

This quasi-experimental analysis using nationwide large database revealed that restriction of use due to narrow antimicrobial shortages may lead to improved susceptibility over the subsequent year. The results suggest that temporary switching of antimicrobial agents on a national scale could be effective.

Antibiotic prophylaxis in patients who had undergone to prostate biopsy in between the EMA warning era: effects of fluoroquinolones in diabetic and non-diabetic patients. Results of an observational cohort study

Purpose

To investigate the effects of different antibiotic prophylaxis regimens in patients with diabetes mellitus (DM) candidates to trans-rectal ultrasound-guided prostate biopsy (TRUSPB).

Methods

143 outpatients with DM who underwent TRUSPB during the period 2018–2020 were selected from a cohort of 1150 patients in 3 different institutions. Exclusion criteria were allergies, concomitant anti-platelet therapies and uncontrolled DM. Different antibiotic prophylaxis regimens were adopted. Bacterial resistance levels to fluoroquinolones into the different communities were also collected. Univariable and multivariable binomial logistic regression analyses were used to assess the odds ratio (OR) with 95% confidence intervals (CIs) testing the risk of infective complications' occurrence after adjusting for clinical covariates.

Results

Overall, DM patients were significantly associated with infective complications' occurrence (p < 0.001). No differences on the event of sepsis were found between diabetic and non-diabetic patients. Clinically relevant infections with fever > 37 °C were found in 9.1% and 1.5% (p < 0.001) in diabetic and non-diabetic patients, respectively. Trimethoprim–sulphametoxazole and fluoroquinolones were six times more efficient than Cefixime in non-diabetic patients. Fluoroquinolones confirmed the same effect in diabetic patients although the level of resistance in the period of study decreased only from 56 to 46%.

Conclusion

Fluoroquinolones were active in antibiotic prophylaxis of diabetic patients who had undergone to TRUSPB independently from the level of bacterial resistance found in the community. These results conflict with the recent European warning and support the Japanese and American guidelines on the topic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-022-04055-7.

Efficacy of fosfomycin in preventing infection after endoscopic combined intrarenal surgery in periods of limited supply of first- and second-generation cephalosporins

OBJECTIVES

In March 2019, cefazolin was unavailable owing to difficulty in procuring the active ingredient. Furthermore, the supply of alternative drugs, such as cefotiam and cefmetazole, was limited. In the Department of Nephro-Urology, fosfomycin-based drugs are used as substitutes for cefazolin, which is a perioperative prophylactic antibacterial drug. Herein, we investigated the effectiveness of fosfomycin sodium and cefotiam in preventing infection after endoscopic combined intrarenal surgery as a retrospective preliminary study.

METHODS

A total of 200 patients who underwent endoscopic combined intrarenal surgery at our department between August 2017 and January 2021 were included. The patients were administered cefotiam (n = 95) or fosfomycin (n = 105) as perioperative antibacterial agents. There were no significant differences in the median age or surgery time between the cefotiam and fosfomycin groups. Propensity score matching was performed to match the preoperative urine bacterial counts of both groups. Sixty-eight patients were selected from each group.

RESULTS

The median postoperative hospital stay duration was 4 days for the two groups. The median maximum postoperative temperatures were 37.5 and 37.4°C, respectively. There were no significant differences between the maximum postoperative temperatures in both groups. Furthermore, there were no differences between the groups regarding the white blood cell counts, C-reactive protein levels, and aspartate aminotransferase and alanine aminotransferase levels postoperatively, as well as in terms of postoperative fever requiring additional antibiotics.

CONCLUSIONS

During a period of difficulty in acquiring cefazolin and cefotiam, the use of fosfomycin allowed us to continue with the procedure without increased clinical complications.

Post-prostate biopsy acute bacterial prostatitis and screening cultures using selective media: An overview

The development of several culture media and the availability to isolate and treat pathogens prior to a surgical procedure give us the ability to minimize treatment-related complications, and ultimately results in better outcomes for patients and avoidance of unwanted post-procedure inpatient admissions. In the last decade, an increasing incidence of multidrug-resistant Escherichia coli, especially extended-spectrum beta-lactamase-producing E. coli and fluoroquinolone-resistant pathogens, has been reported. These resistant species frequently colonize the rectal flora and gain access to the systemic circulation via the rectal plexus following a prostate biopsy. The bacteria can eventually lead to life-threatening complications, which is especially important in high-risk patients with multiple co-morbidities. Previously published studies have focused on the isolation of these pathogens with selective media before an invasive procedure and the potential benefits of incorporating the use of selective media as a mandatory pre-operative step. This preventive measure will allow us to offer a tailored prophylactic treatment that benefits patients and reduces the economic burden for the hospital.

