• American Urological Association Education and Research, Inc. Best practice policy statement on urologic surgery antimicrobial prophylaxis. Baltimore (MD): American Urological Association Education and Research, Inc.; 2007. 45 p. [100 references]

This is the current release of the guideline.

Definitions of the strength of the evidence (Ia – IV) are defined at the end of the "Major Recommendations" field.

Principles of Surgical Antimicrobial Prophylaxis

1. Surgical antimicrobial prophylaxis is the periprocedural systemic administration of an antimicrobial agent intended to reduce the risk of postprocedural local and systemic infections.
2. The potential benefit of surgical antimicrobial prophylaxis is determined by three considerations: patient-related factors (ability of the host to respond to bacterial invasion), procedural factors (likelihood of bacterial invasion at the operative site), and the potential morbidity of infection.
3. Surgical antimicrobial prophylaxis is recommended only when the potential benefit exceeds the risks and anticipated costs.
4. The antimicrobial agent used for prophylaxis should be effective against the disease-relevant bacterial flora characteristic of the operative site. Cost, convenience, and safety of the agent also should be considered.
5. The duration of surgical antimicrobial prophylaxis should extend throughout the period in which bacterial invasion is facilitated and/or is likely to establish an infection.

Table. Recommended Antimicrobial Prophylaxis for Urologic Procedures

Order of agents in each column is not indicative of preference. The absence of an agent does not preclude its appropriate use depending on specific situations.

¹Additional antimicrobial therapy may be recommended at the time of removal of an externalized urinary catheter.

²GU tract: Common urinary tract organisms are Escherichia coli, Proteus species (sp.), Klebsiella sp., Enterococcus.

³See Table 1 in the original guideline document "Patient-related factors affecting host response to surgical infections."

⁴If urine culture shows no growth prior to the procedure, antimicrobial prophylaxis is not necessary.

⁵Or full course of culture-directed antimicrobials for documented infection (which is treatment, not prophylaxis).

⁶Includes transurethral resection of bladder tumor and prostate, and any biopsy, resection, fulguration, foreign body removal, urethral dilation or urethrotomy, or ureteral instrumentation including catheterization or stent placement/removal.

⁷Clindamycin, or aminoglycoside + metronidazole or clindamycin, are general alternatives to penicillins and cephalosporins in patients with penicillin allergy, even when not specifically listed.

⁸Intestine: Common intestinal organisms are E. coli, Klebsiella sp., Enterobacter, Serratia sp., Proteus sp., Enterococcus, and Anaerobes.

⁹Skin: Common skin organisms are Staph. aureus, coagulase negative Staph. sp., Group A Strep. sp.

¹⁰For surgery involving the colon, bowel preparation with oral neomycin plus either erythromycin base or metronidazole can be added to or substituted for systemic agents.

Abbreviations: gen, generation; GU, genitourinary; sp, species; Staph., Staphylococcus; Strep., Streptococcus; TMP-SMX, trimethoprim-sulfamethoxazole.

Refer to Table 3b in the original guideline document for information on recommended dosages of prophylactic antimicrobial agents.

Table. Antimicrobial Prophylaxis for Patients with Orthopedic Conditions

• Antimicrobial prophylaxis is not indicated for urologic patients on the basis of orthopedic pins, plates, and screws, nor is it routinely indicated for most urologic patients with total joint replacements on that basis alone.
• Antimicrobial prophylaxis intended to reduce the risk of hematogenous total joint infection is recommended in patients who meet BOTH sets of criteria in the table below. The recommended antimicrobial regimen in these patients include:
  • A single systemic level dose of a quinolone (e.g., ciprofloxacin, 500 mg; levofloxacin, 500 mg; ofloxacin, 400 mg) orally one to two hours preoperatively.
  • Ampicillin 2 g intravenous (IV) (or vancomycin 1 g IV over one to two hours in patients allergic to ampicillin) plus gentamicin 1.5 mg/kg IV 30 to 60 minutes preoperatively.
  • For some procedures, additional or alternative agents may be considered for prophylaxis against specific organisms and/or other infections.
• For patients NOT meeting BOTH of these criteria, antimicrobial prophylaxis still may be indicated to reduce the risk of other infections.

Adapted from American Urological Association; American Academy of Orthopaedic Surgeons: Antimicrobial prophylaxis for urological patients with total joint replacements. J Urol 2003; 169:1796.

Definitions:

Levels of Evidence

Ia Evidence obtained from meta-analysis of randomized trials

Ib Evidence obtained from at least one randomized trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study

III Evidence obtained from well-designed nonexperimental studies, such as comparative studies, correlation studies, and case reports

IV Evidence obtained from expert committee reports, or opinions, or clinical experience of respected authorities

None provided

The type of supporting evidence is identified and graded for each antimicrobial prophylaxis recommendation (see Major Recommendations" field).

• American Urological Association Education and Research, Inc. Best practice policy statement on urologic surgery antimicrobial prophylaxis. Baltimore (MD): American Urological Association Education and Research, Inc.; 2007. 45 p. [100 references]

Not applicable: The guideline was not adapted from another source.

2007 Jan

American Urological Association Education and Research, Inc. - Medical Specialty Society

American Urological Association Education and Research, Inc. (AUA)

AUA Antimicrobial Prophylaxis Panel

Panel Members: J. Stuart Wolf, Jr., MD, Chairman; Carol J. Bennett, MD; Roger R. Dmochowski, MD; Brent K. Hollenbeck, MD, MS; Margaret S. Pearle, MD, PhD; Anthony J. Schaeffer, MD

Staff: Heddy Hubbard, PhD; Edith M. Budd; Michael Folmer; Katherine Moore; Kadiatu Kebe

Members received no remuneration for their work. Each Panel member provided a conflict of interest disclosure to the American Urological Association (AUA).

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on March 21, 2008. The information was verified by the guideline developer on April 1, 2008. This summary was updated by ECRI Institute on July 28, 2008 following the U.S. Food and Drug Administration advisory on fluoroquinolone antimicrobial drugs.

This NGC summary is based on the original guideline, which is copyrighted by the American Urological Association Education and Research, Inc. (AUA).