Dr. med. Dirk Manski

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Perioperative Antibiotic Prophylaxis in Urologic Surgery

Mechanism and Benefits of Perioperative Antibiotic Prophylaxis

Perioperative antibiotic prophylaxis is the administration of systemic antibiotics before or during a surgical procedure. It lowers the bacterial concentration in the wound and reduces the risk of wound infection. The higher the potential bacterial contamination of the wound, the greater the benefit of antibiotic prophylaxis (Wagenlehner et al., 2011a). In addition, antibiotic prophylaxis reduces urologic complications such as urinary tract infections and urethral strictures.

Classification of Interventions by Level of Contamination

The risk of surgical site infections depends on many factors (see the previous section surgical site infections). An important factor is the degree of contamination of the wound at the end of the operation:

Clean Wound and Risk of SSI:

A clean wound is defined as an uninfected surgical wound without opening the gastrointestinal or genitourinary tract and without encountering inflammation. The most common organisms of SSI are staphylococci, and the risk is (in patients without risk factors) less than 2%. Antibiotic prophylaxis should be considered if the patient has risk factors and if there is a large wound cavity.

Clean-contaminated Wound and Risk of SSI:

The gastrointestinal or urogenital tract was opened in a controlled manner and without unusual contamination of the wound. The risk for wound infection is 2–4% for urinary tract interventions and 5–10% for colon surgery. In addition to staphylococci, the most common pathogens for SSI are enterobacteria and enterococci. Anaerobe pathogens are possible after bowel surgery. Antibiotic prophylaxis is recommended.

Contaminated Wound and Risk of SSI:

Wounds with uncontrolled contamination with infectious urine or gastrointestinal content or fresh traumatic wounds. The risk for wound infection is 10–15%, and the most common pathogens are similar to the category clean-contaminated. Antibiotic prophylaxis is recommended.

Dirty-infected Wound and Risk of SSI:

Dirty-infected wounds result from surgical interventions in body regions with massive bacterial contamination from existing infections or old traumatic wounds. The risk for wound infection is 15–40%, and the most common pathogens are similar to the category clean-contaminated. Antibiotic therapy for several days is recommended.

Timing of Perioperative Antibiotic Prophylaxis

Antibiotics are administered intravenously 30–60 min before skin incision; the maximum antibiotic concentration should be present in the tissue at the time of skin incision. Repeat antibiotic administration is recommended after four hours of surgery (depending on half-life) or after significant blood loss. Instead of a single dose, up to three administrations on the day of surgery are also recognized as prophylaxis. Still, the benefit compared to a single dose is uncertain.


Urologic Indications for Perioperative Antibiotic Prophylaxis

See the following table for indications of preoperative antibiotic prophylaxis in urologic procedures:

Preoperative antibiotic prophylaxis, modified according to EAU guidelines. Antibiotic prophylaxis is given as a single dose intravenously before the start of surgery. Repeat antibiotic administration is recommended after four hours of surgery (depending on half-life) or after significant blood loss.
(*) Patient risk factors for wound infection include cachexia, coagulopathies, shock and burns, polytrauma, diabetes mellitus, immunodeficiency, smoking, alcoholism, glucocorticoid therapy, catheters, or ureteral stents.
Procedure Antibiotic prophylaxis
with entering the urinary tract
Cephalosporin or aminopenicillin with β-lactamase inhibitor, alternatively, clindamycin or gentamicin.
with entering the gastrointestinal tract
Cephalosporin or aminopenicillin with β-lactamase inhibitor combined with metronidazole, alternatively, gentamicin or clindamycin combined with metronidazole.
Surgery without entering the urinary tract Only if risk factors (*) are present, antibiotic prophylaxis with a cephalosporin or aminopenicillin with β-lactamase inhibitor is recommended, alternatively, clindamycin or gentamicin. Antibiotic prophylaxis is recommended for major surgery, independent of risk factors.
TURB, TURP, ureteroscopy, PNL Cephalosporin or aminopenicillin with β-lactamase inhibitor, alternatively, clindamycin, cotrimoxazole or gentamicin.
Perineal prostate biopsy Aminopenicillin with β-lactamase inhibitor or cephalosporin, alternatively, clindamycin or gentamicin. Single administration is sufficient.
Transrectal prostate biopsy Combination administration (possible drugs are aminopenicillin with β-lactamase inhibitor, gentamicin, fosfomycin or cephalosporin) over 1–3 days is necessary. Consider targeted prophylaxis based on a rectal swab. Fluoroquinolones are no longer approved for prophylaxis in many countries.

Dosages of Perioperative Antibiotic Prophylaxis

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


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  Deutsche Version: perioperative Antibiotikaprophylaxe in der Urologie