Definitions of the strength of the evidence (Ia – IV) are defined at the end of the "Major Recommendations" field.
Note from the American Urological Association (AUA) and the National Guideline Clearinghouse (NGC): The table of recommended antimicrobial prophylaxis for urologic procedures, below, was updated in September 2012 to include the use of cephalosporin for transrectal biopsies.
Principles of Surgical Antimicrobial Prophylaxis
- Surgical antimicrobial prophylaxis is the periprocedural systemic administration of an antimicrobial agent intended to reduce the risk of postprocedural local and systemic infections.
- 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.
- Surgical antimicrobial prophylaxis is recommended only when the potential benefit exceeds the risks and anticipated costs.
- 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.
- 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
Procedure |
Organisms |
Prophylaxis Indicated |
Antimicrobial(s) of Choice |
Alternative Antimicrobial(s) |
Duration of Therapy1 |
Lower Tract Instrumentation |
Removal of external urinary catheter (Level of evidence: Ib, III, IV) |
GU tract2 |
If risk factors3,4 |
- Fluoroquinolone5
- TMP-SMX5
|
- Aminoglycoside (Aztreonam6) + Ampicillin5
- 1st/2nd gen. Cephalosporin5
- Amoxicillin/Clavulanate5
|
≤24 hours5 |
Cystography, urodynamic study, or simple cystourethroscopy (Level of evidence: Ib, III, IV) |
GU tract |
If risk factors4 |
|
- Aminoglycoside (Aztreonam6) + Ampicillin
- 1st/2nd gen. Cephalosporin
- Amoxicillin/Clavulanate
|
≤24 hours |
Cystourethroscopy with manipulation7 (Level of evidence: Ia/b, IV) |
GU tract |
All |
|
- Aminoglycoside (Aztreonam6) + Ampicillin
- 1st/2nd gen. Cephalosporin
- Amoxicillin/Clavulanate
|
≤24 hours |
Prostate brachytherapy or cryotherapy (Level of evidence: III, IV) |
Skin |
Uncertain |
|
|
≤24 hours |
Transrectal prostate biopsy (Level of evidence: Ib) |
Intestine9 |
All |
- Fluoroquinolone
- 1st/2nd/3rd gen. Cephalosporin
|
- Aminoglycoside (Aztreonam6) + Metronidazole or Clindamycin8
|
≤24 hours |
Upper Tract Instrumentation |
Shock-wave lithotripsy (Level of evidence: Ia) |
GU tract |
All |
|
- Aminoglycoside (Aztreonam6) + Ampicillin
- 1st/2nd gen. Cephalosporin
- Amoxicillin/Clavulanate
|
≤24 hours |
Percutaneous renal surgery (Level of evidence: IIb, III) |
GU tract and skin10 |
All |
- 1st/2nd gen. Cephalosporin
- Aminoglycoside (Aztreonam6) + Metronidazole or Clindamycin
|
- Ampicillin/Sulbactam
- Fluoroquinolone
|
≤24 hours |
Ureteroscopy (Level of evidence: Ib) |
GU tract |
All |
|
- Aminoglycoside (Aztreonam6) + Ampicillin
- 1st/2nd gen. Cephalosporin
- Amoxicillin/Clavulanate
|
≤24 hours |
Open or Laparoscopic Surgery |
Vaginal surgery (Level of evidence: Ia/b, IIb) |
GU tract, skin, and Group B Strep. |
All |
- 1st/2nd gen. Cephalosporin
- Aminoglycoside (Aztreonam6) + Metronidazole or Clindamycin
|
- Ampicillin/Sulbactam
- Fluoroquinolone
|
≤24 hours |
Without entering urinary tract (Level of evidence: Ib, III, IV) |
Skin |
If risk factors |
|
|
Single dose |
Involving entry into urinary tract (Level of evidence: Ib, III, IV) |
GU tract and skin |
All |
- 1st/2nd gen. Cephalosporin
- Aminoglycoside (Aztreonam6) + Metronidazole or Clindamycin
|
- Ampicillin/Sulbactam
- Fluoroquinolone
|
≤24 hours |
Involving intestine11 (Level of evidence: Ia, IV) |
GU tract, skin, and intestine |
All |
- 2nd/3rd gen. Cephalosporin
- Aminoglycoside (Aztreonam6) + Metronidazole or Clindamycin
|
- Ampicillin/Sulbactam
- Ticarcillin/Clavulanate
- Piperacillin/Tazobactam
- Fluoroquinolone
|
≤24 hours |
Involving implanted prosthesis (Level of evidence: Ia, IV) |
GU tract and skin |
All |
- Aminoglycoside (Aztreonam6) + 1st/2nd gen. Cephalosporin or Vancomycin
|
- Ampicillin/Sulbactam
- Ticarcillin/Clavulanate
- Piperacillin/Tazobactam
|
≤24 hours |
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).
6Aztreonam can be substituted for aminoglycosides in patients with renal insufficiency.
7Includes 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.
8Clindamycin, or aminoglycoside + metronidazole or clindamycin, are general alternatives to penicillins and cephalosporins in patients with penicillin allergy, even when not specifically listed.
9Intestine: Common intestinal organisms are E. coli, Klebsiella sp., Enterobacter, Serratia sp., Proteus sp., Enterococcus, and Anaerobes.
10Skin: Common skin organisms are Staph. aureus, coagulase negative Staph. sp., Group A Strep. sp.
11For 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.
Increased Risk of Hematogenous Total Joint Infection |
Increased Risk of Bacteremia Associated with Urologic Procedures |
- Patients during the first two years after prosthetic joint replacement
- Immunocompromised patients with prosthetic joint replacements
- Inflammatory arthropathies (e.g., rheumatoid arthritis, systemic lupus erythematosus)
- Drug-induced immunosuppression
- Radiation-induced immunosuppression
- Patients with prosthetic joint replacements and comorbidities
- Previous prosthetic joint infections
- Malnourishment
- Hemophilia
- Human immunodeficiency virus (HIV) infection
- Diabetes
- Malignancy
|
- Any stone manipulation (includes shock-wave lithotripsy)
- Any procedure with transmural incision into urinary tract (does not include simple ligation with excision or percutaneous drainage procedure)
- Any endoscopic procedures of upper tract (ureter and kidney)
- Any procedure that includes bowel segments
- Transrectal prostate biopsy
- Any procedure with entry into the urinary tract (except for urethral catheterization) in individuals with higher risk of bacterial colonization:
- Indwelling catheter or intermittent catheterization
- Indwelling ureteral stent
- Urinary retention
- History of recent/recurrent urinary tract infection or prostatitis
- Urinary diversion
|
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