What preoperative antibiotics are recommended for insertion of a penile prosthesis?

Preoperative Antibiotic Recommendations for Penile Prosthesis Insertion

The most effective preoperative antibiotic regimen for penile prosthesis insertion should include an antibacterial agent plus an antifungal, with tailoring based on local infection trends and antibiogram data rather than relying solely on the traditional vancomycin plus gentamicin combination. 1

Current Evidence and Recommendations

• The 2008 AUA Best Practice Statement recommended an aminoglycoside and vancomycin or a first-/second-generation cephalosporin for penile prosthesis placement, with vancomycin plus gentamicin becoming the most commonly used regimen 1

• Recent multicenter analysis (4,161 patients) found that vancomycin plus gentamicin alone was associated with a higher risk of infection (HR: 2.7,95% CI: 1.4 to 5.4) compared to other regimens 1

• The addition of an antifungal agent to the antibacterial regimen decreased infection risk by 92% (HR: 0.08,95% CI: 0.03 to 0.19) 1

Recommended Antibiotic Protocol

Primary Recommendation:

• First-line option: Cefazolin (1-2g IV 30-60 minutes before incision) plus an antifungal agent 2, 1

  • Cefazolin is FDA-approved for perioperative prophylaxis in surgical patients where infection at the operative site would present serious risk 2
  • For lengthy procedures (>2 hours), additional intraoperative doses of 500mg-1g should be administered 2

• For patients with beta-lactam allergy: Vancomycin (1g IV, started 1-2 hours before incision to allow adequate tissue penetration) plus gentamicin (5mg/kg single dose) plus an antifungal agent 3, 1

Antifungal Component:

• An antifungal agent should be added to all regimens as it significantly reduces infection risk 1
• Fluconazole is commonly used (dosing based on institutional protocols) 1

Special Considerations

• Diabetes: Patients with diabetes have a higher risk of infection (HR: 1.9) and may benefit from more aggressive prophylaxis 1

• Gentamicin dosing: No significant difference in infection rates between weight-based and low-dose (80mg) gentamicin has been observed (HR: 2.9,95% CI: 0.83 to 10, P=0.1) 1, 3

• Vancomycin considerations: Requires administration over 1 hour and may take another hour to reach appropriate tissue levels; patients may develop "red man syndrome" necessitating alternative gram-positive coverage 1

• Tissue penetration: Studies show vancomycin achieves higher cavernous tissue levels (55.5 ±5.5 ng/mg) compared to gentamicin (4.7 ±1.2 ng/mg) or aztreonam (8.9 ±2.1 ng/mg) 4

Additional Infection Prevention Strategies

• Antibiotic-impregnated/coated devices, antiseptic surgical scrub, no-touch technique, and wound irrigation should be used in conjunction with appropriate antibiotic prophylaxis 1, 5

• Scrupulous, repeated disinfection of the skin in the genital and perineal region is essential 6

• Consider tailoring antimicrobial prophylaxis based on local infection trends and antibiogram data for optimal infection prevention 1

Common Pitfalls to Avoid

• Relying solely on vancomycin plus gentamicin without an antifungal component 1

• Inadequate timing of preoperative antibiotics (vancomycin should be started 1-2 hours before incision) 1, 4

• Failure to provide additional intraoperative doses during lengthy procedures 2

• Not accounting for patient-specific risk factors such as diabetes 1, 7