International Journal of Antimicrobial Agents 38S (2011) 58–63
Contents lists available at SciVerse ScienceDirect
International Journal of Antimicrobial Agents
journal homepage: http://www.elsevier.com/locate/ijantimicag
Antibiotic prophylaxis in urological surgery, a European viewpoint夽
Magnus Grabe ∗
Department of Urology, Skåne University Hospital, University of Lund, S-20502 Malmö, Sweden
a r t i c l e
i n f o
Keywords:
Surgical site infection
Wound infection
Urinary tract infection
Antibiotic prophylaxis
a b s t r a c t
Surgical site infections (SSI) including urinary tract infections (UTI) cause a signiﬁcant morbidity in urological surgery. Antibiotic prophylaxis is one of several factors impacting on infection rates. Antibiotic
prophylaxis is relevant only for clean and clean-contaminated operations and in the absence of bacterial
growth in the urine. Strict classiﬁcation of urological procedures is lacking, but a proposal is presented
elsewhere. Only TURP and transrectal core prostate biopsy are well documented. The present review
conﬁrms that there is a lack of hard data, insufﬁcient consistency in classiﬁcation and deﬁnitions, and
that new well-powered RCT and large multicentre quality cohort studies including risk factor analysis
are necessary to improve recommendations for antibiotic prophylaxis in urologic surgery.
© 2011 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
1. Summary of recommendations
The summary of recommendations are given in Table 1. The
reader will ﬁnd a paradox in the level of evidence and the policy recommended. The reasons are therefore explained for each
procedure in its respective section.
2. Introduction
This manuscript was published originally in Urogenital Infections
as a section of a chapter on prevention of infections associated
with urological surgery (ch 12), antibiotic prophylaxis being one
of several preventive measures. It has thus to be seen as an article integrated with the associated manuscript on preoperative
assessment of the patient giving a tentative classiﬁcation of urological procedures. The present article focus on what is known
and evidence-based information on antibiotic prophylaxis in most
common urological procedures.
The use of antibiotics in urologic surgery has been controversial
for decades [1,2]. Over the same period of time, surgical procedures
and interventions have evolved remarkably from high-invasive
open to low-invasive surgery due to a fascinating improvement
of technologies and instruments. Also, medical treatment has
replaced surgery in a substantial number of situations and in this
way modiﬁed the proﬁle of patients undergoing surgery.
The basic principle of antibiotic prophylaxis is to protect the
patient undergoing surgery against undesirable infectious complications by lowering the bacterial burden. Antibiotic prophylaxis is
applicable for clean and clean-contaminated operations. For the urinary tract, antibiotic prophylaxis implies the absence of detectable
bacterial growth in urine (<104 CFU/ml). In clean operations, the
urinary tract is not opened. In clean-contaminated operations, the
urinary tract is opened and, in case of urinary diversion, the intestinal tract, implying an increased bacterial burden. In the case of
bacterial growth and surgery associated with opening of the bowel
with spillage – contaminated operations – an individual treatment
strategy is prescribed [3].
Two types of infections dominate urologic surgery: (1) urinary
tract infection (UTI), a space or organ infection, associated with both
endoscopic, endoluminal interventions and open or laparoscopic
surgery, mostly coinciding with catheter and stent placement or
undetected harboured bacterial load and (2) wound infection after
open and laparoscopic surgery. Furthermore, a third form of infection is observed in terms of infection of the male genital system
(prostatitis, epididymitis and orchitis). A fourth form of infection,
blood-stream-borne sepsis, resulting from urologic instrumentation, is feared by patients and urologists, and is far from negligible
accounting for 10–12% of healthcare-associated infections (HAI) in
urologic wards [4].
3. Aim
夽 This manuscript was originally published in: Naber KG, Schaeffer AJ, Heyns CF,
Matsumoto T, Shoskes DA, Bjerklund Johansen TE, editors. Urogenital Infections.
European Association of Urology–International Consultation on Urological Diseases,
1st ed. Arnhem, The Netherlands; 2010, ISBN:978-90-79754-41-0.
∗ Tel.: +46 40 33 18 25; fax: +46 40 33 70 49.
E-mail address: [email protected]
The present report focuses on the most frequent diagnostic and
therapeutic urologic interventions (Table 1) and results from a systematic review. It is out of range to be comprehensive and cover all
speciﬁc or special procedures as several of these have never been
studied. Also paediatric urologic surgery is not covered.
0924-8579/$ – see front matter © 2011 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
doi:10.1016/j.ijantimicag.2011.09.008
M. Grabe / International Journal of Antimicrobial Agents 38S (2011) 58–63
59
Table 1
Summary of recommendations for antibiotic prophylaxis (ABP) per type of procedure.
