Urological Procedures ( Excluding Bladder Catheterisation ) - Guideline for Antimicrobial Prophylaxis During

Publication: 20/11/2009  
Last review: 01/03/2019  
Next review: 01/03/2022  
Clinical Guideline
CURRENT 
ID: 1713 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for Antimicrobial Prophylaxis during Urological Procedures (Excluding Bladder Catheterisation)

Summary

This guideline applies to patients who do NOT have systemic symptoms or signs of infection [e.g. fever >38oC, rigors, chills, unexplained new confusion etc] or symptoms of urinary tract infection. Wherever possible symptomatic urinary tract infection should be treated according to LTHT UTI guidelines and elective procedures delayed until treatment is complete.

Table 1. Antimicrobial prophylaxis recommendations for outpatient urological procedures

Part A. Outpatient procedures

Prophylaxis recommended?

Evidence level

Prophylaxis aims to reduce

NNT

Antimicrobial dose/route ≤ 1 hours prior to procedure

Routine And Penicillin allergy

Ciprofloxacin resistance detected

MRSA risk

Transrectal ultrasound and biopsy of prostate OR implantation of gold markers for guiding prostatic radiotherapy*

YES

A1,7
D for gold markers

Evidence only for reduction of bacteriuria

27

Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin 750 mg PO single dose

Antibiotic choice directed by the results of susceptibility testing. See text

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV single dose PLUS
Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin750mg
PO single dose

Transperineal biopsy of prostate and brachytherapy

YES

D

   

Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin750 mg PO single dose

N/A

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV single dose PLUS
Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin750mg PO single dose.

Cystoscopy - No bacteriuria

NO

A2

         

Cystoscopy - Asymptomatic bacteriuria (as determined by pre-procedural MSU)

Yes

A2

   

Single dose according to organism susceptibility
OR
if dipstick positive for leukocytes and nitrites but culture results unknown Gentamicin 2mg/kg IBW IV single dose

N/A

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Urodynamic examination

Case-by-case

D

         

NNT = number needed to treat; IBW, ideal body weight.
*Patients undergoing these procedures require rectal screening for Ciprofloxacin resistance; please see text for more details.

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Table 2. Antimicrobial prophylaxis recommendations for endourological procedures

Part B. Endourological procedures

Prophylaxis recommended?

Evidence level

Prophylaxis aims to reduce

NNT

Antimicrobial dose/route ≤ 1 hours prior to procedure

Routine

MRSA risk OR endocarditis risk and confirmed bacteriuria

Extracorporeal shock-wave lithotripsy [ESWL] - no bacteriuria

NO

A1,2 conflicting

Urinary tract infection

28

   

Extracorporeal shock-wave lithotripsy [ESWL] - confirmed or suscepted asymptomatic bacteruria

Yes

A1,2 conflicting

Urinary tract infection

 

Single dose according to organism susceptibility
OR
if dipstick positive for leukocytes and nitrites but culture results unknown Gentamicin 2mg/kg IBW IV single dose

Patients with suspected asymptomatic bacteriuria or active infection and endocarditis risk factors:
Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV single dose
PLUS Gentamicin 2mg/kg IBW IV single dose

Ureterorenoscopy (diagnostic, therapeutic, stent change/removal, stone removal)

YES
(Patients with suspected asymptomatic bacteriuria or active infection and endocarditis risk factors)

B1

Bacteriuria, post op fever

10, -15

Gentamicin 2mg/kg IBW IV single dose

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV single dose
PLUS Gentamicin 2mg/kg IBW IV single dose

Transurethral resection of prostate or bladder tumour

YES

A1
D

Infective complication

8

Gentamicin 2mg/kg IBW IV single dose

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV single dose
PLUS Gentamicin 2mg/kg IBW IV single dose

Percutaneous removal of renal stones.

YES

B1

Urosepsis

4

Gentamicin 2mg/kg IBW IV single dose

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV single dose
PLUS Gentamicin 2mg/kg IBW IV single dose

Percutaneous nephrostomy

If kidney infection suspected treat according to UTI guidelines
Give prophylaxis only if stones present,
surgical reconstruction of urinary tract, stent or catheter in situ, diabetes.

