Errata
Article Outline
Best Practice Policy Statement on Antimicrobial Prophylaxis
Volume 179, Number 4, Pages 1383 and 1384, Table 3a, Table 3b (in bold): Second/third cephalosporins have been added as one of the “Antimicrobial(s) of Choice” for transrectal prostate biopsy. This addition provides a non-nephrotoxic alternative to fluoroquinolones for use when fluoroquinolone resistance is elevated. Aztreonam has been added as an alternative to aminoglycosides in cases of renal insufficiency. Clarification has been provided that oral agents can be used for prophylaxis for transrectal prostate biopsy and that vaginal surgery includes urethral sling procedures.
Table 3a. Recommended antimicrobial prophylaxis for urologic procedures
| Procedure | Organisms | Prophylaxis Indicated | Antimicrobial(s) of Choice | Alternative Antimicrobial(s) | Duration of Therapy⁎ |
|---|---|---|---|---|---|
| Lower Tract Instrumentation | |||||
| Removal of external urinary catheter | GU tract† | If risk factors‡,§ | - Fluoroquinolone¶ - TMP-SMX¶ | - 1st/2nd gen. Cephalosporin¶ - Amoxacillin/Clavulanate¶ | ≤24 hours¶ |
| Cystography, urodynamic study, or simple cystourethroscopy | GU tract | If risk factors§ | - Fluoroquinolone - TMP-SMX | - Aminoglycoside (Aztreonam¥) ± Ampicillin - 1st/2nd gen. Cephalosporin - Amoxacillin/Clavulanate | ≤24 hours |
| Cystourethroscopy with manipulation∥ | GU tract | All | - Fluoroquinolone - TMP-SMX | - Aminoglycoside (Aztreonam¥) ± Ampicillin - 1st/2nd gen. Cephalosporin - Amoxacillin/Clavulanate | ≤24 hours |
| Prostate brachytherapy or cryotherapy | Skin | Uncertain | - 1st gen. Cephalosporin | - Clindamycin⁎⁎ | ≤24 hours |
| Transrectal prostate biopsy | Intestine†† | All | - Fluoroquinolone - 2nd/3rd gen. Cephalosporin | - Aminoglycoside (Aztreonam¥) + Metronidazole or Clindamycin⁎⁎ | ≤24 hours |
| Upper Tract Instrumentation | |||||
| Shock-wave lithotripsy | GU tract | All | - Fluoroquinolone - TMP-SMX | - Aminoglycoside (Aztreonam¥) ± Ampicillin - 1st/2nd gen. Cephalosporin - Amoxacillin/Clavulanate | ≤24 hours |
| Percutaneous renal surgery | GU tract and skin‡‡ | All | - 1st/2nd gen. Cephalosporin - Aminoglycoside (Aztreonam¥) + Metronidazole or Clindamycin | - Ampicillin/Sulbactam - Fluoroquinolone | ≤24 hours |
| Ureteroscopy | GU Tract | All | - Fluoroquinolone - TMP-SMX | - Aminoglycoside (Aztreonam¥) ± Ampicillin - 1st/2nd gen. Cephalosporin - Amoxacillin/Clavulanate | ≤24 hours |
| Open or Laparoscopic Surgery | |||||
| Vaginal surgery (includes urethral sling procedures) | GU tract, skin and Grp B Strep. | All | - 1st/2nd gen. Cephalosporin - Aminoglycoside (Aztreonam¥) + Metronidazole or Clindamycin | - Ampicillin/Sulbactam - Fluoroquinolone | ≤24 hours |
| Without entering urinary tract | Skin | If risk factors | - 1st gen. Cephalosporin | - Clindamycin | Single dose |
| Involving entry into urinary tract | GU tract and skin | All | - 1st/2nd gen. Cephalosporin - Aminoglycoside (Aztreonam¥) + Metronidazole or Clindamycin | - Ampicillin/Sulbactam - Fluoroquinolone | ≤24 hours |
| Involving intestine§§ | GU tract, skin and intestine | All | - 2nd/3rd gen. Cephalosporin - Aminoglycoside (Aztreonam¥) + Metronidazole or Clindamycin | - Ampicillin/Sulbactam - Ticarcillin/Clavulanate - Pipercillin/Tazobactam - Fluoroquinolone | ≤24 hours |
| Involving implanted prosthesis | GU tract and skin | All | - Aminoglycoside (Aztreonam¥) + 1st/2nd gen. Cephalosporin or Vancomycin | - Ampicillin/Sulbactam - Ticarcillin/Clavulanate - Pipercillin/Tazobactam | ≤24 hours |
⁎Additional antimicrobial therapy may be recommended at the time of removal of an externalized urinary catheter. |