Type of procedure
Level of recommendation
Remarks
Diagnostic procedures
Cystoscopy
No systematic ABP (GoR A)
Urodynamic study
No systematic ABP (GoR A)
Core prostate biopsy
To all patients (GoR A)
Low frequency of infections
Contradictory ﬁndings
Low frequency of infections
Contradictory ﬁndings
Single dose to all low-risk patients (GoR A) prolonged in
high-risk patients (GoR C)
No available studies
URS diagnostic
Therapeutic procedures
TURB
No systematic ABP (GoR C)
TURP
Shock-wave lithotripsy (ESWL)
As for cystoscopy in standard small TURB (GoR C)
Consider in large tumours (GoR C)
All patients (GoR A)
No systematic ABP (GoR A)
Ureteroscopic stone management
To all patients (GoR B)
Percutaneous stone management
To all patients (GoR B)
Open/lap nephrectomy
Open/lap nephroureterectomy
No systematic ABP (GoR C)
To all patients (GoR C)
PUJ repair
Open/lap bladder resection, ureteral repair
Open/lap prostatectomy
Cystectomy with urine deviation
To all patients (GoR C)
To all patients (GoR C)
To all patients (GoR B)
To all patients (GoR B)
Surgery for hydrocele and spermatocele
Prosthetic procedures
No systematic ABP (GoR B)
To all patients (GoR B)
No concern of tumour burden in studies
Well documented
Low frequency of infections
Contradictory ﬁndings
Simple mid and distal stones
Complex, proximal stones as for PCNL
Single dose to simple stones (GoR C)
Consider prolongation in complex stones (GoR C)
Catheter related BU/UTI
No available studies
Deﬁned as clean-contaminated – single dose
Deﬁned as clean-contaminated – single dose
Deﬁned as clean-contaminated – single dose
Deﬁned as clean-contaminated – single dose
Deﬁned as clean-contaminated – single dose
Prolongation of ABP on individual basis
Review studies contradictory
Regimen not deﬁned
4. Methods
5. Results per type of procedure
A systematic search was performed in Medline, Cochrane
Library and EMBASE and using the keywords antibiotic prophylaxis,
prophylaxis, antibiotics, urological surgery, urogenital surgery and the
procedures one by one. Approximately 200 abstracts were identiﬁed of which over 100 were not directly related to the topic. Of the
remaining 95 reports, a majority was related to transurethral resection of the prostate (TURP). As this procedure has been reviewed
by other authors by means of systematic review [5] and covered
more recently by two meta-analyses [6,7], the outcome was built
on these works. Also urodynamic studies were critically reviewed
[8] and the conclusions reported. For all other procedures, the articles were systematically reviewed and the conclusions compared
to those drawn by one other recent systematic review by a group
from the Netherlands [9] and the conclusions presented by a working group in the USA [10]. The quality of the studies was found to
vary largely, essentially in terms of design, description of randomisation, sample size, level of dropout, power, and strength of the
conclusion.
The procedures were divided between diagnostic procedures
(cystoscopy, urodynamic studies and transrectal core biopsy of the
prostate) and therapeutic endoscopic procedures (transurethral
resection of bladder tumours and of the prostate, endourological
interventions including shock wave lithotripsy), open and laparoscopic interventions (nephrectomy, pelvic junction surgery, total
prostatectomy, cystectomy with urinary diversion) and elective
surgery for benign scrotal surgery.
As far as possible, the expected natural history of infectious rates
is presented followed by the results of randomized placebo/no
antibiotic controlled studies (RCT). Thereafter, RCTs of different
antibiotic regimens are presented to detect the most rational one
(shortest, low cost and effective course) when applicable.
The studies were rated according to the level of evidence (LoE)
and the grade of recommendation (GoR) using ICUD standards (for
details see Preface) [11,12]. The LoE and GoR are given at the end of
each surgical procedure and the recommendation reported to the
summary table.
5.1. Cystoscopy
The natural history of the events following cystoscopy is important. In one study from 1990, Clark and Higgs [13] showed the
appearance of bacteriuria three days after instrumentation in
12/161 (7.5%). In two recent studies, a spontaneous acquired bacteriuria was observed in 2.7% and 4.5% [14,15]. The fate of this
bacterial contamination is not known and the spontaneous cure is
probably high. In a large British study with ﬂexible cystoscopy [16],
a single dose of trimethoprim or ciproﬂoxacin reduced by more
than half, 2% and 3.2% respectively, the post-cystoscopy frequency
of bacteriuria as compared to placebo (6.8%). These results were in
accordance with an older study observing a signiﬁcant reduction
of post-cystoscopy bacteriuria and clinical UTI [17]. Other studies were contradictory in their results, some advocating antibiotic
prophylaxis [18,19], others ﬁnding it no use [20–23]. The overall conclusions are that the frequency of bacteriuria is low and
that of clinical infections even lower, and that the frequencies of
these events are, globally, marginally reduced by antibiotic prophylaxis. Thus, the recommendation of giving systematically antibiotic
prophylaxis to all patients undergoing cystoscopy cannot be advocated in view of the lack of knowledge of the risk associated with
the bacterial contamination and its fate, the low frequency of
clinical infection, the recommendation and praxis in most European countries, the enormous amount of such instrumentation
and overtreatment, and the subsequent amount of antibiotics that
would be used (LoE 1b–2b, GoR A).
5.2. Urodynamic studies
Most studies are carried out on women investigated for incontinence. In a meta-analysis of 995 patients including eight RCT,
bacteriuria (>105 CFU/ml) was reduced by 40% by antibiotic prophylaxis [8]. The authors concluded that it was necessary to treat 13
individuals in order to avoid one episode of bacteriuria. In one other
study combining cystoscopy and urodynamic study in women,
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M. Grabe / International Journal of Antimicrobial Agents 38S (2011) 58–63
there was found to be no difference between one day of antibiotic
prophylaxis and no antibiotics [24]. In one Swedish study of 123
consecutive men undergoing a ﬂow-pressure investigation, 4.1%
acquired bacteriuria and 2.5% fever [25]. The overall interpretation
is, as for cystoscopy, that the frequency of infectious events is low,
that the outcome and role of bacteriuria after urodynamic investigation is unknown and that there is a lack of support in the literature
for the systematic use of antibiotic prophylaxis in patients without
risk factors. For investigations of patients with other underlying
urological diseases such as neurological bladder dysfunction, refer
to the chapter on “UTI in patients with underlying urological diseases”
(LoE 1a, GoR A).
