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Article of the Week: Antibiotic prophylaxis in ureteroscopic lithotripsy

Every Week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Antibiotic prophylaxis in ureteroscopic lithotripsy: a systematic review and meta‐analysis of comparative studies

Tuo Deng*†‡, Bing Liu§, Xiaolu Duan*†‡, Chao Cai*†‡, Zhijian Zhao*†‡, Wei Zhu*†‡Junhong Fan*†‡, Wenqi Wu*†‡ and Guohua Zeng*†‡

 

*Department of Urology, Minimally Invasive Surgery Center, The First Afliated Hospital of Guangzhou Medical University, Guangzhou, China, Guangzhou Institute of Urology, Guangzhou, China, Guangdong Key Laboratory of Urology, Guangzhou, China, and §The First Afliated Hospital of Jinan University, Guangzhou, China

 

Abstract

Objective

To explore the efficacy of antibiotic prophylaxis and the different strategies used to prevent infection in ureteroscopic lithotripsy (URL) by conducting a systematic review and meta‐analysis.

Materials and Methods

A systematic literature search using Pubmed, Embase, Medline, the Cochrane Library, and the Chinese CBM, CNKI and VIP databases was performed to find comparative studies on the efficacy of different antibiotic prophylaxis strategies in URL for preventing postoperative infections. The last search was conducted on 25 June 2017. Summarized unadjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to assess the efficacy of different antibiotic prophylaxis strategies.

Results

A total of 11 studies in 4 591 patients were included in this systematic review and meta‐analysis. No significant difference was found in the risk of postoperative febrile urinary tract infections (fUTIs) between groups with and without antibiotic prophylaxis (OR: 0.82, 95% CI 0.40–1.67; P = 0.59). Patients receiving a single dose of preoperative antibiotics had a significantly lower risk of pyuria (OR: 0.42, 95% CI 0.25–0.69; P = 0.0007) and bacteriuria (OR: 0.25, 95% CI 0.11–0.58; P = 0.001) than those who did not. Intravenous antibiotic prophylaxis was not superior to single‐dose oral antibiotic prophylaxis in reducing fUTI (OR: 1.00, 95% CI 0.26–3.88; P = 1.00).

Conclusions

We concluded that preoperative antibiotic prophylaxis did not lower the risk of postoperative fUTI, but a single dose could reduce the incidence of pyuria or bacteriuria. A single oral dose of preventive antibiotics is preferred because of its cost‐effectiveness. The efficacy of different types of antibiotics and other strategies could not be assessed in our meta‐analysis. Randomized controlled trials with a larger sample size and more rigorous study design are needed to validate these conclusions.

Editorial: Antibiotics and ureteroscopy: a single prophylactic dose is enough, but could we give even less?

Antibiotic resistance is internationally recognized as a threat to global health. As a consequence, there is an ongoing need to review antibiotic prescribing practice, both for treatment and prophylaxis. ‘Antibiotic stewardship’, whereby antimicrobial use, and the associated increase in bacterial resistance, is reduced, is essential worldwide [1].

In this issue of BJUI, Deng et al. [2] present the results of their systematic review and meta‐analysis of the efficacy of antibiotic prophylaxis vs no treatment in patients undergoing upper tract ureteroscopy/ureterorenoscopy. In total, 4591 patients were analysed (from 11 studies, comprising five randomized controlled trials, one prospective comparative study and five retrospective comparative studies), of whom 2700 patients received antibiotic prophylaxis and the remaining 1891 had no prophylactic antibiotics at all. To know more visit walkerstgallery .

Having excluded patients with pre‐operative urinary tract infection (UTI) or bacteriuria, they found that patients who received a single dose of pre‐operative antibiotic had a significantly lower risk of pyuria and bacteriuria than those without antibiotic, but that there was no difference in the risk of post‐operative febrile UTIs between the groups with and without the use of prophylactic antibiotic. There was also no advantage to intravenous antibiotic administration compared with oral administration in reducing febrile UTIs, nor any difference between a single dose of antibiotic drug vs a more prolonged post‐operative regime [2].

