Antibiotic prophylaxis is used to minimize infectious complications resulting from interventions. Side-effects and development of microbial resistance patterns are risks of the use of antibiotics. Therefore, the use should be well considered and based on high levels of evidence. In this review, all available evidence on the use of antibiotic prophylaxis in urology is gathered, assessed, and presented in order to make choices in the use of antibiotic prophylaxis on the best evidence currently available.
Methods
A systematic literature review was conducted, searching Medline, Embase (1980–2006), the Cochrane Library, and reference lists for relevant studies. All selected articles were reviewed independently by two, and, in case of discordance, three, reviewers.
Results
Only the transurethral resection of prostate (TURP) and prostate biopsy are well studied and have a high and moderate to high level of evidence in favour of using antibiotic prophylaxis. Other urologic interventions are not well studied. The moderate to low evidence suggests no need for antibiotic prophylaxis in cystoscopy, urodynamic investigation, transurethral resection of bladder tumor, and extracorporeal shock-wave lithotripsy, whereas for therapeutic ureterorenoscopy and percutaneous nephrolithotomy, the low evidence favours the use of antibiotic prophylaxis. Urologic open and laparoscopic interventions were classified according to surgical wound classification, since no studies were identified. Antibiotic prophylaxis is not advised in clean surgery, but is advised in clean-contaminated and prosthetic surgery.
Conclusions
Except for the TURP and prostate biopsy, there is a lack of well-performed studies investigating the need for antibiotic prophylaxis in urologic interventions.
Introduction
Antibiotic prophylaxis is a brief course of antibiotics administered before or at the start of an intervention and used to minimize the infectious complications resulting from diagnostic and therapeutic interventions. While the rationale for the use of antibiotics is well accepted, possible side-effects and development of microbial resistance patterns are potential risks. Therefore, an antibiotic prophylaxis policy should be well considered and, ideally, based on high levels of evidence.
Urology is a surgical speciality which has undergone many changes in the last decade. Surgical procedures have mainly shifted from open to endoscopic and laparoscopic procedures, and nowadays, a greater number of elderly patients or carriers of temporary urinary derivations are being operated on. These developments can influence the choice of antibiotic prophylaxis policy.
Although it is common practice to administer antibiotic prophylaxis in many urologic procedures, there is still little evidence for the use of antibiotic prophylaxis in most of these procedures. This is mainly due to the lack of well-designed studies as well as the lack of clear definitions of favourable outcome parameters.
The question remains to what extent antibiotic prophylaxis is beneficial in the different urologic procedures. Various authors have addressed this issue in reviews in recent years [1], [2], [3], [4]. Also, the European Association of Urology (EAU) has recently updated the guideline “Management of urinary and male genital tract infections,” including a chapter on perioperative antibacterial prophylaxis in urology [5]. However, with the exception of the transurethral resection of the prostate [6], [7], few of the recommendations in these reviews and guidelines are supported by evidence gathered in a structured systematic review. The aim of this paper is to provide a systematic review on the value of antibiotic prophylaxis during different urologic procedures in order to make choices in the use of antibiotic prophylaxis on the best evidence currently available.
Section snippets
Methods
Between June 2006 and March 2007, the electronic databases Medline, Embase (1980–2006), and the Cochrane Library were searched using the terms postoperative complications, infection, bacteriuria, antibiotic prophylaxis, chemoprophylaxis, antibiotics, and premedication plus randomized controlled trial (RCT). Additional search terms were added for the different urologic interventions investigated (Table 1). Reference lists were screened for relevant trials.
RCTs comparing antibiotic prophylaxis
Results
The included RCTs are presented in Table 2, Table 3, Table 4, Table 5, Table 6, Table 7, Table 8, along with their level of evidence. When no RCT was included, the results and level of evidence of the non-RCTs are described in the corresponding paragraph below, along with the reasons for exclusion of the corresponding RCTs. For uniformity of outcomes, asymptomatic bacteriuria and asymptomatic urinary tract infection are both referred to as bacteriuria and symptomatic urinary tract infection
Discussion
In this systematic review, all currently available RCTs addressing the use of antibiotic prophylaxis in urologic interventions were identified and assessed and the results grouped and presented. For most urologic interventions, there is only moderate to low evidence for the use of antibiotic prophylaxis, with the exception of TURP and prostate biopsy. Strong evidence supports the use of short-term prophylaxis for TURP, and this evidence is moderate to high for prostate biopsy.
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Conclusions
Ideally, antibiotic prophylaxis in urologic procedures should only be administered when well-performed studies demonstrate its beneficial effect on post-intervention infectious complications. Because of the current lack of evidence, those patients with increased risk for infectious complications should receive antibiotic prophylaxis. Further research is needed because, except for TURP and prostate biopsy, there is a lack of well-performed studies.
