Glenn M. Preminger

ANTIBIOTIC USE DURING ENDOUROLOGIC

SURGERY Comprehensive Kidney Stone Center

at Duke University Medical Center Durham, North Carolina

LEADING EDGE UROLOGY 49th Annual Duke Urologic Assembly

Committee on Antibiotics & Handling and Prevention of

Complications Glenn Preminger USA Adrian Joyce UK Mantu Gupta USA Michael Wong Singapore Pilar Laguna Netherlands Stavros Gravas Greece Jorge Gutierrez Mexico / US Luigi Cormio Italy Kunjie Wang China

UTI & ENDOUROLOGY INTRODUCTION

Urinary tract infection (UTI) is the most common complication related to stone intervention Adequate assessment of culture data and adherence to appropriate guidelines may prevent the development of UTI and the potential for post-intervention urosepsis This presentation outlines the evidence for current recommendations regarding prophylaxis to prevent UTI / urosepsis as well as the interpretation of stone culture data to provide an evidence-based approach for the judicious use of antibiotics in urologic stone practice

UTI & ENDOUROLOGY

INTRODUCTION

All patients should be evaluated with a complete history, physical examination, and laboratory tests, including midstream urine culture A full preoperative evaluation will identify high-risk patients with the potential for infectious complications

UTI & ENDOUROLOGY PRE-OPERATIVE EVALUATION

Patient Factors Urinary Tract Factors Immunosuppression Anatomic abnormalities Chemo / steroids Voiding dysfunction Diabetes mellitus Urinary diversion Advanced age, poor nutrition Urinary tract obstruction Obesity Indwelling catheters, stents Renal / liver dysfunction nephrostomy tubes Female patients Coexistent infections Prolonged hospitalization

UTI & ENDOUROLOGY BACTERIOLOGY

Pre-operative urine cultures and understanding of local antibiotic susceptibility patterns are essential E. Coli is the most common pathogen followed by Klebsiella and Proteus Gram-positive bacteria (enterococcus & staphylococcus)must also be considered The increasing incidence of resistant pathogens necessitates the development strategies to reduce the risk of antibiotic resistance Rationalization of the empiric use of antibiotics Limiting antibiotic prophylaxis only to those patients with pre-determined risk

UTI & ENDOUROLOGY BACTERIOLOGY

Patients with a positive culture must receive pre-op antibiotics tailored to culture-specific organisms If UTI is associated with urinary obstruction, one must place a ureteral stent or nephrostomy tube If UTI is related to urinary tract or stone bacterial colonization, culture-specific antibiotics must be administered orally (5-7 days) or IV 24 hours pre-op A persistently positive urine culture in patients with a ureteral stent or nephrostomy tube may require replacing the device and re-evaluating urine culture before surgery

UTI & SWL INCIDENCE

Incidence of UTI after uncomplicated SWL is < 1% rising to 2.7% during treatment of staghorn stones Risk of sepsis increases in the presence of bacteriuria prior to SWL, especially with obstruction

UTI & ENDOUROLOGY LEVELS OF EVIDENCE AND GRADING

LE Grade I Meta-analysis or A Recommendation is good RCT “mandatory” & within clinical care pathway II Low quality RTC B Majority evidence from Good quality cohort level II / III studies III Good quality case- C Depends on level IV control studies studies or expert opinion IV Expert Opinion D No recommendation possible

UTI & SWL RECOMMENDATIONS

Prevention of Infection / Sepsis in SWL LE Grade The risk of sepsis increases in the presence of bacteriuria prior to SWL

II

A

ATB prophylaxis is not necessary for SWL in patients with no or low risk

I

A

Prophylactic ATB recommended only in high-risk stone patients eg: infection stones, recent instrumentation, nephrostomy tubes, positive urine cultures or those with a history of recent UTI or sepsis

I

A

UTI & SWL RECOMMENDATIONS

Prophylactic antibiotics only recommended in high-risk stone groups Infected stones Recent instrumentation N-tubes Positive urine cultures History of recent UTI or sepsis Special consideration given to high risk patients Advanced age Anatomical anomalies Poor nutrition Chronic smokers Chronic steroids Immunodeficiency Externalized tubes Prolonged hospitalization

UTI & URS INCIDENCE

CROES Ureteroscopy Global Study reported a multicenter trial in 11,885 patients Incidence of postoperative infectious events Post-operative fever 1.8% Urinary tract infection 1.0 % Sepsis 0.3% .

