Antibiotic Stewardship in Urology: Surgical Prophylaxis Guidelines
For office cystoscopy, antibiotic prophylaxis is only indicated in patients with specific risk factors, while prophylactic antibiotics are mandatory for all patients undergoing prostate biopsy, particularly with the transrectal approach. 1
Antibiotic Stewardship Principles in Urology
Antibiotic stewardship in urology focuses on:
- Using antimicrobials only when medically necessary
- Administering the lowest effective dose
- Limiting duration to the shortest possible time
- Avoiding antimicrobial use beyond procedure completion
These principles help reduce the development of multidrug-resistant organisms while ensuring effective prophylaxis against surgical site infections (SSIs) and other preventable periprocedural infections 1.
Office Cystoscopy Prophylaxis
Indications for Prophylaxis
Antimicrobial prophylaxis for simple cystoscopy is not routinely recommended but is indicated only in patients with specific risk factors 1:
- Advanced age
- Immunosuppression
- Diabetes or other metabolic dysfunction
- Poor general health
- Neurogenic lower urinary tract dysfunction
- Known/suspected urinary tract abnormalities
- Recent genitourinary instrumentation
- Recent antimicrobial use
Recommended Regimens
When prophylaxis is indicated for cystoscopy, options include:
- Trimethoprim 200 mg orally (single dose) 1
- Ciprofloxacin 500 mg orally (single dose) 1
- Trimethoprim-sulfamethoxazole (single dose) 1, 2
These should be administered within one hour before the procedure 1.
Prostate Biopsy Prophylaxis
Transrectal Prostate Biopsy
Antimicrobial prophylaxis is mandatory for all patients undergoing transrectal prostate biopsy due to the high risk of infection (Level of evidence: Ib) 1, 3.
Preferred Approach
- Targeted prophylaxis based on rectal swab or stool culture obtained 1-2 weeks before biopsy 3
- This allows selection of antibiotics based on the patient's specific rectal flora
Alternative Regimens (when targeted prophylaxis not feasible)
- Fluoroquinolones: Ciprofloxacin 500 mg orally (single dose) 1, 4
- Fosfomycin trometamol: 3g before and 3g 24-48h after biopsy 3
- Cephalosporins: Ceftriaxone 1g IM or cefixime 400mg PO for 3 days 3
- Aminoglycosides: Gentamicin 3mg/kg IV or amikacin 15mg/kg IM 3
Duration
Single-dose or one-day regimens have been shown to be as effective as three-day regimens 1.
Additional Measures
- Rectal preparation with povidone-iodine immediately before the procedure is recommended as an adjunctive measure 3
- For high-risk patients, augmented prophylaxis (using multiple antibiotics) may be considered, though this contravenes antibiotic stewardship principles 3
Common Pitfalls and Caveats
Fluoroquinolone restrictions: Despite being commonly recommended for prostate biopsy prophylaxis, fluoroquinolone use has been restricted in many countries due to serious adverse effects 3. Consider alternative agents based on local resistance patterns.
Pre-procedure urine evaluation: Ensure urine culture with microscopy is performed before selecting prophylaxis, especially for patients with risk factors 1.
Active UTI management: Elective procedures should be deferred in the presence of active urinary tract infection until an appropriate antimicrobial course is complete 1.
Rising antimicrobial resistance: The increasing prevalence of resistant organisms, particularly ESBL-producing bacteria like E. coli (64%) and K. pneumoniae (89%), necessitates careful selection of prophylactic agents 5.
Timing matters: Antimicrobial prophylaxis is most effective when tissue concentrations are maintained throughout the procedure, so proper timing of administration is critical 1.
By following these evidence-based guidelines for antibiotic prophylaxis in urological procedures, clinicians can effectively reduce infection risk while practicing responsible antimicrobial stewardship.