Comparison of drug susceptibility between Escherichia coli detected in stool cultures of patients undergoing transrectal prostate needle biopsy and Escherichia coli in hospital-wide urine antibiograms

A prostate biopsy is essential for prostate cancer diagnosis. However, infections are one of the biopsy-associated complications, and post-biopsy fever is estimated to occur in approximately 1% of all cases. It may thus be beneficial to perform a rectal swab culture before a transrectal prostate biopsy to confirm the presence of resistant bacteria and select preventive antibacterial agents according to the drug susceptibility results. This study aimed to determine whether there is a difference between the drug susceptibility of bacteria detected in the stool of patients who were scheduled to undergo prostate biopsy and the hospital-wide urine antibiogram. Patients suspected of having prostate cancer who underwent transrectal prostate biopsy via transrectal ultrasonography between August 1, 2016, and June 30, 2020, were included in this study. Stool samples were collected and cultured before biopsy. Overall, 99 patients underwent prostate biopsy, and of these, culture results were available for 81 patients (81.8%). Escherichia coli was detected in 74.0% (60 samples) of the stool culture samples, of which 4 samples were extended-spectrum β-lactamase-producing types. We found greater susceptibility of Escherichia coli to ampicillin, fluoroquinolones, sulfamethoxazole/trimethoprim, and cefixime in the stool culture antibiogram than in the hospital-wide urine antibiogram. We also found a significantly low incidence of ESBL-positive Escherichia coli in the stool culture antibiogram with p-values of 0.009, 0.007, and 0.03 compared to the hospital-wide urine antibiograms for 2017, 2018, and 2019, respectively. Stool culture of prostate cancer patients undergoing biopsy may provide useful information for selecting prophylactic antimicrobial agents.

Risk assessment of multi-factorial complications after transrectal ultrasound-guided prostate biopsy: a single institutional retrospective cohort study

BACKGROUND

Transrectal ultrasound-guided prostate biopsy (TRUSPB) is widely used to diagnose prostate cancer (PCa). The aim of this study was to evaluate the risk of multi-factorial complications (febrile genitourinary tract infection (GUTI), rectal bleeding, and urinary retention) after TRUSPB.

METHODS

N = 2053 patients were Japanese patients undergoing transrectal or transperineal TRUSPB for suspicious of PCa. To assess risk of febrile GUTI adequately, the patients were divided into four groups: low-risk patients before starting a rectal culture, low-risk patients after starting a rectal culture, high-risk patients, and patients undergoing transperineal TRUSPB. Furthermore, to identify risk of rectal bleeding and urinary retention, patients were divided into transrectal and transperineal group.

RESULTS

Febrile GUTI significantly decreased owing to risk classification. The frequency of rectal bleeding was 1.43% (transrectal: 25/1742), while it did not happen in transperineal group. The patients with rectal bleeding had a significantly lower body mass index (BMI) (P < 0.01). The frequency of urinary retention was 5.57% (transrectal: 97/1742), while it did not happen in transperineal group. The patients with urinary retention had a significantly higher prostate-specific antigen (PSA) (P = 0.01) in transrectal group.

CONCLUSIONS

Risk classification, rectal swab culture, and selected antimicrobial prophylaxis for transrectal TRUSPB were extremely effective to reduce the risk of febrile GUTI. Furthermore, lower BMI and higher PSA were novel clinical predictors for rectal bleeding and urinary retention, respectively. When urologists perform transrectal TRUSPB to their patients, they can correctly understand and explain each complication risk to their patients based on these novel risk factors.

Nonuse of antimicrobial prophylaxis in clean surgeries for adrenal and renal tumors: Results of the risk-based strategy in 1362 consecutive patients

OBJECTIVES

To evaluate the incidence of perioperative infections without antimicrobial prophylaxis in patients undergoing clean surgeries for adrenal and renal tumors.

METHODS

We prospectively enrolled 1362 consecutive patients who underwent minimally invasive adrenalectomy (n = 303), radical nephrectomy (n = 499), and partial nephrectomy (n = 560) using the gasless laparoendoscopic single-port surgery technique between 2005 and 2019. In 1059 patients, antimicrobial prophylaxis was not administered. The remaining 303 patients were considered at high risk for infection and received single-dose antimicrobial prophylaxis. The endpoint was the incidence of perioperative infections within 1 month from the surgery date. Perioperative infections were classified into surgical site infections, urinary tract infections, and remote infections.

RESULTS

Seventy-four patients whose collecting systems were opened during partial nephrectomy were excluded, and the remaining 1013 patients with nonuse of antimicrobial prophylaxis and 275 patients with single-dose antimicrobial prophylaxis were retrospectively analyzed. The incidence of superficial surgical site infections, deep/organ-space surgical site infections, urinary tract infections, and remote infections was 1.6%, 0.7%, 2.8%, and 1.3%, respectively, in patients with nonuse of antimicrobial prophylaxis and 0.4%, 1.8%, 1.5%, and 1.5%, respectively, in patients with single-dose antimicrobial prophylaxis. All patients who developed perioperative infections were successfully treated. No clinical or surgical variables were significantly associated with the incidence of surgical site infections. One limitation of the present study was its nonrandomized and noncontrolled design.

CONCLUSIONS

In minimally invasive clean surgeries for adrenal and renal tumors, antimicrobial prophylaxis is not necessary when individual risk of infection is considered low.