5.3. Transrectal core prostate biopsy
There are only very few studies on the natural history of infectious complications after transrectal prostate biopsy. In a few
cohort series, infectious complications such as febrile UTI, acute
prostatitis and sepsis are reported in frequencies between 2.9
and 10% [26–28]. In RCT, frequencies of 5–26% bacteriuria and up
to 10% febrile UTI are given in the control groups [29–31]. In older
studies, frequencies up to 48% have been reported [32,33]. There
is a consistent signiﬁcant reduction of the frequencies of both bacteriuria and febrile urogenital infections by antibiotic prophylaxis,
below 5% in low-risk patients [29–34]. Recent studies have shown
that one day [35,36] and even one single dose [31,37,38] is appropriate to keep the infectious rate at 1% or below, including less
than 0.5% of sepsis. These low frequencies are conﬁrmed by a few
consecutive cohort series with antibiotic prophylaxis [39,40]. The
antibiotic dose can be given in direct conjunction with instrumentation and there is now evidence for giving the medication 1–2 h
before the procedure [37]. Fluoroquinolones achieve the highest
concentrations in the prostate [41] and are best documented for
prophylaxis. However, new studies have to be done to avoid the
overuse of ﬂuoroquinolones wherever possible due to the worldwide development of resistant strains in both community and
hospital settings. It is unknown how long prophylaxis should be
given to risk patients (risk factors are presented in the preceding
chapter). It is also unknown whether spontaneous acquired bacteriuria after core prostate biopsy can spontaneously cure (LoE 1b,
GoR A).
5.4. Transurethral resection of bladder tumour (TURB)
Although TURB is one of the most frequent urological procedures, there are no base-line data. Only three older, rather weak,
small-size studies covering antibiotic prophylaxis were disclosed
[18,42,43]. The data from the studies do not give any evidence
in favour of antibiotic prophylaxis in TURB. However, the studies focus only on smaller tumours or fulguration, an intervention
very similar to standard cystoscopy, and do not mirror the large
spectrum of resection of bladder cancer from the single minor
non-muscle-invasive bladder tumours (Ta, G1–2) to large muscleinvasive (T2, G3), sometimes necrotic, tumours that are part of daily
practice. Future studies covering all TURB procedures and breaking
them down according to the intervention’s level of severity and difﬁculty, duration and other risk factors has to be undertaken (LoE
2b, GoR C).
5.5. Transurethral resection of the prostate (TURP)
TURP is the most well studied of all urological studies. More
than 50 studies have been conducted, some of them of medium to
high quality. Postoperative bacteriuria has been reported in up to
70% of the patients. In a systematic review of subsequent studies
from the 1980s, it was shown that antibiotic prophylaxis reduced
the frequency of bacteriuria in men with pre-operative sterile urine
from an average of 34% to 10% [5]. In recent years, two high-quality
meta-analyses have been done including 32 and 28 participantcontrolled studies (respectively [6,7]). The conclusions are similar:
a short course of antimicrobial agents reduces the risk of bacteriuria
from an average of 26% to 9%. Berry and Barrat also analysed the
impact on sepsis: the impact was even more important, reducing
the risk from 4.4% to less than 1%. Both reviews show that a prolonged course (<72 h) is more effective than a single dose, but less
effective than one week [6]. Any antibiotic except nitrofurantoin
would do. In a recent high-quality multicentre study conducted in
Germany, Wagenlehner et al. [44] conﬁrmed these results, although
the difference was less marked. Interestingly, they also showed that
the total amount of antibiotics used in the study was lower in the
antibiotic prophylaxis group, conﬁrming data from one older similar analysis [45]. This observation is interesting in the argument for
antibiotic prophylaxis, as nowadays there is a high level of concern
about the total amount of antibiotics used in the community. Long
operation time, postoperative disconnection of drainage system
and longer catheterisation period were associated with increased
frequency of bacteriuria despite antibiotic prophylaxis [46] (LoE 1a,
GoR A).
Consequently, there is a scientiﬁcally high level of evidence
for the use of short regimens of antibiotic prophylaxis in TURP to
reduce the postoperative frequencies of both bacteriuria and, especially, severe febrile infections and sepsis. The conclusions are not
applicable to other prostate interventions such as adenoma enucleation, micro-wave thermotherapy or laser ablation, as there are
no quality RCT studies on these matters.
5.6. Extracorporeal shock-wave lithotripsy (ESWL)
A remarkably poor number of studies have been conducted for
such an enormous worldwide procedure. In a few follow-up studies, the frequency of post-ESWL bacteriuria has been shown to be
≤5% in patients without known risk factors [47–49]. In only one
[50] of ﬁve randomized placebo/non-antibiotic-controlled studies
was a signiﬁcant reduction demonstrated [50–54]. In most studies,
the sample size or the frequencies of infections were low and no
clear-cut conclusions could be drawn. In a systematic review and
meta-analysis Pearle analysed eight prospective controlled studies
[55]. The frequencies of bacteriuria and/or symptomatic UTI were
reported to be 0–28% in the non-antibiotic control group and 0–7%
in the intervention group. They estimated the risk of acquiring a
UTI to be 5.7% and 2.1%, respectively.
