Urological Procedures ( Excluding Bladder Catheterisation )

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

Publication: 20/11/2009

Next review: 24/01/2026

Clinical Guideline

CURRENT

ID: 1713

Approved By: Improving Antimicrobial Prescribing Group

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.

ANTIMICROBIAL PROPHYLAXIS GUIDELINE: UROLOGICAL PROCEDURES (excluding cathetherisation)

OUTPATIENT PROCEDURES
ENDOUROLOGICAL PROCEDURES
OPEN/LAPAROSCOPIC UROLOGICAL PROCEDURES

This guideline applies to patients undergoing a urological procedure who DO NOT have any signs and symptoms of UTI or systemic signs of infection.

Wherever possible symptomatic UTI should be treated according to the appropriate LTHT guideline, and elective procedures delayed until treatment is complete.

Before giving prophylaxis please review previous Microbiology results for any resistance to the stated antibiotics, and medical notes for any allergies. If there is resistance present, or allergies to all options for a given procedure, a personalised prophylaxis regimen may be required.

For elective procedures, please ensure that any change to prophylaxis is discussed with Microbiology in ADVANCE of the procedure and clearly documented in the patient’s notes.

RECOMMENDED ROUTINE PROPHYLAXIS OPTIONS FOR OUTPATIENT PROCEDURES

Procedure or situation	Antimicrobial dose/route Give within 1 hour before starting the procedure unless otherwise stated All single doses
	Routine	MRSA Risk	Allergy or resistance to Gentamicin
Trans-rectal implantation of gold markers for guiding prostatic radiotherapy	Antibiotic choice directed by the results of susceptibility testing on pre-procedure rectal swab. In order of preference: 1. Ciprofloxacin PO 750mg (ciprofloxacin resistant coliform not isolated on screen) 2. Piperacillin/tazobactam IV 4.5g 3. Cefuroxime IV 1.5 g 4. Fosfomycin PO 3g MRSA risk: Add Teicoplanin IV 400 mg
Ureteroscopy	Gentamicin 2 mg/kg IBW¹ IV or IM		Case-by-case based on recent susceptibility results
Conduitogram	Prophylaxis not recommended
Transperineal biopsy of prostate and brachytherapy
Cystoscopy
Urodynamic examination

RECOMMENDED ROUTINE PROPHYLAXIS OPTIONS FOR ENDOUROLOGICAL PROCEDURES

Procedure or situation	Antimicrobial dose/route Give within 1 hour before starting the procedure unless otherwise stated All single doses
	Routine	MRSA Risk	Allergy or resistance to Gentamicin
Extracorporeal shockwave lithotripsy (ESWL): No bacteriuria	Prophylaxis not recommended
Extracorporeal shockwave lithotripsy (ESWL): Confirmed or suspected asymptomatic bacteriuria, OR stent/nephrostomy in situ	Single dose according to organism susceptibility OR	Add Teicoplanin 400 mg IV	Case-by-case based on recent susceptibility results
Ureterorenoscopy (diagnostic, therapeutic, stent change/removal, stone removal)	Gentamicin 2 mg/kg IBW¹ IV or IM	Add Teicoplanin 400 mg IV	Case-by-case based on recent susceptibility results
Transurethral resection of the prostate for bladder tumour (TURP and TURBT)
Percutaneous removal of stones (PCNL)
Percutaneous nephrostomy: Prophylaxis to be given in the following circumstances: Stones present, previous surgical reconstruction of the urinary tract, stent or catheter in situ, malignancy, diabetes, and for nephrostomy changes where there is a history of nephrostomy related infection.	If kidney infection is suspected, treated according to UTI guidelines. Where not already on antibiotics give:
	Gentamicin 2 mg/kg IBW¹ IV or IM	Add Teicoplanin 400 mg IV	Case-by-case based on recent susceptibility results
Suprapubic catheter insertion	Prophylaxis not recommended

RECOMMENDED ROUTINE PROPHYLAXIS OPTIONS FOR OPEN/LAPAROSCOPIC UROLOGICAL PROCEDURES

Procedure or situation	Antimicrobial dose/route Give within 1 hour before starting the procedure unless otherwise stated All single doses
Procedure or situation	Routine	MRSA Risk or Penicillin allergy	Resistance or allergy to other stated agents
Clean operation	Prophylaxis not recommended
Clean-contaminated (opening of the testing)	Flucloxacillin 1 g IV PLUS Gentamicin 2 mg/kg IBW¹ IV PLUS Metronidazole 500 mg IV	Teicoplanin 400 mg IV PLUS Gentamicin 2 mg/kg IBW¹ IV PLUS Metronidazole 500 mg IV	Case-by-case
Clean-contaminated (opening of the urinary tract)	Flucloxacillin 1 g IV PLUS Gentamicin 2 mg/kg IBW¹ IV	Teicoplanin 400 mg IV PLUS Gentamicin 2 mg/kg IBW¹ IV	Case-by-case
Implantation of prosthetic penile devices²	Teicoplanin 400 mg IV PLUS Gentamicin 2 mg/kg IBW1 IV		Case-by-case

FOOTNOTES:

IBW = Ideal body weight
There is some (retrospective study) evidence (see below) of an increased risk of fungal infection in certain at risk populations (diabetes, obesity) following these procedures, with an advocation for antifungal prophylaxis. This is not currently part of the EAU guidelines, but could be considered in individual higher risk patients.

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

Role of Prophylactic Antibiotics in Transperineal Prostate Biopsy: A Systematic Review and Meta-analysis, Spyridon P Basourakos 1et al. Eur Urol Open Sci. 2022 Jan 29;37:53-63. doi: 10.1016/j.euros.2022.01.001. eCollection 2022 Mar.
European Association of Urologists (EAU) Guidelines on Urological infections, Last update March 2022, https://uroweb.org/guidelines/urological-infections
SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2008. Update 2014.
NICE treatment summaries: Antibacterials, use for prophylaxis. https://bnf.nice.org.uk/treatment-summary/antibacterials-use-for-prophylaxis.
Antibiotic prophlyaxis versus no antibiotic prophylaxis in transperineal prostate biopsies (NORAPP): a randomised, open-label, non-inferiority trial, Jacewicz M, et al. The Lancet Infectious Diseases, Vol 22, Issue 10, Oct 22, Pages 1465-1471
Is there a role for antifungal prophylaxis in patients undergoing penile prosthesis surgery? A systematic review, Siddiqui Z, Pearce I, Modgil V. Urologia Internationalis, 2022; 106:737-743

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

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 , 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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