D

Urosepsis

-

Gentamicin 2mg/kg IBW IV single dose

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV single dose
PLUS Gentamicin 2mg/kg IBW IV single dose

NNT = number needed to treat; IBW, ideal body weight

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Table 3. Antimicrobial prophylaxis recommendations for open/laparoscopic urological procedures

Part C. Open or laparoscopic procedures

Prophylaxis recommended?

Evidence level

Prophylaxis aims to reduce

NNT

Antimicrobial dose/route ≤ 1 hours prior to procedure

Routine

MRSA risk factors or true penicillin allergy.

Clean operation.

NO

A

       

Clean-contaminated [opening of intestine].

YES

A 1

SSI

 

Flucloxacillin Description: electronic Medicines Compendium information on Flucloxacillin1g IV PLUS
Gentamicin 2mg/kg IBW IV PLUS
Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV
All single dose.

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV PLUS Gentamicin
2mg/kg IBW IV PLUS Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV.
All single dose.

Clean-contaminated [opening of urinary tract].

YES

A 1

SSI

 

Flucloxacillin Description: electronic Medicines Compendium information on Flucloxacillin1g IV PLUS
Gentamicin 2mg/kg IBW IV
All single dose

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV PLUS Gentamicin
2mg/kg IBW IV
All single dose.

Implantation of prosthetic penile devices.

YES

D1

Wound or implant infection

 

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV single dose PLUS Gentamicin 2mg/kg
IBW IV
All single dose.

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV single dose PLUS
Gentamicin 2mg/kg IBW IV
All single dose.

NNT = number needed to treat; IBW, ideal body weight

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Introduction

A review of antimicrobial prophylaxis recommendations for urological procedures in Leeds in 2009 was prompted by on-going problems of meticillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile infection (CDI) in the Trust, publication of updated Scottish Intercollegiate Guideline Network (SIGN) surgical prophylaxis guidelines, a recent systematic review of urology prophylaxis, publication of updated European Association of Urology guidelines and publication of NICE endocarditis prophylaxis guidelines 1-9. These guidelines contradict each other in many instances justifying a local review of evidence and practice.

In the 2013 revision, prophylaxis for TRUS and biopsy of the prostate has been revised (see later), while other recommendations remain unchanged.

The aim of this guideline is to maximise the potential benefit of antimicrobial prophylaxis for patients while reducing any associated risks. Antimicrobial prophylaxis will only be offered where there is clear evidence of benefit or an expert consensus that benefit is likely.

In urological practice, one difficulty in interpreting available data and determining optimal antimicrobial prophylaxis is the end point of analysis. The most severe infective consequences of a urological procedure are bloodstream infection [including severe sepsis and septic shock] and infective endocarditis. Such complications are so uncommon that most studies are under-powered to detect any benefit; thus the number of patients exposed to antimicrobials (number needed to treat) without benefit is large compared to the small numbers who may gain. This must therefore be balanced against the increasing problems associated with antimicrobials.

Urinary tract infection is a less severe but important complication of many urological procedures. The clinical significance of post-operative asymptomatic bacteriuria however is questionable and therefore giving prophylaxis to this end is questionable, the risks of particular antimicrobial agents take on a much greater significance in this setting and this is reflected in the choice of agent.

LTHT guidelines should be applicable to the majority of patients. Where the recommendations in these guidelines do not seem appropriate for a particular patient, the urologist is advised to discuss the case with a Microbiologist.

Endocarditis prophylaxis
Routine endocarditis prophylaxis is no longer recommended for patients undergoing urological procedures 3. Both AHA and NICE, having reviewed the evidence, concluded that there was insufficient evidence to support prophylaxis against IE for urological procedures. But, the use of appropriate antimicrobial therapy is recommended for patients at increased risk of developing endocarditis who have known or suspected infection at the site of a procedure/operation (i.e. bacteriuria/urinary tract infection at the time of a urological procedure) 8. The important consideration in this setting is ensuring anti-enterococcal activity. It is important to consider that many urology patients will have undiagnosed cardiac valvular lesions that put them at increased risk of IE.

The agreed pragmatic view in Leeds to the problem of implementing this change in recommendation is to counsel patients who have previously received endocarditis prophylaxis that the benefit of this practice has been questioned (globally) and that prophylaxis carries its own risks – if they continue to want routine prophylaxis and accept the risks it would seem reasonable to offer it to this select group.