The overall conclusion is that in patients with sterile urine,
uncomplicated kidney or ureteral stones and no known risk factors,
the risk of post-ESWL bacteriuria/UTI is low, that the reduction by antibiotic prophylaxis is marginal and that, subsequently,
there is no evidence for antibiotic prophylaxis in this category of
low-risk patients, which represents the majority of patients undergoing ESWL (LoE 1a–2b, GoR A).
5.7. Ureteroscopy (URS)
No studies on ureteroscopy as a diagnostic tool were found. Two
studies concerned with stone management were identiﬁed [56,57].
Both show a reduction of bacteriuria but not of symptomatic UTI.
One study comparing ESWL and URS for mid and distal ureteral
stones demonstrated a higher frequency of complications including infectious complications in the URS-treated group as compared
to the ESWL group [58]. The studies do not differentiate the degree
of invasiveness in terms of stone burden and localisation (impacted
proximal stone versus small mid and lower stones), surgical difﬁculty and complexity of the treatment, duration of operation,
experience of the surgeon; a weakness, as it is known that the
M. Grabe / International Journal of Antimicrobial Agents 38S (2011) 58–63
risk of infectious complications varies [59]. In conclusion, there is
only a weak level of evidence for antibiotic prophylaxis in URS,
although it is probably of value, especially in complex stone situations (diagnostic: LoE 2b, GoR C; stone management: LoE 2b,
GoR B).
5.8. Percutaneous stone extraction (PCNL)
Bacteriuria is reported in up to 35% and febrile UTI in around
10% of patients receiving no antibiotics [60,61]. Only one controlled
study comparing antibiotic prophylaxis with no antibiotics was
identiﬁed [56] and one comparing two different antibiotic regimens [62]. As for complicated URS, the danger of PCNL in terms of
severe, febrile UTI and sepsis has been underlined [59,63]. Antibiotic prophylaxis appears to reduce the frequencies of infectious
complications and there seems to be no difference between antibiotics. As mid-stream urine culture is not a good predictor for the
endogenous presence of pathogens [63], the urologist faces an
incertitude as to the real risk of infectious complications. Moreover, following the remarkable improvement of equipment, older
studies are not necessarily representative of the present proﬁle of
renal stone management. Consequently, as for URS, there is a substantial lack of data on the use of antibiotics in PCNL and only very
limited evidence for antibiotic prophylaxis. Nonetheless, the infectious rates being high and the potential complications severe, there
are reasons to believe that antibiotic prophylaxis is of value. Large
multicentre controlled studies focusing on antibiotic regimens and
risk factor analysis are required (LoE 2b, GoR B).
5.9. Open and laparoscopic urologic surgery
An extensive search on open and laparoscopic surgery, nephrectomy, nephron-sparing surgery, pelvic junction reconstruction
bladder resection, cystectomy, total/radical prostatectomy and
scrotal surgery has revealed the lack of RCT and the weaknesses
of available data [9,10]. Expected data have to be extrapolated
from bottom-line data on type of surgery [3] and from colorectal and abdominal gynaecologic surgery. There are indications that
infectious complications are fewer after laparoscopic and robotic
surgery in abdominal surgery [64]. The issue has however not been
studied in RCT as far as urologic surgery is concerned. A few examples of common surgery by type of intervention follow.
5.9.1. Clean operations
Trans-abdominal open or laparoscopic nephrectomy is classed
as a clean operation. Only one RCT was identiﬁed [65]. Infectious
complications in terms of wound infection were 20.4% when no
antibiotics were given versus 0% for patients receiving one single
preoperative dose. The results indicate a marked impact of antibiotic prophylaxis but no other study conﬁrms the data. In one report
on surgical site infections (SSI) in which antibiotic prophylaxis was
not in the protocol, Montgomery reports wound infections in 6.8%
(range 5.0–7.9%) in clean and clean-contaminated hand-assisted
kidney surgery, with no difference whether the urinary tract was
opened or not [66]. In one study of clean surgery in patients with or
without a risk factor for SSI, antibiotic prophylaxis had no impact
in low-risk patients whereas it reduced the frequency in patients
with at least one risk factor [67].
Scrotal surgery for elective benign conditions, mainly hydrocele and spermatocele, is a reasonably clean procedure. No RCT
was identiﬁed. In a few recent studies [68,69], including a Medline search review, infectious complications were reported in up
to 9%. In most reports, no antibiotic prophylaxis had been used.
A lower frequency of infections (3.6%) was observed in patients
61
receiving antibiotic prophylaxis [70]. Multicentre RCT have yet to
be undertaken to conﬁrm this ﬁnding (LoE 3, GoR C).
5.9.2. Clean-contaminated operations
Nephroureterectomy, kidney resection and pelvic junction
surgery have, to the best of our knowledge, never been studied
in RCT. The searches have revealed no RCT on antibiotic prophylaxis versus placebo/no antibiotic in total prostatectomy. Thus,
there is a lack of baseline data on the infectious proﬁle of this
nowadays so frequent operation. There are a few retrospective and
prospective cohort studies looking at SSI and catheter-associated
bacteriuria following different antibiotic regimens. The conclusion of this series of publications is that the frequency of wound
infections is low and that a single oral antibiotic dose is sufﬁcient
[70–73]. The importance of the post-operative catheter-associated
bacteriuria, observed in the majority of the patients at catheter
removal, is unknown as is whether it has to be treated or not (LoE
3, GoR B).
There are no RCT on antibiotic prophylaxis in urologic surgery
including urine deviation and the use of bowel. Postoperative
wound infection is reported in up to one-third of cases, usually
10–15%, even when using antibiotic prophylaxis [74–76]. Also UTI,
pyelonephritis and sepsis are added to the burden of infections.
