Urological Infections part 3
Urological Infections Peri-Procedural Antibiotic Prophylaxis Part 3 Comprehensive Review Article Prof. Dr. Semir. A. Salim. Al Samarrai The General Principles of Peri-Procedural Antibiotic Prophylaxis: Definition of infectious complications The European Centre for Disease Prevention and Control (ECDC) and the CDC have both presented similar definitions recommended for the evaluation of infectious complications [1,2]. Non-antibiotic measures for asepsis There are a number of non-antibiotic measures designed to reduce the risk of surgical site infection (SSI), many are historically part of the routine of surgery. The effectiveness of measures tested by RCTs are summarized in systematic reviews conducted by the Cochrane Wounds Group (http://wounds.cochrane.org/news/reviews). Urological surgeons and the institutions in which they work should consider and monitor maintenance of an aseptic environment to reduce risk of infection from pathogens within patients (microbiome) and from outside the patient (nosocomial/healthcare-associated). This should include use of correct methods of instrument cleaning and sterilisation, frequent and thorough cleaning of operating rooms and recovery areas and thorough disinfection of any contamination. The surgical team should prepare to perform surgery by effective hand washing [3], donning of appropriate protective clothing and maintenance of asepsis. These measures should continue as required in recovery and ward areas. Patients should be encouraged to shower pre-operatively, but use of chlorhexidine soap does not appear to be beneficial [4]. Although evidence quality is low, any required hair removal appears best done by clipping, rather than shaving, just prior to incision [5]. Mechanical bowel preparation should not be used as evidence review suggests harm not benefit [6,7]. There is some weak evidence that skin preparation using alcoholic solutions or chlorhexidine result in a lower rate of SSI than iodine solutions [8]. Studies on the use of plastic adherent drapes showed no evidence of benefit in reducing SSI [9]. Detection of bacteriuria prior to urological procedures Identifying bacteriuria prior to diagnostic and therapeutic procedures aims to reduce the risk of infectious complications by controlling any pre-operative detected bacteriuria and to optimise antimicrobial coverage in conjunction with the procedure. A systematic review of the evidence identified eighteen studies comparing the diagnostic accuracy of different index tests (dipstick, automated microscopy, dipslide culture and flow cytometry), with urine culture as the reference standard [10]. The systematic review concluded that none of the alternative urinary investigations for the diagnosis of bacteriuria in adult patients prior to urological interventions can currently be recommended as an alternative to urine culture [10]. Choice of agent Urologists should have knowledge of local pathogen prevalence for each type of procedure, their antibiotic susceptibility profiles and virulence in order to establish written local guidelines. These guidelines should cover the five modalities identified by the ECDC following a systematic review of the literature [11]. The agent should ideally not be one that may be required for treatment of infection. When risk of skin wound infection is low or absent, an aminoglycoside (gentamicin) should provide cover against likely uropathogens provided the eGFR is > 20 mL/min; second generation cephalosporins are an alternative [12]. Recent urine culture results including presence of any multi-resistant organisms, drug allergy, history of C. difficile associated diarrhoea, recent antibiotic exposure, evidence of symptomatic infection pre-procedure and serum creatinine should be checked. Specific procedures and evidence question: An updated literature search from February 2017 (cut-off of last update) to June 2021 identified RCTs, systematic reviews and meta-analyses that investigated the benefits and harms of using antibiotic prophylaxis prior to specific urological procedures. The available evidence enabled the EAU Guidelines 2022-panel to make recommendations concerning urodynamics, cystoscopy, stone procedures (extracorporeal shockwave lithotripsy [ESWL], ureteroscopy and percutaneous nephrolithotomy [PCNL]), transurethral resection of the prostate (TURP) and transurethral resection of the bladder (TURB). The general evidence question was: Does antibiotic prophylaxis reduce the rate of post-operative symptomatic UTI in patients undergoing each named procedure? Urodynamics The literature search identified one systematic review for antibiotic prophylaxis in women only [13]. This included three RCTs (n=325) with the authors reporting that prophylactic antibiotics reduced the risk of bacteriuria but not clinical UTI after urodynamics [13]. A previous Cochrane review identified nine RCTs enrolling 973 patients with overall low quality and high or unclear risks of bias [14]. The outcome of clinical UTI was reported in four trials with no benefit found for antibiotic prophylaxis vs. placebo [RR (95%CI) 0.73 (0.52-1.03)]. A meta-analysis of nine trials showed that use of antibiotics reduced the rate of post-procedural bacteriuria [RR (95%CI) 0.35 (0.22-0.56)] [14]. Cystoscopy Three systematic reviews and meta-analyses [15–17] and one additional RCT [18] on cystoscopy for stent removal were identified. Garcia-Perdomo et al., included seven RCTs with a total of 3,038 participants. The outcome of symptomatic UTI was measured by five trials of moderate overall quality and meta-analysis showed a benefit for using antibiotic prophylaxis [RR (95%CI) 0.53 (0.31 – 0.90)]; ARR 1.3% (from 2.8% to 1.5%) with a NNT of 74 [16]. This benefit was not seen if only the two trials with low risk of bias were used in the meta-analysis. Carey et al., included seven RCTs with 5,107 participants. Six trials were included in metaanalysis of the outcome of symptomatic bacteriuria which found benefit for use of antibiotic prophylaxis [RR (95%CI) 0.34 (0.27 – 0.47)]; ARR 3.4% (from 6% to 2.6%) with NNT of 28 [15]. Zeng et al., included twenty RCTs and two quasi-RCTs with a total of 7,711 participants. The outcome of symptomatic UTI was measured by eleven RCTs of low overall quality and meta-analysis showed a possible benefit for using antibiotic prophylaxis [RR (95% CI) 0.49 (0.28 – 0.86)] [17]. For systemic UTI, antibiotic prophylaxis showed no effect compared with placebo or no treatment in five RCTs [RR (95% CI) 1.12 (0.38 – 3.32)]. However, prophylactic antibiotics may increase bacterial resistance [(RR (95% CI) 1.73 (1.04 – 2.87)]. Given the low absolute risk of post-procedural UTI in well-resourced countries, the high number of procedures being performed, and the high risk of contributing to increasing antimicrobial resistance the EAU Guidelines 2022-panel consensus was to strongly recommend not to use antibiotic prophylaxis in patients
Urological Infections part 3 قراءة المزيد »