Prevention and management of infectious complications in prostate biopsy: A review

Prostate biopsies are common procedures for urologists, performed in order to detect and diagnose prostate cancer. Procedures continue to evolve, for instance, recently there has been an increase in the use of the transperineal approach, and the emergence of antibiotic-resistant bacteria has become a challenge. This review examines the recent prostate biopsy literature as well as the guidelines of three urological associations. We review the recent literature, including our own recent studies, and the Japanese Urological Association, European Association of Urology and American Urological Association guidelines, and summarize the current recommendations regarding the prevention of infectious complications that can occur after prostate biopsy, including the use of antimicrobial agents, and the management and treatment of such complications. Current recommendations include single-dose or 1-day use of oral quinolones for infection control, along with consideration of high-risk patients with diabetes, steroid use, large prostates, or high residual urine volume for instance. Targeted therapies based on the results of rectal swabs carried out prior to transrectal prostate biopsy, which can provide better inhibitory data with regard to post-prostate biopsy infectious complications, can also be considered. In conclusion, oral quinolones for low-risk patients and targeted therapies for high-risk patients are recommended when using a transrectal approach to prostate biopsy, and oral quinolones are recommended when using a transperineal approach. Further randomized controlled trials are necessary to draw more definitive conclusions.

Positive urine culture under indwelling urethral catheterization is a risk factor for febrile complications after holmium laser enucleation of the prostate (HoLEP)

OBJECTIVES

To investigate the incidence of and risk factors for febrile complications (FCs) in patients undergoing holmium laser enucleation of the prostate (HoLEP).

METHODS

This retrospective study enrolled 847 consecutive patients who underwent HoLEP in our hospital from June 2006 to December 2018. FCs were defined as a body temperature ≥38.0°C within 30 days after surgery. The incidence of FCs was determined and possible risk factors assessed using multivariate logistic regression analysis.

RESULTS

Overall, 87 (10.3%) patients presented with FCs, and 6 (0.7%) had urosepsis, with no fatal complications. Multivariate logistic regression analysis revealed that patients with preoperative positive urine culture and urethral catheterization had an increased risk of FCs compared with those with a negative culture who did not need catheterization (odds ratio [OR] 2.587, 95% confidence interval [CI] 1.307-5.121). A negative urine culture with catheterization and a positive culture without catheterization were not associated with the development of FCs (OR 0.320, 95% CI 0.040-2.553 and OR 1.370, 95% CI 0.662-2.365, respectively). Other significant risk factors included preoperative serum albumin levels (OR 0.382, 95% CI 0.173-0.846) and immediate postoperative body temperature (OR 2.559, 95% CI 1.549-4.230).

CONCLUSIONS

FCs are relatively common among patients after HoLEP despite preoperative prophylactic antibiotic administration. Surgeons may need to consider performing screening of urine cultures prior to HoLEP, especially in patients with urethral catheterization, even if asymptomatic. If the culture is positive, prophylactic antibiotics should be tailored according to bacterial susceptibility.

Adherence and Acceptability of an Oral Antibiotic Used for the Prevention of Pediatric Urinary Tract Infection in Japan

Urinary tract infection (UTI) is a common health care-associated adverse event and the leading nosocomial complication following pediatric urological surgery. While continuous antimicrobial prophylaxis effectively reduces the risk of UTI following such a surgery, non-adherence is common and represents a distinct clinical entity that is associated with renal scarring. Acceptability is likely to have a significant impact on patient adherence. Herein we used a validated data-driven approach-the ClinSearch acceptability score test (CAST)-to investigate the acceptability of cefaclor, an oral antibiotic widely used for the prevention of pediatric UTI in Japan. Standardized observer reports were collected for 58 intakes of cefaclor 10% fine granules in patients aged from 0 to 17 years. The medicine was classified as positively accepted on the acceptability reference framework. According to the percentage of the prescribed dose taken reported at the end of the treatment, patients exhibited good adherence to this well-accepted medicine. Nonetheless, requirements for greater dosing frequency or poor acceptability in certain patients could affect adherence. Acceptability should be established to ensure patient adherence to medicines used for long-term prophylaxis and consequently guarantee the safety and efficacy of the treatment.

Prostatic Pharmacokinetic/Pharmacodynamic Evaluation of Ampicillin-Sulbactam for Bacterial Prostatitis and Preoperative Prophylaxis

This study aims to define the penetration of ampicillin and sulbactam into prostate tissue, develop a prostatic pharmacokinetic model of each drug, and assess the appropriateness of ampicillin-sulbactam regimens for the treatment of prostatitis and the prophylaxis of postoperative infection, based on a pharmacokinetic and pharmacodynamic simulation. Subjects were prostatic hyperplasia patients prophylactically receiving a 0.5-hour infusion of 1.5 g (1:0.5 g) or 3 g (2:1 g) ampicillin-sulbactam before transurethral resection of the prostate. Ampicillin and sulbactam concentrations in plasma and prostate tissue were measured. The prostate tissue/plasma ratios of both ampicillin and sulbactam were approximately 0.37 (area under the drug concentration-time curve), and penetration was similar. The prostatic population pharmacokinetic model, which included a covariate analysis, adequately predicted prostate tissue concentrations in our patient population. For therapeutic use, aiming for a bactericidal target of 50% of time above minimum inhibitory concentration (T > MIC) in prostate tissue, 3 g ampicillin-sulbactam 4 times daily achieved ≥90% expected probability against only Enterococcus faecalis in typical patients with a creatinine clearance (CL_cr ) of 30 mL/min. For prophylactic use, aiming for a bacteriostatic target of 30% T > MIC, 3 g ampicillin-sulbactam 4 times daily achieved ≥90% expected probability of attaining the bacteriostatic target against E. faecalis and Proteus species when CL_cr was 30 mL/min. Based on prostatic simulations, the present study provides helpful recommendations for the treatment of bacterial prostatitis and preoperative prophylaxis in prostatectomy.