5.9.3. Penile prosthesis
Implantation of penile prosthetic devices is a special case.
Infection of the prosthetic device remains the most troublesome
complication. Infection may lead to more surgery, loss of penile
tissue and even the inability to replace penile prosthesis. Antibiotic prophylaxis in addition to standard sterility and good surgical
technique reduces the risk of infection [77,78].
6. Discussion
The present review requires a certain number of remarks on the
validity and relevance of the references revealed by an in-depth
search of the literature. Firstly, the remarkable technical development and medical achievements in urology during the past 25–30
years mean that older studies from the 1970s and 1980s have partly
lost their relevance. Secondly, the quality of older studies in the
present view of good clinical practice is usually poor in terms of
sample size, consistency in deﬁnitions, statistical estimates and
power. Thirdly, risk factors for infectious complications are rarely
debated and, as shown in the preceding section about preparation
of the patient for surgery, our knowledge of the relative importance
of individual risk factors and their cumulative impact is limited.
Fourthly, numerous reports have given results on a mixture of procedures and the breakdown has shown so low a sample size per
procedure that it is difﬁcult to draw a conclusion. Fifthly, the lack
of consistency in deﬁnitions of infectious complications, especially
UTI, the level of bacterial growth and the relation between clinical
symptoms and bacterial growth weakens the possibility of comparison. Clear deﬁnitions are often lacking. The results are therefore
more indicative, than proof. Against this background, large cohort
studies and historical controls gain indicative importance by giving a “natural history” of the events after a deﬁned intervention and
therefore have also been used to some extent.
It is remarkable that there are so few studies on very frequent
interventions such as transurethral resection of bladder tumours
and endoscopic stone management including ESWL. It is thus not
astonishing that Bootsma et al. stated that “except for TURP and
prostate biopsy, there is a lack of well performed studies investigating the need for antibiotic prophylaxis in urologic interventions”.
On the other hand, urologists need a working hypothesis for antibiotic prophylaxis.
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M. Grabe / International Journal of Antimicrobial Agents 38S (2011) 58–63
One approach is to stick to the classiﬁcation of surgical interventions in clean, clean-contaminated and contaminated classes and
follow the experience of other surgical practices such as general,
orthopaedic and gynaecologic surgery. Theoretically, there should
be no need for antibiotic prophylaxis in clean operations, whilst
a single dose should be advocated for clean-contaminated procedures. In case of contaminated procedures (i.e. urine deviation with
bowel, presence of asymptomatic bacteriuria in urine), the antibiotic regimen’s start and length is less obvious and documentation
is insufﬁcient. In standard colorectal surgery, usually a single dose
or very short regimen is advocated. Bacteriuria is a known risk
factor and, in conjunction with urological procedures should therefore, reasonably, be treated. Thus, individual adjustment has to be
suggested depending on patient susceptibility, bacterial load and
the development of the procedure in terms of spillage and duration. However this approach is not totally satisfactory; it is only
indicative and usually no strong recommendations can be given in
guidelines, such as those of the European Association of Urology,
except in a few situations [79]. Therefore, there is an inevitable
discrepancy between the level of evidence and the grade of recommendation in Table 1.
The role of antibiotics is to reduce the bacterial burden, not
necessarily to cover all potential strains. Also, antibiotics for prophylaxis should ideally be limited to a few and usually different
from those used for therapeutics to avoid an overload of drug doses
and local environmental pressure. Recommendations should be set
in cooperation with specialists in infectious diseases and hospital
environmental hygiene.
7. Further research
This review underlines the absolute need for serious, wellconducted studies and large, multicentre quality registries per
type of procedure including breakdowns in the level of severity
of surgery and the reporting of potential risk factors.
8. Conclusions
An extensive search of the literature and systemic reviews has
revealed a lack of well-built data for antibiotic prophylaxis in urological surgery. Strong recommendations can only be given for
transrectal core biopsy of the prostate and transurethral resection
of the prostate. As surgery has markedly changed over the decades
and because older studies vary so much in quality, it is mandatory to
initiate new large industry-independent, prospective, randomised
controlled studies and to set up large prospective quality registries
and infectious control materials.
Funding: No funding sources.
Competing interests: None declared.
Ethical approval: Not required.
References
[1] Chodak GW, Plaut ME. Systemic antibiotics for prophylaxis in urologic surgery:
a critical review. J Urol 1979;121:695–9.
[2] Grabe M. Controversies in antibiotic prophylaxis in urology. Int J Antimicrob
Agents 2004;23(Suppl. 1):S17–23.
[3] Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices
Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250–78 [quiz
279–80].
[4] Bjerklund Johansen TE, Cek M, Naber K, Stratchounski L, Svendsen MV, Tenke
P. Prevalence of hospital-acquired urinary tract infections in urology departments. Eur Urol 2007;51:1100–11 [discussion 1112].
[5] Grabe M. Antimicrobial agents in transurethral prostatic resection. J Urol
1987;138:245–52.
[6] Berry A, Barratt A. Prophylactic antibiotic use in transurethral prostatic resection: a meta-analysis. J Urol 2002;167(Pt 1):571–7.
[7] Qiang W, Jianchen W, MacDonald R, Monga M, Wilt TJ. Antibiotic prophylaxis for transurethral prostatic resection in men with preoperative urine
containing less than 100,000 bacteria per ml: a systematic review. J Urol
2005;173:1175–81.