In summary, although routine use of endocarditis prophylaxis is no longer recommended it is required for patients who have confirmed or clinically suspected infection at the site of a procedure which may include for example, infected stones. The summary tables recommend appropriate prophylaxis regimens for patients with endocarditis risk factors in this situation.

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Part A. Outpatient procedures. Transrectal ultrasound and biopsy of the prostate (TRUS), transperineal biopsy of the prostate, cystoscopy and urodynamic examination

Background information

For TRUS there is moderate to high level evidence that antibiotic prophylaxis reduces bacteriuria but no evidence that the harder endpoints of UTI or bloodstream infection are reduced. There is however agreement between SIGN guidelines and Bootsma, et al. that prophylaxis is indicated 1, 2.

A meeting between urologists, radiologists and Microbiologists was convened because: 1) the 2009 recommendation for Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav (Amoxicillin-Clavulanate) had not been universally adopted and those that had used it had experienced an apparent increase in infections and had reverted to Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin use and 2) In 2011, concerns were raised by urologists and Microbiologists about use of Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin as a sole agent for TRUS prophylaxis is less effective than previously thought, highlighted by a patient spending some weeks in ITU with severe sepsis post TRUS caused by a ciprofloxacin-resistant coliform. It was also noted that we should attempt to limit Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacinuse because of increasing ciprofloxacin-resistant bacteria in our population and its association with CDI. To try to address the problem of Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin resistance we agreed to modify prophylaxis regimen for TRUS to include a single dose of Gentamicin. There is no evidence that prolonged prophylaxis regimes are better than single-dose regimes. It was also agreed to stop using Metronidazole electronic Medicines Compendium information on Metronidazole (current practise in urology).

In 2013 a number of Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin resistant bacteraemias post TRUS biopsy were detected (4 in a 3 month period of surveillance) despite the addition of Gentamicin. A review of the literature identified two papers which addressed this problem by completing rectal swab (labelled “TRUS prostate resistance screen”) looking for Ciprofloxacin resistant E. coli before the TRUS biopsy 3,4. After review by Microbiologists and urologists these papers were deemed to provide sufficient evidence to introduce rectal screening into routine practice, with review after 6 months. Most patients do not carry Ciprofloxacin resistant E. coli and their rectal screens will be reported as: Ciprofloxacin resistant coliform not detected. These patients should receive Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin mono-therapy as prophylaxis. Where Ciprofloxacin resistance is detected the coliform will be identified to species level e.g. E. coli and antimicrobial sensitivity testing completed and reported. The choice of prophylaxis will depend on the results of the sensitivity testing, see Table 1.

Implantation of gold markers into the prostate as part of radiotherapy uses a very similar approach to TRUSS and therefore the recommendations for prophylaxis are the same.

Transperineal biopsy of the prostate (TBP) does not require the biopsy needle to traverse the rectal wall, only the perineal skin, it is therefore a “clean” procedure, requiring optimal skin disinfection. The reported incidence of infection in the literature is very low (<1%) even without prophylaxis 10-12, however, it is custom and practise in most centres worldwide to give some form of prophylaxis. It has therefore been agreed locally to use the same prophylaxis regimen for all prostate biopsy procedures. Prostatic brachytherapy involves implantation of radioactive active iodine seeds into the prostate using the same technique as TBP; the antimicrobial prophylaxis regimen for TBP is therefore recommended for this procedure.

Cystoscopy may be followed by a transient bacteraemia 13 and may predispose to bacteriuria and urinary tract infection but this is uncommon. A recent systematic review concluded that prophylaxis was not indicated in the absence of risk factors for UTI, and prophylaxis has been variably used in Leeds. A commonly held and pragmatic view is to offer prophylaxis only to patients with bacteriuria 13,14 and to postpone procedures in those with symptomatic UTI.

Urodynamic examination is a variation on cystoscopy but repeated catheterisation and catheter manipulation may be required. There is low-level evidence that antimicrobial prophylaxis is of no benefit 2. Low level evidence also suggests that there may be benefit in certain patients with specific risk factors for UTI post procedure e.g. neurogenic bladder, transplant patients, immunosuppressed patients and carriers of vesicoureteral reflux 2.

Aim
Reduction in post procedure UTI or bloodstream infection.