Efficacy of fosfomycin in the prevention of postoperative infection following transurethral resection of bladder tumor during periods of limited cefazolin, cefotiam, and cefmetazole supply

INTRODUCTION

In March 2019, cefazolin availability was limited owing to the contamination of the drug substance. In addition, there was a difficulty in supplying drugs alternative to cefazolin, such as cefotiam and cefmetazole. In our Department of Nephro-urology, we used fosfomycin-based drugs to substitute cefazolin as perioperative preventive antibacterial drugs. In this study, we aimed to evaluate the usage status of perioperative prophylactic antibacterial drugs before and after the period of limited cefazolin supply and to investigate the efficacy and safety of fosfomycin sodium in preventing infections following transurethral resection of bladder tumor.

METHODS

We enrolled 346 patients who underwent transurethral resection of bladder tumor in our department from April 2018 to August 2020. The patients received the following perioperative antibacterial agents: cefotiam (n = 146), fosfomycin (n = 166), and other antibacterial agents (n = 34). There was no significant difference in the median age or surgery time.

RESULTS

The median length of hospital stay was 6, 5, and 5 days in the cefotiam, fosfomycin, and other antibacterial groups, respectively, with significant difference. The median maximum postoperative temperature was 37.1 °C in all groups, with no significant difference. There were no differences in C-reactive protein, aspartate aminotransferase, and alanine aminotransferase levels determined by postoperative blood tests; preoperative and postoperative urinary white blood cell counts; preoperative urine bacterial counts; and surgery-related infection requiring additional antibiotic treatments among the groups.

CONCLUSIONS

The use of fosfomycin-based agents helped overcome the limited supply of cefazolin without worsening clinical outcomes.

Clinical guidelines on erectile dysfunction surgery: EAU-AUA perspectives

INTRODUCTION

The implantation of a penile prosthesis is considered a third-line treatment and is indicated in patients who do not respond adequately to pharmacotherapy or require definitive treatment. Currently, the most used devices are 3-component penile prostheses, which presently account for more than 90% of the implants used.

MATERIAL AND METHODS

We reviewed the evidence and the recommendations of the clinical practice guidelines regarding surgery in patients with erectile dysfunction.

RESULTS

The recommendations of the clinical practice guidelines on surgery in patients with erectile dysfunction are summarized as follows: men with erectile dysfunction should be informed about the option of penile prosthesis implant treatment, commenting on the benefits, risks and consequences; men with erectile dysfunction who have agreed to receive penile prosthesis should be advised on post-surgical expectations; penile prosthesis implants should not be performed in patients with systemic, cutaneous or urinary tract infection; in young men with erectile dysfunction and focal penile or pelvic arterial obstruction who do not have generalized vascular disease or veno-occlusive dysfunction, penile arterial reconstruction can be considered; in men with erectile dysfunction, penile venous surgery is not recommended.

CONCLUSIONS

The use of penile prostheses offers high satisfaction rates to both the patient and his partner. However, it is crucial to adequately inform and warn patients about possible complications and consequences.

Create a predictive model for neurogenic bladder patients: upper urinary tract damage predictive nomogram

Objective: To create a nomogram to evaluate the risk of upper urinary tract damage (UUTD) in patients with neurogenic bladder (NGB) Methods: A retrospective analysis was conducted on 301 patients with NGB who were admitted to certain hospitals. Data collected included clinical symptoms, patients' characteristics, laboratory parameters, imaging findings, and urodynamic parameters. The least absolute shrinkage and selection operator（LASSO）regression model was used to optimise the selection of predictors. Multivariate logistic regression analysis was performed to develop a UUTD risk predictive model. Validation was performed by bootstrap. Results: The predictors included in the nomogram included sex, duration of disease, history of UTI, bladder compliance, and fecal incontinence. The model presented good discrimination with a C-index value of 0.796 (95% confidence interval: 0.74896-0.84304) and good calibration. The C-index value of the interval validation was 0.7872112. The results of decision curve analysis (DCA) demonstrated that the UUTD-risk predictive nomogram was clinically useful. Conclusion: The nomogram incorporating the sex, duration of disease, history of UTI, bladder compliance, and fecal incontinence could be an important tool of UUTD risk prediction in NGB patients.