This is an important article, potentially leading many urological surgeons to change their current practice with regard to prescribing post‐operative antibiotics, and raising the question of whether antibiotic prophylaxis is needed in patients who have sterile urine pre‐operatively and no specific operative risk factors.

The next question for endourologists to answer will be ‘What is the most appropriate management of asymptomatic bacteriuria detected during pre‐operative investigations?’ Whilst current practice is to treat pre‐operative bacteriuria in patients managed in urology departments, Herr [3] has shown it is reasonable not to give prophylactic antibiotics to asymptomatic patients undergoing flexible cystoscopy, even if there is bacteriuria on pre‐procedure urine analysis. Herr evaluated >3000 outpatients undergoing flexible cystoscopies (of whom 78% had sterile urine and 22% had asymptomatic bacteriuria). The cystoscopies were performed without any antibiotic prophylaxis at all. Overall, 1.9% of patients experienced febrile UTIs, all of which resolved rapidly with oral antibiotics and without any complications (no sepsis or hospital admission). Although the rate was higher in patients with prior infected urine (UTI rate 3.7% compared with 1.4% in patients with sterile urine), Herr concluded that prophylactic antibiotics are not necessary in asymptomatic patients regardless of the presence of bacteriuria, and therefore advised that pre‐procedure urine analysis itself is not required [3].

These findings challenge the belief that pre‐operative urine analysis is essential in asymptomatic patients. Kavoussi et al. [4] studied this issue in patients undergoing insertion of an artificial urinary sphincter or inflatable penile prosthesis, of whom 41% had no pre‐operative urine culture; the authors demonstrated a low risk of 1.5% of prosthesis infection in patients receiving standard peri‐operative antibiotics. This suggests that, even in ‘high stakes’ prosthetic implantation (where the consequences of infection are considerable, requiring explanation and later re‐insertion of a new device), surgery can be performed without pre‐operative urine cultures [4].

Perhaps even more contentiously, Cai et al. [5] have questioned the need for treatment of asymptomatic bacteriuria before urological procedures when ‘standard antibiotic prophylaxis’ is given pre‐operatively. They analysed 2201 patients treated in accordance with European Association of Urology guidelines for antibiotic prophylaxis, of whom 70.1% had sterile urine and 30.4% had asymptomatic bacteriuria pre‐operatively. They reported no increased risk in patients with pre‐operative asymptomatic bacteriuria, with 10.4% of affected patients having a symptomatic post‐operative UTI and a 0.3% risk of sepsis, compared with a 8.3% UTI rate and 0.26% chance of sepsis in patients with pre‐operatively sterile urine [5].

In their article, Deng et al. [2] have shown that patients with sterile urine undergoing ureteroscopy had a similar risk of a post‐operative febrile UTI whether or not pre‐ and post‐operative antibiotics were given. This implies the need for specific high‐risk groups to be targeted for antibiotic prophylaxis, and, extending the arguments above, suggests that a more selective approach is needed for pre‐operative urine analysis in low‐risk patients.

In this regard, Grabe and Wullt [6] have commented that ‘undetected pre‐operative bacteriuria is like walking straight into a minefield’. Whilst the knowledge that one is walking into a minefield has the advantage of leading one to take a cautious approach (i.e. treating asymptomatic bacteriuria pre‐operatively), it is possible that not all of the mines in the minefield are live (i.e. certain patients with asymptomatic bacteriuria may be at lower risk of post‐operative problems than others). The real challenge is to determine which patients with asymptomatic bacteriuria need antibiotic treatment and for how long, and therefore which patients need urine analysis before which procedures in the first place. This approach, if shown to be safe, would not only reduce the cost of urine cultures and pre‐surgical eradication of asymptomatic bacteriuria, but also the wider global cost of antibiotic overuse and bacterial resistance.