Antimicrobial prophylaxis recommendations
TRUS

Rectal screen result: Ciprofloxacin resistant coliform NOT isolated
Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin 750mg PO [Evidence level A for prophylaxis D for choice of agent].
Rectal screen result: Ciprofloxacin resistant coliform isolated. Please review sensitivity testing results.

The following alternative antibiotics are recommended in order of choice

*Fosfomycin is only routinely tested in patients with penicillin allergy.

In the absence of a rectal screen result, the patient should either be re-scheduled and a screen sent, or if urgent, discussed with Microbiology.

In 2018 the MHRA published a risk advice notice regarding fluroquinolone and an increased risk of aneurysms and dissection. As such it is advised that a risk assessment for each patient prescribed ciprofloxacin is undertaken to evaluate the risk versus benefit. Where the risk is deemed high, then please discuss with Microbiology for a suitable alternative agent. Advice note available here: https://www.gov.uk/drug-safety-update/systemic-and-inhaled-fluoroquinolones-small-increased-risk-of-aortic-aneurysm-and-dissection-advice-for-prescribing-in-high-risk-patients

Transperineal biopsy of the prostate (TPB) of the prostate does require screening for Ciprofloxacin resistance. Antimicrobial prophylaxis has been agreed pending further information [Evidence level D]. The agreed choice of prophylaxis is: Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin750mg PO.

Routine prophylaxis for cystoscopy is not indicated, but if a particular case was considered to require prophylaxis, Gentamicin has broad activity against common Gram-negative causes of UTI and would be an appropriate empirical choice if required. When patients have a positive urine sample, prophylaxis should be guided by susceptibilities. [Evidence level D].

Urodynamic procedures – there is no Leeds consensus and an evaluation of pre-procedure bacteriuria is to be undertaken and a review of peri-procedural infective complications.

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Part B. Endourologic procedures

1. Extracorporeal shock-wave lithotripsy [ESWL] for removal of renal stones.

Background information
Routine antimicrobial prophylaxis is not currently used in Leeds for ESWL. SIGN recommendations and those from a recent systematic review are conflicting, SIGN recommending prophylaxis. Infection rates are variable but not insignificant. As a minimum, prophylaxis should be offered to patients with asymptomatic bacteruria and/or immunocompromise.

 

ESWL Median [95% CI]

URS Median [95% CI]

SEPSIS

   

Distal Ureter

3% [2 - 5]%

2%[1 - 4]%

Mid Ureter

5%[0 - 20]%

4% [1 - 11]%

Proximal Ureter

3%[2 - 4]%

4% [2 - 6]%

     

UTI

   

Distal Ureter

4% [1-12]%

4%[2-7]%

Mid Ureter

6%[1-16]%

2% [0-7]%

Proximal Ureter

4%[2 - 7]%

4% [1 - 8]%

Table 1. Infective complication rates with extracorporeal shock-wave lithotripsy [ESWL] or ureterorenoscopic removal of renal stones (URS) Overall Population 15

Aim
Reduction in post procedure UTI or bloodstream infection.

Antimicrobial prophylaxis recommendations
Gentamicin has broad activity against common Gram-negative causes of UTI and would be an appropriate empirical choice. When a patient has a positive urine sample, prophylaxis can be guided by susceptibilities. [Evidence level B]

2. Ureterorenoscopy

Background information
Only two studies of prophylaxis for ureterorenoscopic stone removal have been undertaken 16,17. One found a significant reduction in post-operative bacteriuria but no serious infective complications or symptomatic UTI in either the prophylaxis or control groups 11. The length of hospital stay was also the same in both groups.

This study did not therefore demonstrate any benefit for patients taking antimicrobial prophylaxis. The second compared a period on single dose with multiple dose prophylaxis and found no difference 17.

These studies were undertaken in patients without clinical evidence of infection [e.g. fever >38oC] or laboratory evidence of infection [e.g. peripheral white cell count >15x109/L] 16-18.

On the basis of the two studies, a European guideline has recommended routine use of antimicrobial prophylaxis for ureteroscopic stone removal. SIGN and 2 have come to the same conclusion, with level B evidence.

Aim
Reduction in symptomatic urinary tract or bloodstream infection.