Clinical practice guidelines for surgical antimicrobial prophylaxis: Qualitative appraisals and synthesis of recommendations

RATIONALE, GOALS, AND OBJECTIVES

Clinical practice guidelines (CPGs) for preoperative care have been developed for surgical antimicrobial prophylaxis (SAP). The objective of this study was to synthetize recommendations for SAP based on best-evaluated CPGs.

METHODS

A systematic literature search for documents related to SAP, published between January 2011 and December 2016, was conducted on MEDLINE (PubMed), EMBASE, and specific CPG websites. Three reviewers independently assessed the rigour of development and editorial independence of CPGs based on domains 3 and 6 of the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. CPGs with domain 3 scores of 50% and greater were selected for synthesis of recommendations. Two reviewers independently extracted CPG recommendations from among these documents. A third reviewer performed the synthesis of recommendations.

RESULTS

The search retrieved 363 documents, of which 29 CPGs were appraised using AGREE II. Only eight (28%) scored 50% and greater in domain 3. Most CPGs addressed topics related to preoperative care, including SAP. No conflicting recommendations were found, and most recommendations were based on clinical practice. The only recommendation for which there was a difference among CPGs was with respect to the time to initiate the administration of antibiotics (1 hour before or close to the time of the surgical incision). Four CPGs provide recommendations that demonstrate concern about inadequate SAP prolongation.

CONCLUSION

Several CPGs for SAP were developed without the desired methodological rigour or transparency. Synthesis of recommendations for best-evaluated CPGs provides a broad approach owing to the complementarity of the recommendations.

A nationwide surveillance of surgical site infection after mid-urethral slings in Japan

We performed a questionnaire-based, retrospective, nationwide survey on perioperative management and antimicrobial prophylaxis for mid-urethral sling surgery for stress urinary incontinence in Japan to realize the clinical practice and risk factors for SSI. Records of women receiving transobturator tape (TOT) and tension-free vaginal tape (TVT) surgeries from 2010 to 2012 were obtained from hospitals belonging to the Japanese Society of Pelvic Organ Prolapse Surgery. The questionnaire addressed hospital volume, perioperative management, and SSI. Risk factors for SSI were investigated by comparing cases with and without SSI. The data from 97 hospitals and a total 1627 TOT and 1045 TVT surgeries were analyzed. Mean case volumes of TOT and TVT surgeries were 7.3 ± 14.9 and 7.1 ± 17.8 cases per year, respectively. Preoperative hair removal, bowel preparation, and urine culture were routinely performed at 44 (45.3%), 31 (32.0%), and 22 (22.7%) hospitals, respectively. First-generation (51.5%) or second-generation (34.0%) cephalosporin was mostly used for antimicrobial prophylaxis. SSI was reported only in 6 patients (0.22%) and none of them developed abscesses. None of the factors we could evaluate from the questionnaire were found to be significantly associated with SSI. SSI after mid-urethral slings rarely occurred in Japan (0.22%) and no parameters about perioperative managements significantly increased SSI. However, further studies with more detail information of each patient and operation are required to confirm their appropriate perioperative managements for mid-urethral slings.

Critical Appraisal of International Clinical Practice Guidelines in Kidney Transplantation Using the Appraisal of Guidelines for Research and Education II Tool: A Systematic Review

BACKGROUND

Although clinical practice guidelines (CPGs) are used for the development of local protocols in kidney transplantation (Ktx), the quality of their methodology is variable. This systematic review aimed to critically appraise international CPGs in all aspects of Ktx using the Appraisal of Guidelines for Research and Evaluation II tool.

METHODS

Clinical Practice Guidelines in Ktx and donation published between 2010 and 2017 were identified from MEDLINE, Embase, National Guideline Clearinghouse, National Health Service and National Institute for Health and Care Excellence Evidence Searches, and the websites of transplant societies. Using Appraisal of Guidelines for Research and Evaluation II, 3 appraisers assessed the quality of CPGs. Interrater reliability was measured using the intraclass correlation coefficient (ICC).

RESULTS

Searches identified 3168 records, and 115 CPGs were included. The highest scoring Appraisal of Guidelines for Research and Evaluation II domain was "scope and purpose" (80%; range, 30%-100%), followed by "clarity of presentation" (77%; range, 43%-98%), "editorial independence" (52%; range, 0%-94%), "rigor of development" (47%; range 6%-97%) and "stakeholder involvement" (41%; range, 11%-85%). The poorest scoring domain was "applicability" (31%; range, 3%-74%). Most CPGs were recommended for future use either with (63%) or without (18%) modifications. A small number (14%) were not recommended for future use or reviewers (5%) did not agree on recommending the CPG. The overall mean CPG quality score was 4 of 7 (range, 2-7). The mean ICC of 0.74 indicated substantial agreement between reviewers.

CONCLUSIONS

The quality of international CPGs in Ktx was variable, and most CPGs lacked key aspects of methodological robustness and transparency. Improvements in methodology, patient involvement, and strategies for implementation are required.