†GU tract: Common urinary tract organisms are E. coli, Proteus sp., Klebsiella sp., Enterococcus. |
‡See Table 1 “Patient-related factors affecting host response to surgical infections.” |
§If urine culture shows no growth prior to the procedure, antimicrobial prophylaxis is not necessary. |
¶Or full course of culture-directed antimicrobials for documented infection (which is treatment, not prophylaxis). |
¥Aztreonam can be substituted for aminoglycosides in patients with renal insufficiency. |
∥Includes transurethral resection of bladder tumor and prostate, and any biopsy, resection, fulguration, foreign body removal, urethral dilation or urethrotomy, or ureteral instrumentation including catheterization or stent placement/removal. |
⁎⁎Clindamycin, or aminoglycoside + metronidazole or clindamycin, are general alternatives to penicillins and cephalosporins in patients with penicillin allergy, even when not specifically listed. |
††Intestine: Common intestinal organisms are E. coli, Klebsiella sp., Enterobacter, Serratia sp, Serratia sp., Proteus sp., Enterococcus, and Anaerobes. |
‡‡Skin: Common skin organisms are S. aureus, coagulase negative Staph. sp., Group A Strep. sp. |
§§For surgery involving the colon, bowel preparation with oral neomycin plus either erythromycin base or metronidazole can be added to or substituted for systemic agents. |
Table 3b. Antimicrobial agents and doses for periprocedure use
•For surgical prophylaxis, all agents should be administered IV except fluoroquinolones, trimethoprim-sulfamethoxazole, oral agents for bowel preparation, and some agents given at catheter removal or transrectal prostate biopsy. •Dosages may vary with specific patient and situation. •For prolonged procedures, repeat intraoperative dosing may be indicated sooner than the intervals indicated in the Table. •Level-based dosing can be used for several agents, but is not applicable to periprocedural use less than or equal to 24 hours, and as such are not included in the Table. •Drug classification lists are not all-inclusive. | |
| Fluoroquinolones | Levafloxacin: 500 mg PO single dose Ciprofloxacin: 500 mg PO [q12h] Ofloxacin: 400 mg PO [q12h] |
| Aminoglycosides | Gentamicin: 5 mg/kg IV single dose Tobramycin: 5 mg/kg IV single dose Amikacin: 15 mg/kg IV single dose |
| 1st Generation cephalosporins | Cephalexin: 500 mg PO [q6h] Cephradine: 500 mg PO [q6h] Cefadroxil: 500 mg PO [q12h] Cefazolin: 1 g IV [q8h] |
| 2nd Generation cephalosporins | Cefaclor: 500 mg PO [q8h] Cefprozil: 500 mg PO [q12h] Cefuroxime: 500 mg PO [q12h] Cefoxitin: 1–2 g IV [q8h] |
| 3rd Generation cephalosporins (oral agents not listed) | Ceftizoxime: 1 g IV [q8h] Ceftazidime: 1 g IV [q12h] Ceftriaxone: 1–2 IV single dose Cefotaxime: 1 g IV [q8h] |
| Others | Amoxicillin/clavulanate: 875 mg PO [q12h] Ampicillin: 1–2 g IV [q6h] Ampicillin/sulbactam: 1.5–3 g IV [q6h] Aztreonam: 1–2 g IV [q8h] Clindamycin: 600 mg IV [q8h] Erythromycin base (for bowel preparation): 1–2 g PO [variable] Metronidazole: 1 g IV [q12h]; (for bowel preparation) 1–2 g PO [variable] Neomycin (for bowel preparation): 1–2 g PO [variable] Pipercillin/tazobactam: 3.375 g IV [q6h] Ticarcillin/clavulanate: 3.1 g IV [q6h] Trimethoprim-sulfamethoxazole: 1 double-strength tablet PO [q12h] Vancomycin: 1 g IV [q12h] |
PII: S0022-5347(08)02505-6
doi:10.1016/j.juro.2008.09.059
© 2008 American Urological Association. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Best Practice Policy Statement on Urologic Surgery Antimicrobial Prophylaxis , 18 February 2008