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9. Peri-operative antibacterial prophylaxis in urology
9.1 Summary
The
main aim of antimicrobial prophylaxis in urology is to prevent
symptomatic/febrile genito-urinary infections, such as acute
pyelonephritis, prostatitis, epididymitis and urosepsis, as well as
serious woundinfections.
The need for prophylaxis depends on the type of intervention and the individual risk for each individual patient. General antibiotic prophylaxis is not required in open operations without bowel segments. The same is true for reconstructive operations in the genital area, with the exception of long or secondary interventions, or implant surgery. For diagnostic interventions, peri-operative antibacterial prophylaxis is generally recommended only in transrectal prostate biopsy with a thick needle. Prophylaxis should always be considered in patients who have an increased risk of infection, and especially before a transurethral resection of the prostate (TURP) if there is a history of a UTI.
Generally, a single full dose of a suitable antibiotic, preferably administered parenterally (alternatively with oral drugs with excellent bioavailability, e.g. fluoroquinolones), is appropriate for prophylaxis. Only in the case of a prolonged intervention (> 3 hours) may additional doses be required, the size and timing of which are dictated by the pharmacokinetics of the antibiotic. Antibiotic prophylaxis should not be continued for > 24 hours. When continuous urinary drainage, e.g. indwelling catheter, stent, nephrostomy, etc., is left in place after an operation, prolongation of peri-operative antibacterial prophylaxis is contra-indicated.
Many antibiotics meet the criteria for use in prophylaxis (Appendix 4), e.g. second-generation cephalosporins, fluoroquinolones and aminopenicillins plus a BLI. Aminoglycosides should be reserved for high-risk patients and those who are allergic to (3-lactams. Broad-spectrum antibiotics, such as third-generation cephalosporins, acylaminopenicillins plus a BLI, or carbapenems, should be used only sparingly, e.g. if the site of the operation is contaminated with multi-resistant nosocomial bacteria. This applies also to the use of vancomycin.