Antimicrobial prophylaxis is effective in a wide range of urological procedures and has contributed to reduce the rate of postoperative infectious complications . Adherence to European Association of Urology (EAU) guidelines on antimicrobial prophylaxis reduces antimicrobial usage without increasing postoperative infection rates, lowers the prevalence of resistant uropathogens, and saves costs . Nevertheless, adherence to EAU guidelines is not optimal. Antimicrobials are used for clean procedures without evidence and the types of antimicrobials used are not according to guidelines recommendations . Also, antimicrobial prophylaxis is often extended beyond the recommended 24-h period with important consequences such as appearance of multi-resistant organisms, including strains resistant to newer agents, worsened clinical outcome, and increased treatment costs . Patients as well as the hospital ecology are unnecessary exposed to broad-spectrum antimicrobials and their adverse effects. It is of outmost importance to preserve the arsenal of effective antimicrobials at a hospital level and even beyond the hospital. A revision of clinical practice in terms of antimicrobial prophylaxis is urgently needed. The correct use of antimicrobial prophylaxis in urological procedures rests on three pillars: (1) knowledge of the local pathogen profile and antimicrobial resistance, (2) careful evaluation of patient-related risk factors for the development of infectious complications after urological procedures, and (3) adherence to EAU guidelines on urological infections. This clinical consultation guide aims to give a short update on evidence-based recommendations.
1. Knowledge of the local pathogen profile and antibiotic resistance
Recent surveillance programs have demonstrated a dramatic increase in bacterial resistance to antimicrobials worldwide . However, there are important regional differences in bacterial resistance profiles that should be taken into account as well. Several European countries have a high prevalence of fluoroquinolone and/or cephalosporin-resistant Escherichia coli and extended-spectrum beta-lactamase producing strains . In Italy, about 45% of isolates of E. coli are resistant to fluoroquinolones . Information about the local prevalence of fluoroquinolone-resistant E. coli is necessary for a correct choice of antimicrobial for prophylaxis. The EAU guidelines on urological infections clearly underline this aspect . Indeed, EAU guidelines suggest choosing antimicrobials on the basis of local pathogen profile and antimicrobial susceptibility pattern . Patients at risk of harboring fluoroquinolone-resistant strains and patients living in areas with a high percentage of fluoroquinolone-resistant strains shall receive an alternative antimicrobial prophylaxis . A recent paper based on data from the Global Prevalence Study of Infections in Urology showed that fluoroquinolones were administered as prophylaxis to 98.2% of patients who had undergone prostate biopsy, while the resistance to fluoroquinolones was seen in 60% of isolated bacterial strains from patients who developed infectious complications .
2. Patient-related risk factors for infectious complications
The risk assessment to identify patients at higher risk for infective complications should be a priority task for every urologist. Several factors must be taken into account: (1) general health of the patient (American Society of Anesthesiologists score), (2) general risk factors such as older age, diabetes mellitus, impaired immune system, malnutrition, extreme weight (Charlson comorbidity score), and (3) presence of specific endogenous or exogenous risk factors such as a history of urinary tract infections (UTIs) or urogenital infection, indwelling catheters, bacterial burden, previous instrumentation, and genetic factors . Presence of asymptomatic bacteriuria (ABU) is generally not considered as a risk factor in diagnostic and therapeutic procedures and interventions not opening or entering the urinary tract, and screening and treatment of ABU are not necessary in these cases  and . In all procedures where the urinary tract is entered and there is a breakage of the mucosa, particularly in endoscopic urological surgery, ABU should be considered a risk factor. However, there is not a universal consensus about this issue . A history of UTIs or previous treatment of a UTI is a very important risk factor for the development of infectious complications. In fact, Sundvall and coworkers  recently demonstrated that any antimicrobial treatment during the previous month and any hospitalization during the previous 6 mo, predicted higher resistance rates among urinary pathogens, in particular to fluoroquinolones.
3. Adherence to EAU guidelines on urogenital infections
The 2016 version of the EAU guidelines on urogenital infections have been updated according to emerging global problems like increasing levels of antimicrobial resistance, increasing prevalence of healthcare-associated UTIs, lack of new antimicrobial compounds in the pipelines of pharmaceutical companies, and the need for political, social, and health-related initiatives in the spirit of antibiotic stewardship . Adherence to EAU guidelines reduces not only the rate of bacterial resistance but also reduces costs without increasing the risk of postoperative infection after urologic procedures . Moreover, EAU guidelines provide detailed information about correct timing and dosage of all antimicrobials. Common errors in everyday clinical urological practice are an extended duration of antimicrobial prophylaxis, using wrong antimicrobials, and a suboptimal dosing. All errors facilitate the selection of resistant strains.
4. Recommendations for clinical practice
- 1. Establish collaboration with your microbiologist and obtain information about local pathogen profiles and antimicrobial resistance, in particular about fluoroquinolone-resistant strains. Use alternative prophylactic strategies such as sampling of the fecal flora prior to prostate biopsy in order to identify resistance to specific antimicrobial agents. Consider alternative antimicrobials with a low potential for collateral damage, such as fosfomycin or nitrofurantoin.
- 2. Evaluate all patient-related risk factors for development of infectious complications.
- 3. Take a careful UTI history and ask about recent hospitalization and use of antimicrobials. Do not give fluoroquinolones for prophylaxis if the patient was treated with these drugs within the previous 3 mo.
- 4. Monitor and always try to improve your adherence to EAU guidelines on urogenital infections.
- 5. Prescribe antimicrobials according to the principles of the EAU guidelines: activity against causative bacteria, low side-effects profile, and ability to achieve efficacious concentration at the site of infection.
- 6. Be aware that treatment and prophylaxis are two different issues. Antimicrobial prophylaxis should be given approximately 1 h before the procedure if you use oral administration and about 30 min before the procedure or at the start of anesthesia if you use the intravenous route. Radical cystectomy with urine diversion (small intestine) might be the only procedure where antimicrobial prophylaxis could be extended up to 48 h after surgery.
Conflicts of interest
The authors have nothing to disclose.
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a Department of Urology, Santa Chiara Regional Hospital, Trento, Italy
b Department of Urology, University of Basel, Basel, Switzerland
c Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne, UK
d Department of Urology, University of Pisa, Pisa, Italy
e Klinik und Poliklinik für Urologie, Kinderurologie und Andrologie, Universitätsklinikum Giessen und Marburg GmbH, Justus-Liebig-Universität Giessen, Germany
f Department of Urology, University of Malmo, Malmo, Sweden
g Department of Urology, Oslo University Hospital, Oslo, Norway
Corresponding author. Department of Urology, Santa Chiara Regional Hospital, Largo Medaglie d’Oro, Trento 938123, Italy. Tel. +39 461903306; Fax: +39 461902400.
© 2016 European Association of Urology, Published by Elsevier B.V.