Martov and de la Rosette, 2014

UTI & URS ANTIBIOTIC PROPHYLAXIS

In patients with a negative baseline urine culture undergoing URS for ureteral or renal stones, rates of postoperative UTI and fever were not reduced by preoperative antibiotic prophylaxis Female gender and a high ASA score were specific risk factors for postoperative infection in this patient group

Martov and de la Rosette, 2014

UTI & URS INTRA-OPERATIVE FACTORS

In patients with active UTI and obstruction, decompress with ureteral stent or N-tube, treat infection, followed by staged procedure Maintain low irrigation pressures Gravity irrigation Ureteral access sheath Consider forced diuresis

UTI & URS MANAGEMENT OF POST-OP INFECTION

Early recognition and management of sepsis Culture-directed ATB when possible Broad spectrum ATB if culture not available Best management of any infectious complication is prevention

UTI & URS RECOMMENDATIONS

Prevention of Infection / Sepsis in URS LE Grade Identify high-risk patients

II

B

Treat active UTI pre-procedure

II

A

Ensure a pre-operative negative urine culture

II

B

UTI & URS RECOMMENDATIONS

Prevention of Infection / Sepsis in URS LE Grade

Antimicrobial prophylaxis in all patients II A

Never perform stone manipulation in the presence of active UTI – Relieve obstruction, treat infection, proceed with staged treatment

I A

In patients with chronic bacteruria, administer at least 5 days of culture-specific ATB prior to instrumentation

II B

UTI & URS RECOMMENDATIONS

Prevention of Infection / Sepsis in URS LE Grade

Maintain low intra-renal pressure during procedure III B

Forced diuresis with diuretics during procedure IV C

UTI & PNL INCIDENCE

Fever 21.0 – 39.8% Sepsis 0.3 – 9.3% Reasons for UTI after PNL Release of bacteria during stone fragmentation Introduction of bacteria through nephrostomy tract

UTI & PNL ANTIBIOTIC REGIMENS FOR PNL

When the pre-op urine culture is negative, a single dose of ATB appears to be as effective in preventing post-operative infections as multiple doses, irrespective of ATB used

Bootsma, et al, 2008

UTI & PNL RISK FACTORS FOR FEVER-SEPSIS-SIRS

Pre-operative factors Female gender Hydroureteronephrosis Pre-op nephrostomy tube Complex stone burden Neurogenic bladder Diabetes mellitus

UTI & PNL RISK FACTORS FOR FEVER-SEPSIS-SIRS

Intra-operative factors Number of access tracts Operative time Volume of irrigation fluid Purulent urine during percutaneous puncture

UTI & PNL RECOMMENDATIONS

Prevention of Infection / Sepsis in PNL LE Grade A urine culture should be performed in all patients prior to PNL III A

Patients with a positive pre-op culture should be treated prior to PNL II A

All patients who undergo PNL should receive antibiotic prophylaxis III B

When ATB prophylaxis is used, not specific regimen can be recommended – prophylaxis should be chose according to regional antibiogram and safety of ATB agents

III A

UTI & ENDOUROLOGY TAKE HOME MESSAGES

General recommendations before an active stone removal procedure LE Grade

Treat pre-operative UTI with culture-specific ATB – Repeat culture obtained before surgery II A

Drain urine if UTI is associated with obstruction I A

Treat persistent UTI not associated with obstruction with culture-specific ATB for 5-7 days orally or IV 24-hrs prior to surgery

II A