Antimicrobial prophylaxis in urologic procedures: AUA guidelines

American Urology Association has released its guidelines for Antibiotic Prophylaxis in urologic procedures.

The primary rationale for antimicrobial prophylaxis (AP) is to decrease the incidence of surgical site infection (SSI) and other preventable periprocedural infections, with the secondary goal of reducing antibiotic overuse. Beyond the rapid changes in antimicrobial resistance patterns and antimicrobial stewardship concerns, there remains much debate on the use of single-dose regimes in urology, specifically in the setting of indwelling catheters and stents outside the immediate perioperative period. While a complex topic, this Best Practice Statement is intended to be a comprehensive and user-friendly reference for the clinicians and providers caring for patients undergoing urologic procedures.

Main recommendations include-

•Periprocedural antimicrobial prophylaxis for the reduction of surgical site infections may be considered for all urologic procedures where a break in normal tissue barriers will occur.

•Antimicrobials should not be used except where medically indicated. Systemic antimicrobial usage is the primary driver of antimicrobial resistance both in the index patient and the community.

•The choice of periprocedural systemic antimicrobial agent(s) to reduce the risk of post-procedural surgical site infections and systemic infections should be carefully considered for any invasive procedure. The use of any antimicrobial should consider the patient's medical risks and allergies and the inherent risks associated with antimicrobial prophylaxis chosen.

•The potential benefit of antimicrobial prophylaxis should be considered with assessment of five points: 1. the patient's ability to respond to an infection, 2. the procedure being performed, 3. procedural factors that increase the likelihood of bacterial invasion at the operative site, 4. the virulence of the bacterial pathogen, and 5. the potential morbidity of any subsequent infection. The morbidity of antimicrobials includes the potential treatment emergent adverse events and the development of drug resistance.2

•Single-dose antimicrobial prophylaxis is appropriate in the majority of uncomplicated urologic cases.

•Single-dose antimicrobial prophylaxis coverage for usual skin flora may not be necessary for skin incisions Class I/clean procedures (uninfected, no inflammation, closed primarily without entrance into the gastrointestinal or genitourinary tracts). Exceptions are appropriate for prosthetic device implantation and may be considered for groin and perineal incisions where the surgical site infection risk may be increased.

•Single-dose periprocedural antimicrobial prophylaxis is currently recommended for patients undergoing specific Class II/clean-contaminated genitourinary procedures as the risk reduction of a serious surgical site infection or systemic infection exceeds the anticipated risks of increasing antimicrobial resistance and other adverse events. Specific Class II/clean-contaminated procedures requiring antimicrobial prophylaxis include prostate biopsy. Routine cystoscopy and urodynamic studies do NOT require antimicrobial prophylaxis in healthy adults in the absence of infectious signs and symptoms.

•Single-dose antimicrobial prophylaxis agents are recommended for patients undergoing Class III/ contaminated procedures as the risk of a serious surgical site infection or systemic infection is high.

•Class IV wounds are by definition infected. Antimicrobial prophylaxis guidelines may help choose the most appropriate empiric antimicrobial agent(s) for the most common offending pathogens until cultures inform targeted therapy.

•Surgeons should define and document any surgical site infection when it occurs using standardized definitions of surgical site infection.

•Parenteral antimicrobial prophylaxis agents should be administered within one hour of an incision to establish an appropriate bactericidal concentration of the agents in the tissues at the time the incision is made. If used, vancomycin and fluoroquinolones may be administered within two hours of the procedure.

•Antimicrobial prophylaxis should target the likely local organisms. For example, incisions into the urinary system should be covered by antimicrobials whose profile covers the most recent local antibiogram for genitourinary organisms. Cost, convenience, and safety of the agent as well as impact on emerging resistant organisms should be considered.

•Surgical antimicrobial prophylaxis may require re-dosing, weight-adjustment, or renal adjustment to ensure desired antimicrobial tissue levels during a procedure.

•Antimicrobial prophylaxis should be stopped after wound closure and case completion, even in the presence of a drain.

•Prior to any urologic procedure, the proceduralist or his/her team should inquire about urinary tract symptoms suggestive of a urinary tract infection.

•If antimicrobial prophylaxis is to be considered prior to an operative procedure on the urinary tract, the urine should be tested and the results obtained and reviewed to properly inform selection of an antimicrobial agent.

•Elective procedures should be deferred in the presence of symptoms consistent with an active infection until an antimicrobial course is complete and associated symptoms have improved.

•Asymptomatic bacteriuria and/or funguria may not require antimicrobial prophylaxis prior to a low-risk urologic surgical procedure in otherwise low-risk patients, with the exception of pregnant females, who DO require treatment of asymptomatic bacteriuria prior to an invasive urologic surgical procedure.

•Asymptomatic bacteriuria and asymptomatic funguria do not require treatment prior to an elective surgical procedure not entering the genitourinary system.

•Urgent and semi-urgent urologic procedures required in the setting of an active urinary tract infection should have current urine microscopy available as well as microbiologic cultures with antimicrobial sensitivities prior to proceeding if the clinical presentation allows. Antimicrobial usage is not prophylactic in this setting and requires active assessment of the most probable organisms, their sensitivities, and the antimicrobial's ability to penetrate the infected site.

•Antimicrobial prophylaxis, when indicated, is to be accompanied by best surgical practices for surgical site infection reduction, and is never a substitute for these best practices.

•Antimicrobial prophylaxis is not recommended for routine cystoscopy or for urodynamic studies in healthy adults in the absence of infectious signs and symptoms.

•Antimicrobial prophylaxis solely for the prevention of infectious endocarditis is not required for genitourinary procedures, even in the setting of a high-risk cardiac condition.

•Antimicrobial prophylaxis for the prevention of prosthetic hip or knee prostheses is recommended, particularly for genitourinary procedures at high risk of bacteremia, within two years of prosthetic joint placement and for high-risk populations.

•Antimicrobial prophylaxis may be considered at the time of clinical procedures such as trials of voiding, or removal of catheter or drain tubing, or stent or nephrostomy tube, especially when other patient and procedural risk factors are present.

•Noninvasive procedures such as shock wave lithotripsy do not require antimicrobial prophylaxis if the pre-procedural urine microscopy is negative for infection.

•Antifungal treatment, rather than single-dose prophylaxis, is recommended for patients with symptomatic fungal urinary tract infections at the time of exchange of any permanent drainage tube or stent once fungicidal levels are present.

•Antifungal prophylaxis may not be necessary for those with asymptomatic funguria undergoing routine urinary catheter, nephrostomy or stent placement or exchange.

•Single-dose antifungal prophylaxis is recommended for patients with asymptomatic funguria undergoing endoscopic, robotic, or open surgery on the urinary tract.

•A longer course of periprocedural antifungal treatment is strongly recommended in neutropenic patients with funguria who have a urinary tract obstruction and are undergoing surgery on the genitourinary tract.

•Fungal cultures and sensitivities are recommended in patients who have fungus balls. Periprocedural antifungal treatment based on those sensitivities is strongly recommended at the time of treatment, or any subsequent treatments, of the fungus balls.