Daron Smithand Bruce Macrae
*EndoLuminal EndoUrologist, Department of Urology, Westmoreland Street Hospital, and Clinical Microbiology, UCLH NHS Foundation Trust, London, UK
Read the full article

References

  1. WHO. Global action plan on antimicrobial resistance. 2015 (accessed March 23, 2018)https://apps.who.int/iris/bitstream/handle/10665/193736/9789241509763_eng.pdf?sequence=1
  2. Deng T, Liu B, Duan X et al. Antibiotic prophylaxis in ureteroscopic lithotripsy: a systematic review and meta‐analysis of comparative studies. BJU Int 2018122: 29–39
  3. Herr HW. The risk of urinary tract infection after flexible cystoscopy in patients with bladder tumor who did not receive prophylactic antibiotics. J Urol 2015193: 548–51
  4. Kavoussi NL, Viers BR, Pagilara TJ et al. Are urine cultures necessary prior to urologic prosthetic surgery? Sex Med Rev 20186: 157–61
  5. Cai T, Verze P, Palmieri A et al. Is preoperative assessment and treatment of asymptomatic bacteriuria necessary for reducing the risk of postoperative symptomatic urinary tract infections after urologic surgical procedures? Urology 201799: 100–5
  6. Grabe M, Wullt B. Re: Is preoperative assessment and treatment of asymptomatic bacteriuria necessary for reducing the risk of postoperative symptomatic urinary tract infection after urologic surgical procedures? Eur Urol 2017; 73: 476-477

Article of the Month: Guideline of Guidelines – Thromboprophylaxis for Urological Surgery

Every Month the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Kari Tikkinen, discussing his paper.

If you only have time to read one article this week, it should be this one.

Guideline of guidelines: thromboprophylaxis for urological surgery

Philippe D. Violette*, Rufus Cartwright†‡, Matthias Briel§, Kari A.O. Tikkinen¶ and Gordon H. Guyatt**,

 

*Division of Urology, Department of Surgery, Woodstock Hospital, Woodstock, ON, Canada, † Department of Epidemiology and Biostatistics, Imperial College London, London, UK, Department of Urogynaecology, St. MaryHospital, London, UK, §Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland, Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, **Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada, and ††Department of Medicine, McMaster University, Hamilton, ON, Canada

 

Read the full article

 

Decisions regarding thromboprophylaxis in urologic surgery involve a trade-off between decreased risk of venous thromboembolism (VTE) and increased risk of bleeding. Both patient- and procedure-specific factors are critical in making an informed decision on the use of thromboprophylaxis. Our systematic review of the literature revealed that existing guidelines in urology are limited. Recommendations from national and international guidelines often conflict and are largely based on indirect as opposed to procedure-specific evidence. These issues have likely contributed to large variation in the use of VTE prophylaxis within and between countries. The majority of existing guidelines typically suggest prolonged thromboprophylaxis for high-risk abdominal or pelvic surgery, without clear clarification of what these procedures are, for up to 4 weeks post-discharge. Existing guidance may result in the under-treatment of procedures with low risk of bleeding and the over-treatment of oncological procedures with low risk of VTE. Guidance for patients who are already anticoagulated are not specific to urological procedures but generally involve evaluating patient and surgical risks when deciding on bridging therapy. The European Association of Urology Guidelines Office has commissioned an ad hoc guideline panel that will present a formal thromboprophylaxis guideline for specific urological procedures and patient risk factors.

AOTM Key Points

 

Editorial: Optimal Thromboprophylaxis Remains a Challenge

The ‘Guideline of guidelines: thromboprophylaxis for urological surgery’, published in this month’s issue of BJUI by Violette et al. [1], addresses a critical issue in urological practice and offers a comprehensive overview of available guidelines. Many urological surgeries, especially cancer surgeries, present a significant risk of thromboembolism, as well as bleeding. Therefore, urological surgeons should be well educated in the matter in order to be able to offer optimal prophylaxis to patients. Reading through the current recommendations and guidelines, one realises the wide variety of possible ways to risk stratify a patient, but also the large differences in opinions on how and when to offer prophylaxis. Consequently, even members within the same national society treat their patients in completely different ways.

