What is the recommended antibiotic prophylaxis for patients post Double J (DJ) stenting?

Antibiotic Prophylaxis After Double J (DJ) Stent Placement

A single dose of a fluoroquinolone (ciprofloxacin 500 mg, levofloxacin 500 mg, or ofloxacin 400 mg) is recommended as first-line prophylaxis following DJ stent placement. 1

First-Line Antibiotic Options

• Oral options: Single dose of fluoroquinolone (ciprofloxacin 500 mg, levofloxacin 500 mg, or ofloxacin 400 mg) administered 1-2 hours before the procedure 1
• Intravenous options: Ceftriaxone (1-2 g IV), Ampicillin/sulbactam (1.5-3 g IV), or Gentamicin (5 mg/kg IV) administered 30-60 minutes before the procedure 1

Risk Factors for Infection with DJ Stents

• Longer duration of stent placement significantly increases colonization rates 2, 3
• Female sex is associated with higher risk of stent colonization 2, 3
• Immunocompromised states significantly increase infection risk:
  • Diabetes mellitus (P < 0.01) 2, 4
  • Chronic renal failure (P < 0.001) 2, 4
  • Malignancies 4
  • Pregnancy (P < 0.01) 2

Special Considerations for High-Risk Patients

• For immunocompromised patients (inflammatory arthropathies, drug-induced immunosuppression, radiation-induced immunosuppression), consider more aggressive prophylaxis 1, 5
• In patients with previous history of febrile UTIs or lower urinary tract symptoms, continuous antibiotic prophylaxis (CAP) during the entire period of stent placement should be considered 6
• Trimethoprim/sulfamethoxazole or nitrofurantoin (if history of resistance) can be used for continuous prophylaxis in high-risk patients 6

Important Clinical Considerations

• Ensure urine is sterile before DJ stent placement; if bacteriuria is present, treat the bacteriuria before stent placement 1, 5
• The most common pathogens in DJ stent infections include Escherichia coli, Enterococcus species, Staphylococcus species, Pseudomonas, and Klebsiella 2, 7, 3
• Bacterial biofilms can form on stents, making infections more resistant to treatment if they occur 1, 8

Management of Infected DJ Stents

• For infected DJ stents with systemic symptoms, consider:
  • Amoxicillin plus an aminoglycoside
  • A second-generation cephalosporin plus an aminoglycoside
  • An intravenous third-generation cephalosporin 1, 8
• Treatment duration should be 7-14 days, with 14 days recommended for men when prostatitis cannot be excluded 1, 8

Prevention of Recurrent Infections

• Periodically reassess the need for DJ stents to determine whether removal is possible 1, 8
• The main risk factor for infection is the duration of stent placement, with significantly higher colonization rates when stents remain in place for ≥30 days (76.08% vs. 23.91%) 3
• Approximately 30-42% of DJ stents become colonized with bacteria, even with initial prophylaxis 7, 3, 4

Common Pitfalls to Avoid

• Do not neglect to screen for and treat bacteriuria before stent placement 1, 5
• Remember that a negative urine culture does not rule out a colonized stent - studies show that in 60% of patients with positive stent cultures, urine culture was sterile 7
• Bacteria cultured from urine after stent insertion and from the stents are more resistant to antibiotics than those cultured from urine before stent insertion 7