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General News

Avoiding Urologic Surgery Infections

J. Stuart Wolf, MD

January 05, 2009

The AUA released a new set of guidelines to address nosocomial infections.

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Recommendations

The most recent American Heart Association guidelines for the prevention of infectious endocarditis no longer recommend antimicrobial prophylaxis for genitourinary procedures solely to prevent infectious endocarditis. Similarly, guidelines published by the AUA and the American Academy of Orthopaedic Surgeons recommend that antimicrobial prophylaxis is not indicated for urologic patients based on the insertion or presence of orthopedic pins, plates, and screws.

Antimicrobial prophylaxis is recommended, however, for some urologic patients with total joint replacements if there are both an increased risk of joint infection and increased risk of bacteremia from the urologic procedure. The risk of joint infection is elevated during the first two years after joint replacement and in replacement patients with such comorbidities as immunosuppression, prior joint infection, inflammatory arthropathies, diabetes mellitus, malignancy, malnourishment, or HIV infection.

Procedures carrying an increased risk of bacteremia include any stone procedure, any bowel surgery, transrectal prostate biopsy, or entry into urinary tract in patient with increased risk of UTI. Appropriate agents would include oral fluoroquinolones or ampicillin (or vancomycin) plus gentamicin. In the setting of either cardiac valvular disease or total joint replacement, antimicrobial prophylaxis might be appropriate based on consideration of the patient and the urologic procedure, regardless of the cardiac or orthopedic conditions.

The antimicrobial prophylaxis recommendations are summarized in several tables in the Best Practice Statement. Justifications for the recommendations, including indication of the levels of evidence underlying the recommendations, are provided in the text. The key table is reproduced below (Table 1) and has been mailed to all members of the AUA.

Urologists can use these recommendations as a guide to efficacious, safe, and cost-effective administration of periprocedural antimicrobial prophylaxis. In the end, however, guidelines such as these are only a good starting point, as management of an individual patient requires consideration of not only these guidelines but also evaluation of the specific clinical circumstances.

Dr. Wolf is the David A. Bloom Professor of Urology and director of the Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical School, in Ann Arbor. He serves as vice-chair of the American Urological Association (AUA) Practice Guidelines Committee and chair of the AUA Urologic Surgery Antimicrobial Prophylaxis Best Practice Statement Panel. Other members of the panel included Carol J. Bennett, MD; Roger R. Dmochowski, MD; Brent K. Hollenbeck, MD, MS; Margaret S. Pearle, MD, PhD; and Anthony J. Schaeffer, MD.

Table 1.

Procedure	Prophylaxis Indicated	Antimicrobial(s) of Choice	Alternative Antimicrobial(s)
Prophylaxis for Lower Tract Instrumentation
Removal of external urinary catheter, cystography, urodynamic study, or simple cystourethroscopy	If risk factors	- Fluoroquinolone - Trimethoprim-sulfamethoxazole	- Aminoglycoside (Aztreonam) ± ampicillin - 1^st/2^nd gen. cephalosporin - Amoxicillin/Clavulanate
Cystourethroscopy with manipulation	All	- Fluoroquinolone - Trimethoprim-sulfamethoxazole	- Aminoglycoside (Aztreonam) ± ampicillin - 1^st/2^nd gen. cephalosporin - Amoxicillin/Clavulanate
Prostate brachy- or cryotherapy	Uncertain	- 1^st gen. gephalosporin	- Clindamycin
Transrectal prostate biopsy	All	- Fluoroquinolone - 2^nd/3^rd gen. cephalosporin	- Aminoglycoside (Aztreonam) + metronidazole or clindamycin
Prophylaxis for Upper Tract Instrumentation
Shock-wave lithotripsy and ureteroscopy	All	- Fluoroquinolone - Trimethoprim-sulfamethoxazole	- Aminoglycoside (Aztreonam) ± ampicillin - 1^st/2^nd gen. cephalosporin - Amoxicillin/Clavulanate
Percutaneous renal surgery	All	- 1^st/2^nd gen. cephalosporin, - Aminoglycoside (Aztreonam) + metronidazole or clindamycin	- Ampicillin/Sulbactam - Fluoroquinolone
Prophylaxis for Open or Laparoscopic Surgery
Vaginal surgery (includes urethral sling procedures) and surgery entering the urinary tract	All	- 1^st/2^nd gen. cephalosporin, - Aminoglycoside (Aztreonam) + metronidazole or clindamycin	- Ampicillin/Sulbactam - Fluoroquinolone
Surgery without entering urinary tract	If risk factors	- 1^st gen. cephalosporin (single dose)	- Clindamycin (single dose)
Surgery involving intestine	All	- 2^nd/3^rd gen. cephalosporin, - Aminoglycoside (Aztreonam) + metronidazole or clindamycin	- Ampicillin/Sulbactam - Ticarcillin/Clavulanate - Piperacillin/Tazobactam - Fluoroquinolone
Surgery involving implanted prosthesis	All	- Aminoglycoside (Aztreonam) + 1^st/2^nd gen. cephalosporin or vancomycin	- Ampicillin/Sulbactam - Ticarcillin/Clavulanate - Piperacillin/Tazobactam