Antimicrobial prophylaxis recommendations
Since diagnostic ureterorenoscopy may become therapeutic and this cannot be predicted, the pragmatic approach is to prophylaxis all patients. Gentamicin has broad activity against common Gram-negative causes of UTI and would be an appropriate empirical choice. Where a patient has a positive urine sample, prophylaxis can be guided by susceptibilities. Evidence level A

3. Transurethral resection of prostate and transurethral resection of bladder tumour

Background information
Current guidelines do not recommend prophylaxis for transurethral resection of bladder tumour1 but there is high-level evidence and general agreement that prophylaxis is indicated for transurethral resection of the prostate 1. The view in Leeds is that prophylaxis in transurethral resection of bladder tumours has not been studied and that is why no recommendation can be made. Since these procedures are not considered vastly different in their risk of causing infection prophylaxis is recommended.

Aim
Reduction in urinary tract infection and sepsis.

Antimicrobial prophylaxis recommendations
Urinary pathogens should be covered, Gentamicin provides a reasonably broad spectrum anti-Gram negative cover but lacks anti-enterococcal activity. Anti-enterococal cover is required in patients with endocarditis risk factors and suspected infection. Evidence level C.

4. Percutanous nephrolithotomy and nephrostomy placement.

Background information
Low-level evidence supports the use of prophylaxis.

Aim
Reduction in urinary tract infection and sepsis.

Antimicrobial prophylaxis recommendations
Gentamicin has broad activity against common Gram-negative causes of UTI and would be an appropriate empirical choice. Evidence level B.

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Part C Open/laparoscopic procedures

Background information
The principle of classifying infection risk according to the degree of wound contamination is applied to open and laparoscopic procedures according to NICE and SIGN guidelines 1.

Penile implant surgery is a special case because the presence of the implant impacts on infection risk and type of pathogen. Staphylococci, including coagulase negative staphylococci (which are frequently resistant to beta-lactam antibiotics) are the predominant pathogens.

Evidence supports the use of prophylaxis for implant surgery and clean-contaminated surgery.

Aim
Reduction in urinary tract infection and sepsis, wound infection and/or implant infection.

Antimicrobial prophylaxis recommendations
Gentamicin has broad activity against common Gram-negative causes of UTI and would be an appropriate empirical choice when the renal tract is opened. Evidence level B

For implant surgery a single dose of both iv teicoplanin and Gentamicin is recommended to provide both broad-spectrum Gram-positive cover (including both Staphylococcus aureus and coagulase negative staphylococci) and Gram negative activity. Evidence level A- for indication, D for choice of antimicrobial.

Provenance

Record: 1713
Objective:

To optimise the benefits and standardise antimicrobial prophylaxis for urological procedures

Clinical condition:

Urological procedures (excluding bladder catheterisation).

Target patient group: Any patient undergoing urological procedures at LTHT
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

