Antibiotic Prophylaxis for Cystoscopy with Stone Retrieval
For cystoscopy with stone manipulation or retrieval, antimicrobial prophylaxis is mandatory and should consist of a single dose of either oral fluoroquinolone (ciprofloxacin 500 mg or levofloxacin 500 mg) or trimethoprim-sulfamethoxazole 160/800 mg administered 1-2 hours before the procedure. 1
Why Prophylaxis is Required
Stone manipulation during cystoscopy significantly increases bacteremia risk and mandates prophylaxis in all patients, regardless of individual risk factors. 1, 2 This differs from simple diagnostic cystoscopy where prophylaxis is not routinely indicated in low-risk patients. 2
First-Line Antibiotic Options
Oral Fluoroquinolones (Preferred in Most Cases)
- Ciprofloxacin 500 mg as a single oral dose 1, 3
- Levofloxacin 500 mg as a single oral dose 1, 4
- Ofloxacin 400 mg as a single oral dose 1
Fluoroquinolones provide excellent coverage against gram-positive and gram-negative uropathogens with superior tissue penetration. 5, 6 Ciprofloxacin specifically reduced post-cystoscopy bacteriuria from 9% to 3% in a randomized trial of 2,083 patients. 6
Trimethoprim-Sulfamethoxazole (Cost-Effective Alternative)
This option demonstrates efficacy similar to fluoroquinolones with lower cost and reduced contribution to fluoroquinolone resistance. 1, 2 In the same large trial, trimethoprim reduced bacteriuria from 9% to 5%. 6
Alternative Agents When Fluoroquinolones Cannot Be Used
When to Avoid Fluoroquinolones
Do not use fluoroquinolones if: 2
- Patient used them within the last 6 months
- Local resistance rates exceed 10%
- History of severe fluoroquinolone adverse reactions
Second-Line Options
First-generation or second-generation cephalosporins:
Aminopenicillin with beta-lactamase inhibitor:
Aminoglycosides (parenteral):
Gentamicin prophylaxis reduced post-cystoscopy positive urine cultures from 21% to 5% in a prospective study of 162 patients. 8 However, this requires IV administration, making it less practical for outpatient procedures. 8
Critical Timing and Administration
- Administer oral antibiotics 1-2 hours before the procedure to ensure adequate tissue levels at the time of instrumentation. 1, 2, 5
- Administer IV antibiotics within 60 minutes before the procedure, ideally at induction if using anesthesia. 1, 5
- Single-dose prophylaxis is sufficient; extended courses are not indicated and violate antimicrobial stewardship principles. 1
Special Circumstances Requiring Modified Approach
If Purulent Urine is Encountered
Immediately abort the stone retrieval procedure if purulent urine is visualized during cystoscopy. 1 You must:
- Establish drainage with ureteral stent or nephrostomy tube 1
- Obtain urine culture from the purulent specimen 1
- Continue broad-spectrum antibiotics pending culture results 1
- Reschedule the procedure after infection is adequately treated 1
Pre-existing Bacteriuria
Base antibiotic selection on prior urine culture results and local antibiogram patterns when available. 1 If documented bacteriuria exists, treat it appropriately before elective stone manipulation rather than relying solely on prophylactic dosing. 1
Common Pitfalls to Avoid
Do not skip prophylaxis for "simple" stone retrieval. Any stone manipulation—including basket retrieval during cystoscopy—increases bacteremia risk and requires prophylaxis. 1, 2
Do not use fluoroquinolones indiscriminately. The increasing prevalence of multidrug-resistant gram-negative bacteria has made fluoroquinolone-based regimens less reliable in many settings. 5 Check local resistance patterns and recent patient antibiotic exposure. 2
Do not continue antibiotics beyond 24 hours post-procedure unless treating an established infection rather than providing prophylaxis. 1 Prolonged courses increase resistance without improving outcomes. 1
Do not rely on negative urinalysis to exclude infection risk. Pyuria is common and does not differentiate infection from colonization, and a negative urinalysis does not completely exclude post-procedure infection risk. 2