[8] Latthe PM, Foon R, Toozs-Hobson P. Prophylactic antibiotics in urodynamics: a systematic review of effectiveness and safety. Neurourol Urodyn
2008;27:167–73.
[9] Bootsma AM, Laguna Pes MP, Geerlings SE, Goossens A. Antibiotic prophylaxis
in urologic procedures: a systematic review. Eur Urol 2008;54:1270–86.
[10] Wolf Jr JS, Bennett CJ, Dmochowski RR, Hollenbeck BK, Pearle MS, Schaeffer AJ.
Best practice policy statement on urologic surgery antimicrobial prophylaxis.
J Urol 2008;179:1379–90.
[11] Department of Health and Human Services, Public Health Service, Agency for
Health Care Policy and Research; 1992. p. 115–27.
[12] Abrams P, Khoury S, Grant A. Evidence-based medicine overview of the
main steps for developing and grading guideline recommendations. Prog Urol
2007;17:681–4.
[13] Clark KR, Higgs MJ. Urinary infection following out-patient ﬂexible cystoscopy.
Br J Urol 1990;66:503–5.
[14] Almallah YZ, Rennie CD, Stone J, Lancashire MJ. Urinary tract infection and
patient satisfaction after ﬂexible cystoscopy and urodynamic evaluation. Urology 2000;56:37–9.
[15] Burke DM, Shackley DC, O’Reilly PH. The community-based morbidity of ﬂexible cystoscopy. BJU Int 2002;89:347–9.
[16] Johnson MI, Merrilees D, Robson WA, Lennon T, Masters J, Orr KE, et al. Oral
ciproﬂoxacin or trimethoprim reduces bacteriuria after ﬂexible cystoscopy. BJU
Int 2007;100:826–9.
[17] Jimenez Cruz JF, Sanz Chinesta S, Otero G, Diaz Gonzalez R, Alvarez Ruiz F, Flores
N, et al. [Antimicrobial prophylaxis in urethrocystoscopy. Comparative study].
Actas Urol Esp 1993;17:172–5.
[18] MacDermott JP, Ewing RE, Somerville JF, Gray BK. Cephradine prophylaxis in
transurethral procedures for carcinoma of the bladder. Br J Urol 1988;62:136–9.
[19] Rane A, Cahill D, Saleemi A, Montgomery B, Palfrey E. The issue of prophylactic
antibiotics prior to ﬂexible cystoscopy. Eur Urol 2001;39:212–4.
[20] Manson AL. Is antibiotic administration indicated after outpatient cystoscopy.
J Urol 1988;140:316–7.
[21] Karmouni T, Bensalah K, Alva A, Patard JJ, Lobel B, Guille F. [Role of antibiotic
prophylaxis in ambulatory cystoscopy]. Prog Urol 2001;11:1239–41.
[22] Tsugawa M, Monden K, Nasu Y, Kumon H, Ohmori H. Prospective randomized
comparative study of antibiotic prophylaxis in urethrocystoscopy and urethrocystography. Int J Urol 1998;5:441–3.
[23] Wilson L, Ryan J, Thelning C, Masters J, Tuckey J. Is antibiotic prophylaxis
required for ﬂexible cystoscopy? A truncated randomized double-blind controlled trial. J Endourol 2005;19:1006–8.
[24] Cundiff GW, McLennan MT, Bent AE. Randomized trial of antibiotic prophylaxis
for combined urodynamics and cystourethroscopy. Obstet Gynecol 1999;93(Pt
1):749–52.
[25] Logadottir Y, Dahlstrand C, Fall M, Knutson T, Peeker R. Invasive urodynamic
studies are well tolerated by the patients and associated with a low risk of
urinary tract infection. Scand J Urol Nephrol 2001;35:459–62.
[26] Enlund AL, Varenhorst E. Morbidity of ultrasound-guided transrectal core
biopsy of the prostate without prophylactic antibiotic therapy. A prospective
study in 415 cases. Br J Urol 1997;79:777–80.
[27] Larsson P, Norming U, Tornblom M, Gustafsson O. Antibiotic prophylaxis for
prostate biopsy: beneﬁts and costs. Prostate Cancer Prostatic Dis 1999;2:88–90.
[28] Puig J, Darnell A, Bermudez P, Malet A, Serrate G, Bare M, et al. Transrectal
ultrasound-guided prostate biopsy: is antibiotic prophylaxis necessary? Eur
Radiol 2006;16:939–43.
[29] Kapoor DA, Klimberg IW, Malek GH, Wegenke JD, Cox CE, Patterson AL, et al.
Single-dose oral ciproﬂoxacin versus placebo for prophylaxis during transrectal
prostate biopsy. Urology 1998;52:552–8.
[30] Isen K, Kupeli B, Sinik Z, Sozen S, Bozkirli I. Antibiotic prophylaxis for transrectal
biopsy of the prostate: a prospective randomized study of the prophylactic use
of single dose oral ﬂuoroquinolone versus trimethoprim-sulfamethoxazole. Int
Urol Nephrol 1999;31:491–5.
[31] Aron M, Rajeev TP, Gupta NP. Antibiotic prophylaxis for transrectal needle
biopsy of the prostate: a randomized controlled study. BJU Int 2000;85:682–5.
[32] Crawford ED, Haynes Jr AL, Story MW, Borden TA. Prevention of urinary tract infection and sepsis following transrectal prostatic biopsy. J Urol
1982;127:449–51.
[33] Melekos MD. Efﬁcacy of prophylactic antimicrobial regimens in preventing
infectious complications after transrectal biopsy of the prostate. Int Urol
Nephrol 1990;22:257–62.
