Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
The following is a summary of the recommendations for peri-operative antibacterial prophylaxis in urology. Refer to the original guideline for more detailed recommendations and discussion.
The aim of antimicrobial prophylaxis in urological surgery is to prevent infective complications resulting from diagnostic and therapeutic procedures. However, the evidence on the best choice of antibiotics and prophylactic regimens is limited.
There is no evidence for any benefits of antibiotic prophylaxis in standard non-complicated endoscopic procedures and extracorporeal shockwave lithotripsy (ESWL), though it is recommended in complicated procedures and patients with identified risk factors.
For open surgery, the same rules as in abdominal surgery can be applied. No antibiotic prophylaxis is required for clean operations, while a single or 1-day dosage is recommended in clean-contaminated operations. Opening of the urinary tract should be considered as clean-contaminated surgery.
It is essential to categorize patients according to risk factors for infection. These include:
- History of genitourinary infection
- Previous instrumentation
- Assumed bacterial colonization
- Prolonged hospital or institutional stay
- Risk factors related to general health (e.g., diabetes mellitus, impaired immune system, malnutrition)
A single dose or a short course of antimicrobials can be given, either parenterally or orally. The administration route will depend on the type of intervention and patient characteristics. Oral administration requires drugs having good bioavailability. In a case of continuous urinary drainage, prolongation of peri-operative antibiotic prophylaxis is not recommended.
Many antibiotics are suitable for peri-operative antibacterial prophylaxis (e.g., second-generation cephalosporins, co-trimoxazole-sulphamethoxazole [TMP-SMZ], fluoroquinolones, aminopenicillins plus a beta-lactam inhibitor [BLI], and aminoglycosides). Broader-spectrum antibiotics should be used sparingly and reserved for treatment. This applies also to the use of vancomycin.
The use of antimicrobials should be based on knowledge of the local pathogen profile and antibiotic susceptibility pattern. Best practice includes surveillance and an audit of infectious complications.
Table: Recommendations for Antibiotic Prophylaxis in Standard Urological Surgery
Procedure |
Pathogens
(Expected)
|
Prophylaxis |
Antibiotics |
Remarks |
Diagnostic Procedures |
Transrectal biopsy of the prostate |
Enterobacteriaceae Anaerobes? |
All patients |
Fluoroquinolones TMP ± SMX Metronidazole? |
Short course (<72h) |
Cystoscopy Urodynamic examination |
Enterobacteriaceae Enterococci Staphylococci |
No |
Cephalosporin 2nd generation TMP ± SMX |
Consider only in risk patients |
Ureteroscopy |
Enterobacteriaceae Enterococci Staphylococci |
No |
Cephalosporin 2nd generation TMP ± SMX |
Consider in risk patients |
Endourological Surgery and ESWL |
ESWL |
Enterobacteriaceae Enterococci |
No |
Cephalosporin 2nd or 3rd generation TMP ± SMX Aminopenicillin/BLI |
In patients with stent or nephrostomy tube Consider in risk patients |
Ureteroscopy for uncomplicated distal stone |
Enterobacteriaceae Enterococci Staphylococci |
No |
Cephalosporin 2nd or 3rd generation TMP ± SMX Aminopenicillin/BLI Fluoroquinolones |
In patients with stent or nephrostomy tube Consider in risk patients |
Ureteroscopy of proximal or impacted stone and percutaneous stone extraction |
Enterobacteriaceae Enterococci Staphylococci |
All patients |
Cephalosporin 2nd or 3rd generation TMP ± SMX Aminopenicillin/BLI Fluoroquinolones |
Short course Length to be determined Intravenous suggested |
TUR of the prostate |
Enterobacteriaceae Enterococci |
All patients |
Cephalosporin 2nd or 3rd generation TMP ± SMX Aminopenicillin/BLI |
Low-risk patients and small-size prostate require no prophylaxis |
TUR of bladder tumour |
Enterobacteriaceae Enterococci |
No |
Cephalosporin 2nd or 3rd generation TMP ± SMX Aminopenicillin/BLI |
Consider in risk patients and large necrotic tumours |
Open Urological Surgery |
Clean operations |
Skin-related pathogens, e.g., staphylococci catheter-associated uropathogens |
No |
|
Consider in high-risk patients Short post-operative catheter treatment |
Clean-contaminated (opening of urinary tract) |
Enterobacteriaceae Enterococci Staphylococci |
Recommended |
Cephalosporin 2nd or 3rd generation TMP + SMX Aminopenicillin/BLI |
Single peri-operative course |
Clean-contaminated (use of bowel segments) |
Enterobacteriaceae Enterococci Anaerobes Skin-related bacteria |
All patients |
Cephalosporin 2nd or 3rd generation Metronidazole |
As for colonic surgery |
Implant of prosthetic devices |
Skin-related bacteria, e.g., staphylococci |
All patients |
Cephalosporin 2nd or 3rd generation Penicillin (penicillinase stable) |
|
Laparoscopic procedures |
|
|
|
As for open surgery |
BLI = beta-lactamase inhibitor; ESWL = extracorporeal shockwave lithotripsy; TMP ± SMX = trimethoprim with or without sulphamethoxazole (co-trimoxazole); TUR = transurethral resection