Evidence base

  1. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2008. Update 2014.
  2. Bootsma AM, Laguna Pes MP, Geerlings SE, Goossens A. Antibiotic Prophylaxis in Urologic Procedures: A Systematic Review. European urology. 2008. Update 2017
  3. Batura D, Rao GG, Nielsen PB. Prevalence of antimicrobial resistance in intestinal flora of patients undergoing prostatic biopsy: implications for prophylaxis and treatment of infections after biopsy. BJU Int. 2010 Oct;106(7):1017-20.
  4. Taylor AK, Zembower TR, Nadler RB, Scheetz MH, Cashy JP, Bowen D, Murphy AB, Dielubanza E, Schaeffer AJ. Targeted antimicrobial prophylaxis using rectal swab cultures in men undergoing transrectal ultrasound guided prostate biopsy is associated with reduced incidence of postoperative infectious complications and cost of care. J Urol. 2012 Apr;187(4):1275-9.
  5. Zani EL, Clark OA, Rodrigues Netto N Jr. Antibiotic prophylaxis for transrectal prostate biopsy. Cochrane Database Syst Rev. 2011 May 11;(5):CD006576.
  6. Brewster SF, MacGowan AP, Gingell JC. Antimicrobial prophylaxis for transrectal prostatic biopsy: a prospective randomized trial of cefuroxime versus piperacillin/tazobactam. Br J Urol. 1995 Sep;76(3):351-4.
  7. The effectiveness of single-dose fosfomycin as antimicrobial prophylaxis for patients undergoing transrectal ultrasound-guided biopsy of the prostate. Ongün S, Aslan G, Avkan-Oguz V. Urol Int. 2012;89(4):439-44.
  8. NICE. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. NICE clinical guideline 64. National Institue for Health and Clinical Excellence; 2008.
  9. Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al. Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor.: Royal College of Obstetrics and Gynaecology, Press; 2008.
  10. Hughes PD, Anderson JE. Hazards of transrectal biopsy of prostate. The Medical journal of Australia. 1995; 163(5): 276-7.
  11. Glancy JJ, Cartoon J. Hazards of transrectal biopsy of the prostate. The Medical journal of Australia. 1996; 164(5): 320.
  12. Miller J, Perumalla C, Heap G. Complications of transrectal versus transperineal prostate biopsy. ANZ J Surg. 2005; 75(1-2): 48-50.
  13. Madsen PO, Larsen EH, Dorflinger T. Infectious complications after instrumentation of urinary tract. Urology. 1985; 26(1 Suppl): 15-7.
  14. Olson ES, Cookson BD. Do antimicrobials have a role in preventing septicaemia following instrumentation of the urinary tract? The Journal of hospital infection. 2000; 45(2):
    85-97.
  15. Tiselius H-G, Alken P, Buck C, Gallucci M, Knoll T, Sarica K, et al. Guidelines on Urolithiasis.: European Association of Urology; 2008.
  16. Knopf HJ, Graff HJ, Schulze H. Perioperative antibiotic prophylaxis in ureteroscopic stone removal. European urology. 2003; 44(1): 115-8.
  17. Takahashi S, Takeyama K, Miyamoto S, Tanuma Y, Takagi Y. Surgical antimicrobial prophylaxis in transurethral ureterolithotripsy. J Infect Chemother. 2005; 11(5): 239-43.
  18. Grabe M. Perioperative antibiotic prophylaxis in urology. Current opinion in urology. 2001; 11(1): 81-5.
  19. NICE treatment summaries: Antibacterials, use for prophylaxis. https://bnf.nice.org.uk/treatment-summary/antibacterials-use-for-prophylaxis.html last accessed 23/11/2018
  20. Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70:195-283

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Peer review 2018
Comment: It was questioned whether fosfomycin was routinely tested and if not, whether it should be removed if it were not routine
Response: clarification in the text that Fosfomycin is a second line agent in testing, which is only undertaken if the patient is noted to be allergic to penicillin. It has been left in the text as it is noted only to be used with sensitivity results.
Comment: It was noted that the recommendations for prophylaxis for open/laparoscopic urological procedures are inconsistent with the gastrointestinal surgery guidelines.
Response: It was noted that this was not a change from the previous guidance and that in gastrointestinal surgery antimicrobial routinely has to target a broader spectrum of bacteria, including anaerobes, than in urological procedures. It therefore makes sense that in the majority of cases the antimicrobials do not cover anaerobes and just focus on gram negatives potentially related to the renal tract and gram positive skin organism cover for the incisional aspect. Where there is opening of the intestinal tract it was therefore consistent with the rest of the procedures in this guideline to add Metronidazole electronic Medicines Compendium information on Metronidazole , rather than offer an entirely different agent (such as co-amoxiclav). This was discussed with the peer reviewer and it was agreed that no change to the guideline would be made.
Comment: It was noted that the BNF dose for surgical prophylaxis with ciprofloxacin is 750mg PO as a single dose and for gentamicin the dose is stated as 1.5mg/kg, both of which are at odds with the doses in the draft version of the guideline.
Response: Neither dose had been changed from the previous guidance. Whilst SIGN1, NICE and European Association of Urologists2 guidance all offer both agents as choices for prophylaxis, none state doses. The dose in use across prophylaxis guidelines within the Trust for Gentamicin is 2mg/kg, and following this precedence it has not been changed. It is noted that the American guidelines20, advise a dose of 5mg/kg of gentamicin for surgical prophylaxis. Reviewing the available guidelines and evidence the single dose of 1000mg PO of ciprofloxacin has been changed to reflect the dosing in the BNF of 750mg instead.
It was noted that there was no guidance for prophylaxis choice for TRUS biopsy where there are no screening results available. As this is a planned procedure, this scenario should rarely occur. However, it was agreed that the current practice in radiology to give Ciprofloxacin and Gentamicin in these patients is reasonable and is now reflected in the guidance. However, it may be advisable to audit the screening in these patients to clarify how much of an issue this is.

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