The ideal recommendation will have to be individualised, taking thromboembolic and bleeding risk into account for each individual patient and specific surgery type. This stratification of patients not only presents a challenge in clinical practice but also for the design of meaningful clinical trials. As many medical questions regarding thromboprophylaxis remain unanswered, the currently available recommendations are based on our pathophysiological understanding and remain eminence-based, rather than evidence-based.

For many years, the ‘Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines’ [2] were viewed as the most respected guidelines in surgery. They include recommendations for a wide variety of surgical procedures, including urological surgeries. With an ageing population, our patients will more often be on anticoagulant treatment before surgery. While most guidelines still recommend stopping the anticoagulant treatment and bridging with heparin, new evidence from randomised controlled trials [3, 4] indicate that bridging by heparin significantly increases the risk for major bleeding without reducing the thromboembolic risk in most patients. Despite a recent appeal by internists and cardiologists [5], revised guidelines from the American College of Chest Physicians to replace the partially outdated recommendations have yet to be published. As mentioned by Violette et al. [1] in their current review, bridging should probably only be offered to a limited number of patients with a very high risk of thromboembolic complications.

The European Association of Urology has recognised the problem and presented the prospect of providing a guideline on thromboprophylaxis for urological procedures later this year. Looking at the landscape of available high-quality publications it will still be highly challenging to provide clear recommendations for urological surgeries. The key to a comprehensive application will be the clinical practicality. With this review, the authors have set the stage to a critical review of the recommendations from a urological point of view.

Read the full article

 

Daniel Eberli
University and University Hospital of Zurich, Zurich, Switzerland

 

References

 

1 Violette PD, Cartwright R, Briel M, Tikkinen KAO, Guyatt GHGuideline of guidelines: thromboprophylaxis for urological surgery. BJU Int 2016; 118: 35158

 

 

 

4 Douketis JD, Spyropoulos AC, Kaatz S et al. Perioperative bridging anticoagulation in patients with atrial brillation. N Engl J Med 2015; 373: 82333

 

 

6 Devereaux PJ, Mrkobrada M, Sessler DI et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014; 370: 1494503

 

Video: Guideline of Guidelines – Thromboprophylaxis for Urological Surgery

Guideline of guidelines: thromboprophylaxis for urological surgery

Philippe D. Violette*, Rufus Cartwright†‡, Matthias Briel§, Kari A.O. Tikkinen¶ and Gordon H. Guyatt**,

 

*Division of Urology, Department of Surgery, Woodstock Hospital, Woodstock, ON, Canada, † Department of Epidemiology and Biostatistics, Imperial College London, London, UK, Department of Urogynaecology, St. MaryHospital, London, UK, §Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland, Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, **Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada, and ††Department of Medicine, McMaster University, Hamilton, ON, Canada
Read the full article
Decisions regarding thromboprophylaxis in urologic surgery involve a trade-off between decreased risk of venous thromboembolism (VTE) and increased risk of bleeding. Both patient- and procedure-specific factors are critical in making an informed decision on the use of thromboprophylaxis. Our systematic review of the literature revealed that existing guidelines in urology are limited. Recommendations from national and international guidelines often conflict and are largely based on indirect as opposed to procedure-specific evidence. These issues have likely contributed to large variation in the use of VTE prophylaxis within and between countries. The majority of existing guidelines typically suggest prolonged thromboprophylaxis for high-risk abdominal or pelvic surgery, without clear clarification of what these procedures are, for up to 4 weeks post-discharge. Existing guidance may result in the under-treatment of procedures with low risk of bleeding and the over-treatment of oncological procedures with low risk of VTE. Guidance for patients who are already anticoagulated are not specific to urological procedures but generally involve evaluating patient and surgical risks when deciding on bridging therapy. The European Association of Urology Guidelines Office has commissioned an ad hoc guideline panel that will present a formal thromboprophylaxis guideline for specific urological procedures and patient risk factors.

 

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