From the Guidelines
Prophylactic antibiotics are not routinely recommended for most patients with kidney stones, but may be considered in specific situations such as before stone removal procedures or for patients with infected stones, as indicated by the most recent guidelines 1. When indicated, common antibiotic choices include trimethoprim-sulfamethoxazole, ciprofloxacin, or amoxicillin-clavulanate, with the specific choice depending on the clinical scenario and patient risk factors.
Key Considerations
- For surgical prophylaxis, a single dose of antibiotics is typically given within 60 minutes before the procedure, as recommended by recent studies 1.
- Patients with positive urine cultures should receive targeted antibiotics based on sensitivity testing before any intervention.
- Prophylactic antibiotics are particularly important for patients with risk factors such as diabetes, immunosuppression, or a history of urinary tract infections.
- The rationale for selective antibiotic use is to prevent serious infections like urosepsis while avoiding unnecessary antibiotic exposure that could contribute to antimicrobial resistance, as highlighted in a recent consensus statement 1.
Clinical Approach
- Routine cystoscopy and urodynamic studies do not require antimicrobial prophylaxis in asymptomatic patients.
- Preoperative antibiotics do not appear to reduce infectious complications from routine cystoscopic stent removal nor nephrostomy tube placement.
- However, in patients undergoing percutaneous nephrolithotomy, a single dose of antimicrobial prophylaxis may reduce the risk of infection, although extended perioperative dosing may be considered in high-risk patients 1.
From the Research
Prophylactic Antibiotics for Kidney Stone Treatment
- The use of prophylactic antibiotics in patients undergoing percutaneous nephrolithotomy (PCNL) has been studied to prevent surgical site infections, postoperative fever, and possible sepsis 2, 3, 4, 5, 6.
- According to the American Urological Association and the European Association of Urology, different preoperative antimicrobial prophylaxis regimens are recommended for various urological procedures, including PCNL 2.
- A study comparing ciprofloxacin infusion and third-generation cephalosporin as surgical prophylaxis for PCNL found that a single dose of ciprofloxacin infusion showed higher efficacy in protecting against postoperative fever 2.
- Another study evaluated the use of extended antimicrobial therapy in patients undergoing PCNL and found a low rate of adverse antibiotic-related events, with trimethoprim/sulfamethoxazole associated with an increased likelihood of adverse events 3.
- A prospective randomized trial comparing ciprofloxacin and cefazolin as perioperative antibiotics for PCNL found no difference in systemic inflammatory response syndrome (SIRS) episodes between the two groups 4.
- A study on the use of ciprofloxacin for 1 week before PCNL found that it significantly reduced the risk of upper tract infection and urosepsis in patients with stones ≥20 mm or pelvicalyceal dilatation 5.
- A randomized controlled trial on preoperative prophylactic antibiotics for PCNL in moderate to high infectious risk population found that 7 days of antibiotics decreased the risk of sepsis compared to 2 days of antibiotics 6.
Antibiotic Regimens
- Ciprofloxacin infusion: a single dose of 200 mg showed higher efficacy in protecting against postoperative fever 2.
- Cefazolin: no difference in SIRS episodes compared to ciprofloxacin 4.
- Trimethoprim/sulfamethoxazole: associated with an increased likelihood of adverse events 3.
- Ciprofloxacin for 1 week: significantly reduced the risk of upper tract infection and urosepsis 5.
- 7 days of antibiotics: decreased the risk of sepsis compared to 2 days of antibiotics in moderate to high infectious risk population 6.
Patient Risk Factors
- Stone size ≥20 mm: associated with increased risk of urosepsis 5.
- Pelvicalyceal dilatation: associated with increased risk of urosepsis 5.
- Positive preoperative urine culture: associated with increased risk of sepsis 6.
- Existing indwelling urinary drainage tube: associated with increased risk of sepsis 6.