Protocol for a comparison study of 1-day (single dose) versus 2-day prophylactic antibiotic administration in Holmium Laser enucleation of the prostate (HoLEP): a randomized controlled trial

Background: The best method of antimicrobial prophylaxis administration for surgical site infection (SSI) in transurethral holmium laser resection and enucleation of the prostate (HoLEP)/bipolar transurethral enucleation (TUEB) remains controversial. The purpose of this study is to compare one-day and two-day cefazolin in a randomized 2 nd-phase study to help establish a protocol with a 95% confidence interval (CI) for SSI prevention. Methods: Patients undergoing HoLEP/TUEB for benign prostate hyperplasia without preoperative pyuria will be enrolled and randomized to receive prophylactic antibiotic administration for HoLEP/TUEB in two groups, 1-day (single dose) cefazolin and 2-day cefazolin. The primary endpoint is the occurrence rate of postoperative urinary tract infection or urogenital infection within 30 days after HoLEP/TUEB with a statistical 95% CI in comparison between those groups. Secondary outcomes include the kind of infectious disease and evidence of diagnosis, day of diagnosis of infectious disease, performance of urine or blood culture, detection of bacteria, treatments, duration of treatments, AEs other than surgical site infection, and drug-induced AEs. Discussion: The results of this study will provide evidence for defining the optimal duration of cefazolin prophylactic antibiotic administration for SSI. Trial registration: This study was registered in the University Hospital Medical Information Network-Clinical Trial Registry ( UMIN000027955) based on recommendations from the International Committee of Medical Journal Editors (ICMJE) on July 1 st 2017.

Use of single-dose perioperative antimicrobial therapy is acceptable in recipients of living-donor renal transplants in the rituximab era

OBJECTIVE

The aim of this study was to evaluate the efficacy of single-dose perioperative antimicrobial therapy as infection prophylaxis in recipients of living-donor renal transplants in the rituximab era.

PATIENTS AND METHODS

Between 2009 and 2017, 84 recipients underwent living-donor renal transplantation (LDRT) at Okayama University Hospital; 3 with vascular/urinary complications requiring additional surgery were excluded from this analysis. Data including recipient characteristics, antimicrobial prophylaxis and administration of rituximab were retrospectively examined for an association with perioperative infections. Prophylactic antimicrobial agents, selected according to the Results of preoperative urine cultures, were administered just before incision. Perioperative infections, which consisted of surgical site infections, remote infections, and urinary tract infections, were defined as a positive culture indicating required administration of additional antimicrobial agents.

RESULTS

Among the 81 recipients, prophylactic cefazolin, ampicillin/sulbactam, and others were administered to 66 (82%), 13 (16%), and 2 (3%) recipients, respectively. Twenty-one (26%) received single-dose antimicrobial prophylaxis, while 60 (74%) received multiple doses up to 7 days. Rituximab was used in 59 (72.8%) recipients. The incidence of urinary tract infection, surgical site infection and remote infection was 13 (16%), 1 (1%), and 0, respectively. Univariate analysis could not demonstrate any significant risk factors for postoperative urinary tract infections, including a single dose vs multiple doses of antimicrobial therapy (P = 0.069) and administration of rituximab (P = 0.717).

CONCLUSIONS

Our data suggest that the use of single-dose perioperative antimicrobial therapy is acceptable for prophylaxis of infections in patients undergoing LDRT, even in the rituximab era.

Antimicrobial prophylaxis for transurethral resection of bladder tumor: A retrospective comparison of preoperative single-dose administration of piperacillin and tazobactam/piperacillin

We aimed to clarify prophylactic antimicrobial effects of single-dose piperacillin (PIPC) for perioperative infections in the transurethral resection of bladder tumor (TURBT) in comparison with those of single-dose tazobactam/piperacillin (TAZ/PIPC) through a retrospective analysis. We analyzed data from 192 TURBT patients treated with single-dose (4 g) intravenous PIPC (P group) between April 2015 and April 2017. For comparison, we analyzed data from 50 TURBT patients treated with single-dose (4.5 g) intravenous TAZ/PIPC (T/P group) between June 2013 and April 2014. We compared the perioperative incidences of fever (≥38 °C) and bacteriuria in the two groups. The number of febrile patients was four (2.1%) in the P group and one (2.0%) in the T/P group, without significant difference (p = 0.970). Among these febrile patients, urine and blood samples of two patients in the P group tested positive for bacterial cultures of Citrobacter koseri and Enterococcus faecalis, respectively. None of the patients in the T/P group tested positive for urine culture, postoperatively. However, 22 patients (18.2%) in the P group tested positive for urine culture, and Staphylococcus epidermidis (six patients), E. faecalis (three patients), Escherichia coli (three patients), Streptococcus agalactiae (two patients), Staphylococcus aureus (two patients), and C. koseri (one patient) were isolated. There was no significant difference in the incidence of bacteriuria in these two groups (p = 0.055). Based on these results, single-dose PIPC administration for the prevention of perioperative infections in TURBT was as effective as TAZ/PIPC.

Healthcare-Associated Infections after Lower Urinary Tract Endoscopic Surgery: Analysis of Risk Factors, Associated Microorganisms and Patterns of Antibiotic Resistance

OBJECTIVES

To review the incidence of healthcare-associated infections/urinary tract infection (UTI), risk factors, microorganisms isolated and antibiotic resistances in patients who underwent lower urinary tract endoscopic surgery (LUTES) in a tertiary care hospital.