[34] Yamamoto S, Ishitoya S, Segawa T, Kamoto T, Okumura K, Ogawa O. Antibiotic
prophylaxis for transrectal prostate biopsy: a prospective randomized study of
tosuﬂoxacin versus levoﬂoxacin. Int J Urol 2008;15:604–6.
[35] Sabbagh R, McCormack M, Peloquin F, Faucher R, Perreault JP, Perrotte P, et al.
A prospective randomized trial of 1-day versus 3-day antibiotic prophylaxis for
transrectal ultrasound guided prostate biopsy. Can J Urol 2004;11:2216–9.
[36] Schaeffer AJ, Montorsi F, Scattoni V, Perroncel R, Song J, Haverstock DC, et al.
Comparison of a 3-day with a 1-day regimen of an extended-release formulation of ciproﬂoxacin as antimicrobial prophylaxis for patients undergoing
transrectal needle biopsy of the prostate. BJU Int 2007;100:51–7.
[37] Lindstedt S, Lindstrom U, Ljunggren E, Wullt B, Grabe M. Single-dose antibiotic
prophylaxis in core prostate biopsy: Impact of timing and identiﬁcation of risk
factors. Eur Urol 2006;50:832–7.
M. Grabe / International Journal of Antimicrobial Agents 38S (2011) 58–63
[38] Briffaux R, Merlet B, Normand G, Coloby P, Leremboure H, Bruyere F, et al. [Short
or long schemes of antibiotic prophylaxis for prostate biopsy. A multicentre
prospective randomised study]. Prog Urol 2009;19:39–46.
[39] Shandera KC, Thibault GP, Deshon Jr GE. Efﬁcacy of one dose ﬂuoroquinolone
before prostate biopsy. Urology 1998;52:641–3.
[40] Grifﬁth BC, Morey AF, Ali-Khan MM, Canby-Hagino E, Foley JP, Rozanski TA.
Single dose levoﬂoxacin prophylaxis for prostate biopsy in patients at low risk.
J Urol 2002;168:1021–3.
[41] Naber KG. Which ﬂuoroquinolones are suitable for the treatment of urinary
tract infections? Int J Antimicrob Agents 2001;17:331–41.
[42] Upton JD, Das S. Prophylactic antibiotics in transurethral resection of bladder
tumors: are they necessary? Urology 1986;27:421–3.
[43] Delavierre D, Huiban B, Fournier G, Le Gall G, Tande D, Mangin P. [The value of
antibiotic prophylaxis in transurethral resection of bladder tumors. Apropos of
61 cases]. Prog Urol 1993;3:577–82.
[44] Wagenlehner FM, Wagenlehner C, Schinzel S, Naber KG. Prospective,
randomized, multicentric, open, comparative study on the efﬁcacy
of a prophylactic single dose of 500 mg levoﬂoxacin versus 1920 mg
trimethoprim/sulfamethoxazole versus a control group in patients undergoing
TUR of the prostate. Eur Urol 2005;47:549–56.
[45] Grabe M. Risk factors at TURP. Discussion of RA Janknegt’s presentation. Infection 1992;20(Suppl. 3):S217–20.
[46] Colau A, Lucet JC, Rufat P, Botto H, Benoit G, Jardin A. Incidence and risk
factors of bacteriuria after transurethral resection of the prostate. Eur Urol
2001;39:272–6.
[47] Charton M, Vallancien G, Veillon B, Prapotnich D, Mombet A, Brisset JM. Use
of antibiotics in the conjunction with extracorporeal lithotripsy. Eur Urol
1990;17:134–8.
[48] Deliveliotis C, Giftopoulos A, Koutsokalis G, Raptidis G, Kostakopoulos A.
The necessity of prophylactic antibiotics during extracorporeal shock wave
lithotripsy. Int Urol Nephrol 1997;29:517–21.
[49] Dincel C, Ozdiler E, Ozenci H, Tazici N, Kosar A. Incidence of urinary tract
infection in patients without bacteriuria undergoing SWL: comparison of stone
types. J Endourol 1998;12:1–3.
[50] Claes H, Vandeursen R, Baert L. Amoxycillin/clavulanate prophylaxis for
extracorporeal shock wave lithotripsy—a comparative study. J Antimicrob
Chemother 1989;24(Suppl. B):217–20.
[51] Gattegno B, Sicard F, Alcaidinho D, Arnaud E, Thibault P. [Extracorporeal lithotripsy and prophylactic antibiotic therapy]. Ann Urol (Paris)
1988;22:101–2.
[52] Pettersson B, Tiselius HG. Are prophylactic antibiotics necessary during extracorporeal shockwave lithotripsy? Br J Urol 1989;63:449–52.
[53] Knipper A, Bohle A, Pensel J, Hofstetter AG. [Antibiotic prophylaxis with
enoxacin in extracorporeal shockwave lithotripsy]. Infection 1989;17(Suppl.
1):S37–8.
[54] Bierkens AF, Hendrikx AJ, Ezz el Din KE, de la Rosette JJ, Horrevorts A, Doesburg
W, et al. The value of antibiotic prophylaxis during extracorporeal shock wave
lithotripsy in the prevention of urinary tract infections in patients with urine
proven sterile prior to treatment. Eur Urol 1997;31:30–5.
[55] Pearle MS, Roehrborn CG. Antimicrobial prophylaxis prior to shock wave
lithotripsy in patients with sterile urine before treatment: a meta-analysis and
cost-effectiveness analysis. Urology 1997;49:679–86.
