Antimicrobial prophylaxis in urology and transplantation

Abstract

The main source of infection in urological practice is from the presence of an indwelling catheter. The risk of catheteracquired infection is determined by the duration of catheterization, the adequacy of free drainage, and the efficiency of the closed drainage system. Many catheter‐acquired infections are due to multiresistant strains ofEscherichia coli, Klebsiella sp.,Pseudomonas aeruginosa, Proteus sp., and Providentia sp. Antibiotic prophylaxis has no place in the prevention of catheter‐acquired infections, and prophylaxis should be achieved by scrupulous aseptic technique and reducing the duration of drainage. The problems of catheters in the paraplegic are discussed. Septicemia and endotoxemia are the most feared complications of cystoscopy and retropubic prostatectomy if the urinary tract is infected and of transrectal biopsy of the prostate. For this reason, antibiotic cover is generally advised for these procedures. Sepsis is still a major cause of death in patients who have received a renal transplant. These infections are not only bacterial, but viral, protozoal, and fungal. The severity and frequency of these infections have been reduced by less aggressive immunosuppression. There is probably a place for perioperative antibiotic cover, but long‐term antibiotics should be avoided.

Asepsis and Out‐Patient Cystoscopy

“…Measures taken to reduce the infection rate following out-patient cystoscopy include adequate sterilisation of instruments, the use of full sterile theatre technique, gentle instrumentation, the inclusion of antibacterial agents in the irrigating fluid and parenteral prophylactic antibiotics. These have achieved only partial success (Chisholm, 1982). Lytton (1961) found that less than 2% of men attending for out-patient cystoscopy developed an infection provided the instruments were adequately sterilised and a careful, clean aseptic technique was employed.…”

Survey of Antibiotic Prophylaxis in British Urological Practice

“…A critical review of the literature on prophylaxis in urological operations was frustrated by the conflicting results reported (Chodak and Plaut, 1979). More recent studies have produced more reliable data and guidelines for the use of prophylactic antimicrobials have been put forward (Chisholm, 1982;Russo et al, 1983).…”

“…Removal of intrarenal stones may be associated with a wound and urinary tract complication rate ranging from 5 to 30% (Maddern, 1967;Wickham and Mathur, 1971;Boyce and Elkins, 1974). The risk of septicaemia during manipulation of the stone is high, and this has been effectively reduced by antibacterial prophylaxis (Chisholm, 1982). Only 17% used routine prophylactic antibiotics and the majority relied on selection, using the MSSU for guidance, yet it has been shown that whilst the MSSU may be sterile the pelvic urine or the stone itself may be infected and still constitute a high risk group that cannot be identified pre-operatively (Lewi et af., 1984).…”

“…The routine use of antibiotics was more common in prostatic biopsy than in the other situations we studied. Following prostatic biopsy by the transrectal route, between 5 and 40% of patients have infective complications and the routine use of antibiotics has been recommended (Chisholm, 1982;Russo et al, 1983). The use of a povidone iodine enema in transrectal prostatic biopsy has been studied with encouraging results (Brown et af., 1981) and its use is now advocated in this procedure (Chisholm, 1982), but only one urologist used this measure.…”

“…Suggestions regarding the necessity for antibiotic prophylaxis in various areas of urological surgery have been made but conflicting results have been obtained (Chodak and Plaut, 1979) and the role is confused; nevertheless, guidelines have been proposed (Chisholm, 1982;Russo et al, 1983).…”