METHODS

A prospective observational study was carried out including 1,498 patients who undergo LUTES. Patients with and without UTI after surgery were compared. We analysed infection incidence, risk factors, microorganisms isolated and antibiotic resistances.

RESULTS

Postoperative UTI incidence was 4.7%. Risk factors found: higher American Society of Anesthesiologists classification (OR 2.82; 95% CI 1.8-4.5; p < 0.00), immunosuppression (OR 2.89; 95% CI 1.2-7.2; p = 0.01), indwelling urinary catheter prior admission (OR 2.6; 95% CI 1.6-4.2; p < 0.00) and postoperative catheterization longer than 2 days (OR 1.74; 95% CI 1.7-4.3; p < 0.00). Transurethral resection of the bladder (TURB) had the highest infection rates (5.5%). Microorganisms isolated were Pseudomonas aeruginosa (23.5%), Escherichia coli (17.6%), Klebsiella pneumoniae and Enterococcus spp (11.8%). Resistance rates for flourquinolones varied between 28 and 80%, and Carbapenem-resistant Enterobacteriaceae rose up 20%.

CONCLUSIONS

Low percentage of UTI after endoscopic surgery was registered. TURB was the procedure with highest infection rate. Pseudomonas aeruginosa stands out as the most frequently isolated microorganism. Patient comorbidities, previous urinary catheter and postoperative catheter were identified as risk factors.

Risk factors for surgical site infection after transvaginal mesh placement in a nationwide Japanese cohort

AIMS

We conducted a nationwide survey on perioperative management and antimicrobial prophylaxis of transvaginal mesh surgeries for pelvic organ prolapse in Japan to understand the practice and risk factors for surgical site infection (SSI).

METHODS

Health records of women undergoing tension-free vaginal mesh (TVM) surgeries from 2010 to 2012 were obtained from 135 medical centers belonging to the Japanese Society of Pelvic Organ Prolapse Surgery. The questionnaire addressed hospital volume, perioperative management, and SSI. Risk factors for SSI were investigated by comparing cases with and without SSI.

RESULTS

The hospital volume among institutions varied from 0 to 248 per year (median 16.7). Preoperative hair removal, bowel preparation, and urine culture were routinely performed at 74 (55%), 66 (49%), and 24 (18%) hospitals, respectively. Prophylactic antimicrobials used were mostly first-generation (43%) or second-generation (42%) cephalosporin. SSI was reported in 86 of 9323 patients (0.92%). A multivariate analysis indicated lower hospital volume (odds ratio [OR], 0.995 [by 1-point increase]; P < 0.001), preoperative bowel preparation (OR, 2.08; P = 0.013), non-routine urine culture (OR, 3.00; P = 0.0006), and the use of antibiotics other than first-generation cephalosporin (OR, 5.29; P = 0.0011) as significant risk factors for SSI. In contrast, the cut-off points of hospital volume for preventing SSI was 116.7 cases (area under curve: 0.61).

CONCLUSION

The prevalence of SSI in TVM surgeries was 0.92% in Japan. Lower hospital volume, bowel preparation, non-routine preoperative urine culture, and prophylactic antibiotics other than first-generation cephalosporin significantly elevated the incidence of SSI.

The effectiveness of targeted relative to empiric prophylaxis on infectious complications after transrectal ultrasound-guided prostate biopsy: a meta-analysis

PURPOSE

Rectal culture screening for fluoroquinolone (FQ)-resistant Enterobacteriaceae before transrectal ultrasound guided prostate (TRUSPB) biopsy and targeted antibiotic prophylaxis (TAP) may decrease post-TRUSPB infection rates compared to empiric (EAP) regimens. The objective of this study was to evaluate the effectiveness of targeted relative to empiric prophylaxis regimens on rates of infectious complications after TRUSPB and to determine the baseline prevalence of FQ resistance based on prior rectal swabs.

METHODS

An electronic search within literature databases including EMBASE and Web of Science (all databases) for articles assessing TAP as an approach to TRUSPB prophylaxis was conducted. Quality assessment was performed using the Hoy instrument. Meta-analysis was performed using MetaXL 5.3.

RESULTS

From 15 studies (eight retrospective and seven prospective) representing 12,320 participants, infectious complication incidence was 3.4% in EAP and 0.8% in TAP patients. The number needed to treat with TAP to avoid one more infection when compared to the EAP group was 39. Effect sizes were homogeneous. Prevalence of FQ resistance showed low (15%) and high (28%) subgroups, likely due to region of origin (within and outside USA, respectively).

CONCLUSIONS

Rectal culture prior to TRUSPB and use of TAP adjusts for endemic FQ resistance and is associated with less infectious complications and resulting morbidity when compared to EAP. Overtreatment associated with augmented prophylaxis approaches may be reduced as a result. Further prospective assessment and cost-benefit analyses are required before widespread implementation can be recommended.

