You are here: Urology Textbook > Surgical management > Perioperative antibiotic prophylaxis
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:
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
- Aminopenicillins: amoxicillin and clavulanic acid 2.2 g i.v., ampicillin and sulbactam 3 g i.v.
- Cephalosporins: cefazolin 2 g i.v., over 100 kg body weight 3 g i.v., cefuroxime 1,5 g i.v., over 100 kg body weight 3 g.
- Clindamycin: as an alternative in allergies: 600 mg i.v., over 100 kg body weight 900 mg i.v.
- Cotrimoxazole: as an alternative in allergies: 960 mg i.v.
- Gentamicin: as an alternative in allergies: 3 mg/kgKG
- Metronidazole: 500 mg i.v., over 100 kg body weight 1000 mg i.v.
|Surgical site infection||Index||Abbreviations|
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
Cummings 1994 CUMMINGS, P.:
Antibiotics to prevent infection in patients with dog bite wounds: a
meta-analysis of randomized trials.
In: Ann Emerg Med
23 (1994), Nr. 3, S. 535–40
Cuthbertson u.a. 1991 CUTHBERTSON, A. M. ;
MCLEISH, A. R. ; PENFOLD, J. C. ; ROSS, H.:
A comparison between single and double dose intravenous Timentin for
the prophylaxis of wound infection in elective colorectal surgery.
In: Dis Colon Rectum
34 (1991), Nr. 2, S. 151–5
Jensen u.a. 1990 JENSEN, L. S. ; ANDERSEN,
A. ; FRISTRUP, S. C. ; HOLME, J. B. ; HVID,
H. M. ; KRAGLUND, K. ; RASMUSSEN, P. C. ;
Comparison of one dose versus three doses of prophylactic
antibiotics, and the influence of blood transfusion, on infectious complications in acute and elective colorectal surgery.
In: Br J Surg
77 (1990), Nr. 5, S. 513–8
McCray u.a. 1986 MCCRAY, E. ; MARTONE, W. J. ;
WISE, R. P. ; CULVER, D. H.:
Risk factors for wound infections after genitourinary reconstructive
In: Am J Epidemiol
123 (1986), Nr. 6, S. 1026–32
Medeiros und Saconato 2001 MEDEIROS, I. ;
Antibiotic prophylaxis for mammalian bites.
In: Cochrane Database Syst Rev
(2001), Nr. 2, S. CD001738
Mishriki u.a. 1990 MISHRIKI, S. F. ; LAW,
D. J. ; JEFFERY, P. J.:
Factors affecting the incidence of postoperative wound infection.
In: J Hosp Infect
16 (1990), Nr. 3, S. 223–30
Moro u.a. 1996 MORO, M. L. ; CARRIERI, M. P. ;
TOZZI, A. E. ; LANA, S. ; GRECO, D.:
Risk factors for surgical wound infections in clean surgery: a
multicenter study. Italian PRINOS Study Group.
In: Ann Ital Chir
67 (1996), Nr. 1, S. 13–9
Pessaux u.a. 2003 PESSAUX, P. ; MSIKA, S. ;
ATALLA, D. ; HAY, J. M. ; FLAMANT, Y.:
Risk factors for postoperative infectious complications in
noncolorectal abdominal surgery: a multivariate analysis based on a
prospective multicenter study of 4718 patients.
In: Arch Surg
138 (2003), Nr. 3, S. 314–24
A. W. Partin, C. A. Peters, L. R. Kavoussi, R. R. Dmochowski, and A. J. Wein, Campbell-Walsh-Wein Urology, 12th ed. ISBN-13: 978-1455775675: Elsevier, 2020.
Zimmerli 1998 ZIMMERLI, W.:
[Antibiotic therapy in surgery].
69 (1998), Nr. 12, S. 1392–8
Deutsche Version: perioperative Antibiotikaprophylaxe in der Urologie