[56] Fourcade RO. Antibiotic prophylaxis with cefotaxime in endoscopic extraction
of upper urinary tract stones: a randomized study. The Cefotaxime Cooperative
Group. J Antimicrob Chemother 1990;26(Suppl. A):77–83.
[57] Knopf HJ, Graff HJ, Schulze H. Perioperative antibiotic prophylaxis in ureteroscopic stone removal. Eur Urol 2003;44:115–8.
[58] Hendrikx AJ, Strijbos WE, de Knijff DW, Kums JJ, Doesburg WH, Lemmens WA.
Treatment for extended-mid and distal ureteral stones: SWL or ureteroscopy?
Results of a multicenter study. J Endourol 1999;13:727–33.
63
[59] Rao PN, Dube DA, Weightman NC, Oppenheim BA, Morris J. Prediction of septicemia following endourological manipulation for stones in the upper urinary
tract. J Urol 1991;146:955–60.
[60] Charton M, Vallancien G, Veillon B, Brisset JM. Urinary tract infection in percutaneous surgery for renal calculi. J Urol 1986;135:15–7.
[61] Osman M, Wendt-Nordahl G, Heger K, Michel MS, Alken P, Knoll T. Percutaneous nephrolithotomy with ultrasonography-guided renal access: experience
from over 300 cases. BJU Int 2005;96:875–8.
[62] Dogan HS, Sahin A, Cetinkaya Y, Akdogan B, Ozden E, Kendi S. Antibiotic prophylaxis in percutaneous nephrolithotomy: prospective study in 81 patients. J
Endourol 2002;16:649–53.
[63] Mariappan P, Smith G, Bariol SV, Moussa SA, Tolley DA. Stone and pelvic urine
culture and sensitivity are better than bladder urine as predictors of urosepsis
following percutaneous nephrolithotomy: a prospective clinical study. J Urol
2005;173:1610–4.
[64] Lunevicius R, Morkevicius M. Systematic review comparing laparoscopic and
open repair for perforated peptic ulcer. Br J Surg 2005;92:1195–207.
[65] Steiner T, Traue C, Schubert J. [Perioperative antibiotic prophylaxis in transperitoneal tumor nephrectomy: does it lower the rate of clinically signiﬁcant
postoperative infections?]. Urologe A 2003;42:34–7.
[66] Montgomery JS, Johnston 3rd WK, Wolf Jr JS. Wound complications after hand
assisted laparoscopic surgery. J Urol 2005;174:2226–30.
[67] Pessaux P, Atallah D, Lermite E, Msika S, Hay JM, Flamant Y, et al. Risk factors
for prediction of surgical site infections in “clean surgery”. Am J Infect Control
2005;33:292–8.
[68] Kiddoo DA, Wollin TA, Mador DR. A population based assessment of complications following outpatient hydrocelectomy and spermatocelectomy. J Urol
2004;171(Pt 1):746–8.
[69] Swartz MA, Morgan TM, Krieger JN. Complications of scrotal surgery for benign
conditions. Urology 2007;69:616–9.
[70] Stranne J, Aus G, Hansson C, Lodding P, Pileblad E, Hugosson J. Single dose
orally administered quinolone appears to be sufﬁcient antibiotic prophylaxis
for radical retropubic prostatectomy. Scand J Urol Nephrol 2004;38:143–7.
[71] Terai A, Ichioka K, Kohei N, Ueda N, Utsunomiya N, Inoue K. Antibiotic prophylaxis in radical prostatectomy: 1-day versus 4-day treatments. Int J Urol
2006;13:1488–93.
[72] Takeyama K, Takahashi S, Maeda T, Mutoh M, Kunishima Y, Matsukawa M,
et al. Comparison of 1-day, 2-day, and 3-day administration of antimicrobial
prophylaxis in radical prostatectomy. J Infect Chemother 2007;13:320–3.
[73] Sakura M, Kawakami S, Yoshida S, Masuda H, Kobayashi T, Kihara K. Prospective
comparative study of single dose versus 3-day administration of antimicrobial
prophylaxis in minimum incision endoscopic radical prostatectomy. Int J Urol
2008;15:328–31.
[74] Takeyama K, Matsukawa M, Kunishima Y, Takahashi S, Hotta H, Nishiyama
N, et al. Incidence of and risk factors for surgical site infection in patients with
radical cystectomy with urinary diversion. J Infect Chemother 2005;11:177–81.
[75] Hara N, Kitamura Y, Saito T, Komatsubara S, Nishiyama T, Takahashi K. Perioperative antibiotics in radical cystectomy with ileal conduit urinary diversion:
efﬁcacy and risk of antimicrobial prophylaxis on the operation day alone. Int J
Urol 2008;15:511–5.
[76] Studer UE, Danuser H, Merz VW, Springer JP, Zingg EJ. Experience in 100
patients with an ileal low pressure bladder substitute combined with an afferent tubular isoperistaltic segment. J Urol 1995;154:49–56.
[77] Mould JW, Carson CC. Infectious complications of penile prostheses. Infect Urol
1989;139:50–2.
[78] Carson CC. Diagnosis, treatment and prevention of penile prosthesis infection.
Int J Impot Res 2003;15(Suppl. 5):S139–46.
[79] Grabe M, Bishop M, Bkerklund-Johansen TE, Botto H, Cek M, Naber KG, Tenke P,
et al. Guidelines on urological infections. European Association of Urology;
2009. Latest update 2011 on www.uroweb.org.