Prevention of infectious complications after prostate biopsy procedure

Although febrile complications are rarely encountered after a prostate biopsy procedure, in recent years the number of cases of fatal infection after that have increased along with increases in resistant bacteria. The available biopsy approaches are transrectal and transperineal, with the transrectal approach primarily used. As the invasion path of the puncture needle differs between these approaches, pretreatment and the method of administration of preventive antimicrobial drugs should be separately considered for infection prevention. Recently, the Japanese guidelines for perioperative infection prevention in the field of urology were revised after receiving approval from the Japanese Urological Association. With use of the transrectal approach, attempts have been made to selectively administer prophylactic antibiotics by confirming the presence or absence of resistant bacteria in rectal swab culture results before carrying out a prostate biopsy procedure because of potential problems associated with resistant bacteria in rectal flora. For preventive antibiotics, a single dose of oral quinolone is recommended for patients with low risk, whereas daily administrations of piperacillin/tazobactam are recommended for those considered to be high risk. In contrast, for the transperineal procedure, a single dose of oral quinolone is recommended as a preventive antibiotic. With both approaches, it is important to empirically administer broad-spectrum antimicrobials when occurrence of a febrile infection after a prostate biopsy procedure is confirmed.

Prevalence and characteristics of fecal antimicrobial-resistant Escherichia coli in a cohort of Japanese men undergoing prostate biopsy

OBJECTIVES

To examine resistant Escherichia coli in rectal swab culture of Japanese men undergoing prostate biopsy, and to determine its prevalence, genotypic characteristics and carriage risk factors.

METHODS

Rectal swabs of consecutive men undergoing transrectal ultrasound-guided prostate biopsy from April 2013 to March 2015 were cultured to isolate fluoroquinolone-resistant and extended-spectrum β-lactamase-producing E. coli. The prevalence and antimicrobial susceptibility of these resistant E. coli strains and extended-spectrum β-lactamase genotyping were examined. The risk factors of antimicrobial resistance carriage were also examined.

RESULTS

The cohort was 376 men with a mean age of 67.8 years. Fluoroquinolone-resistant E. coli and extended-spectrum β-lactamase-producing E. coli were detected in 37 men (9.8%) and 22 men (5.9%), respectively, with fluoroquinolone-resistant and/or extended-spectrum β-lactamase-producing E. coli in 48 men (13.0%). All 49 antimicrobial-resistant strains were susceptible to tazobactam/piperacillin, amikacin, fosfomycin, meropenem and faropenem. CTX-M-9 and CTX-M-1 group were detected in 14 (63.6%) and eight (36.4%) men, respectively. CTX-M-9 showed relatively higher susceptibility to LVFX and minocycline compared with CTX-M-1. Diabetes mellitus was a significant factor for carriage of resistance by multivariate analysis (odds ratio 2.12, P = 0.039).

CONCLUSIONS

The present study showed the fecal carriage of fluoroquinolone-resistant E. coli and extended-spectrum β-lactamase-producing E. coli at 9.8% and 5.9%, respectively, with CTX-M-9 group of extended-spectrum β-lactamase-producing E. coli comprising 63.6%, in Japanese men receiving prostate biopsy. The carriage of fluoroquinolone-resistant and/or extended-spectrum β-lactamase-producing E. coli was significantly related to diabetes.

[STUDY OF NEW ORAL QUINOLONES (LEVOFLOXACIN AND SITAFLOXACIN) AS PROPHYLACTIC ANTIMICROBIAL AGENTS IN TRANSRECTAL PROSTATE NEEDLE BIOPSY]

(Objective) A single prophylactic dose of new quinolones is recommended to prevent infection associated with transrectal prostate needle biopsy (TRPB), except in high-risk patients, and a single dose of levofloxacin (LVFX) 500 mg is often administered. We examined single administrations of LVFX and sitafloxacin (STFX), in relation to the frequency of febrile infection. (Patients and methods) The subjects were 411 patients deemed to be suitable candidates for TRPB and ranging in age from 52 to 84 years (median, 75 years). Their PSA values ranged from 3.89 to 2,450 ng/mL (median, 6.92 ng/mL). They were randomly assigned to receive LVFX (group A, 204 patients) or STFX (group B, 207 patients), and the two groups were compared for the incidence of infection with a temperature of 38°C or more within 48 hours after TRPB. (Results) Febrile infection was observed in 8 (3.92%) of the 204 patients in group A and 1 (0.48%) of the 207 patients in group B. Of the 9 patients with febrile infection, 8 had acute prostatitis. There was a significant difference in the incidences of febrile infection between the two groups (p = 0.041; odds ratio, 8.41; 95% confidence interval, 1.04-67.85). The pathogenic bacteria in the 9 patients were Escherichia coli in 7 (Extended-spectrum beta-lactamase [ESBL]-producing bacteria in 3, LVFX-resistant bacteria in 2), Klebsiella pneumoniae in one, and Enterococcus faecalis in one. (Discussion) Measures against quinolone-resistant bacteria, ESBL-producing bacteria, and gram-positive bacteria should be considered for the prevention of infections associated with TRPB. Based on our present observations, STFX is considered to have more favorable effects than LVFX.