Non antibiotic strategies for prevention of surgical infection:
- Aseptic environment
- Maintenance of sterile fields
- Cleaning of operative site with surgical skin preparation fluid
- 5 minute surgical scrub
- No touch technique gloving and gowning
- Sterilisation of surgical instruments
- Laminar airflow
- Reducing theatre traffic
- Shaving of hair with clippers prior to incision
- Waterproof sterile dressings
- Avoiding intraoperative hypothermia
- Optimising blood glucose control
Detection of bacteriuria prior to procedures:
- Urine culture, and treatment of any detected bacteriuria is standard of care
Potential benefit for prophylaxis should be considered in context of:
- Patients ability to respond to infection
- Immunosuppression, previous infections, neutropenic
- Specific procedure
- Risk of infection and morbidity of that infection (i.e., prosthetic)
- Procedural factors likely to increase likelihood of bacterial invasion
- Virulence of bacterial pathogen
- Potential morbidity of subsequent infection
Host factors which may increase risk:
- Frailty
- Diabetes
- COPD or recent pneumonia
- Significant cardiac disease
- Urological abnormalities or impaired drainage
- Malnutrition
- Smoking
- Steroids
- Immunodeficiency
- Recent chemotherapy
- Long term catheters
- Colonised foreign bodies
- Concurrent infection
- Prolonged hospitalisation
- Scrotal, inguinal or perineal incision
- Pregnancy
Choice of agent:
- Depending on local protocols and susceptibilities/resistance
- In conjunction with local ID and microbiological guidance
- Patient specific factors
- Allergies
- Renal function contra-indicating gentamicin
- Pre-operative and historical urine cultures
- Weight / ideal body weight
- Cost of the agent
- Availability
Antibiotic prophylaxis should be administered for the shortest appropriate time – in most cases single dose is sufficient.
Urological practice not well covered by standard categorisation of clean/contaminated procedures – e.g. cystoscopy and TURP both enter urinary tract but very different rates of infection.
EAU guidelines
- Do not routinely use prophylaxis for urodynamics, cystoscopy and ESWL
- Use prophylaxis to reduce rate of symptomatic UTI for ureteroscopy, PCNL, TURP, TURBT
- TP biopsy preferred over TRUS, with skin cleansing recommended for TP, and rectal iodine for TRUS
Notes from AUA best practice statement
- Administer ABx within an hour of incision to establish adequate bactericidal concentration of these agents at the time incision is made
- Elective operations should be deferred until symptomatic UTI is completely treated
- AUA – asymptomatic bacteriuria and/or funguria may not require ABx prophylaxis prior to low risk procedure in low risk patients
- ABx not needed for routine cystoscopy or urodynamics in absence of infectious signs and symptoms
- Consider prophylaxis at the time of catheter, drain or stent removal in the presence of other risk factors
- Single dose antifungal prophylaxis is recommended for patients with asymptomatic funguria undergoing endoscopic, open or robotic surgery to urinary tract