What is the recommended chronic antibiotic therapy for recurrent Urinary Tract Infections (UTIs) after cystectomy?

Chronic Antibiotic Prophylaxis for Recurrent UTI Post-Cystectomy

For patients with recurrent UTIs following cystectomy, discharge on culture-directed suppressive antibiotics until stent/catheter removal significantly reduces UTI rates (from 36% to 12%) and urosepsis-related readmissions (from 17% to 2%), with fluoroquinolones showing superior efficacy compared to other regimens when susceptibility allows. 1, 2

Evidence-Based Prophylaxis Strategy

Initial Perioperative Management

• Administer standard perioperative antibiotics (e.g., cefuroxime 1.5g + metronidazole 500mg IV) within 60 minutes of incision and discontinue within 24 hours post-surgery 3, 4
• Obtain intraoperative or early postoperative urine culture to guide subsequent suppressive therapy 1
• Do not extend perioperative prophylaxis beyond 24 hours without culture guidance 3

Suppressive Antibiotic Regimen Until Stent/Catheter Removal

• Fluoroquinolones (ciprofloxacin or levofloxacin) are the preferred suppressive agents when local resistance patterns permit, as they demonstrate significantly lower UTI rates (32.7% vs 45.2%, P=0.04) and urosepsis rates (5.3% vs 11.9%, P=0.04) compared to other regimens 2
• Alternative agents include trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin, tailored to culture sensitivities 1, 2
• Continue suppressive therapy until all ureteral stents and catheters are removed (typically 2-3 weeks post-operatively) 1, 4

Post-Stent Removal Considerations

• The highest risk period for UTI is immediately after stent removal (median 13 days post-cystectomy, with 30% of non-prophylaxis patients developing UTI within 1 day of stent removal) 1, 2
• Consider extending prophylaxis for 3-7 days after final stent/catheter removal in high-risk patients 1

Risk Stratification for Extended Prophylaxis

High-Risk Features Requiring Aggressive Prophylaxis

• Orthotopic neobladder reconstruction (OR 2.3 for UTI, P<0.05) 2
• Perioperative blood transfusion (OR 1.71 for UTI, P<0.05) 2
• Palliative cystectomy (P<0.0001 for complicated UTI) 4
• Prior pelvic radiation therapy (P<0.0001 for complicated UTI) 4
• Prolonged time from diagnosis to surgery (>3 months, P=0.036) 4

Expected Pathogen Profile and Resistance Patterns

Most Common Organisms Post-Cystectomy

• Candida species (25.6%) and Escherichia coli (22.2%) are the most frequently isolated pathogens 2
• Enterococcus faecium accounts for 32% of UTIs and is associated with surgical site infections requiring intervention 1, 4
• Staphylococcus haemolyticus commonly colonizes ileal conduits by day 12 (40% of patients) 4

Antibiotic Resistance Considerations

• Avoid fluoroquinolones if local E. coli resistance exceeds 10% 5
• Nitrofurantoin maintains low resistance rates (20.2% at 3 months, 5.7% at 9 months) compared to other agents 3
• TMP-SMX should only be used when community resistance rates are <10-20% 5

Long-Term Prophylaxis for Persistent Recurrent UTIs

When to Consider Extended Prophylaxis Beyond Stent Removal

If UTIs continue after stent/catheter removal and initial healing period (>90 days post-surgery), consider:

• Daily low-dose prophylaxis for 6-12 months with TMP-SMX (single-strength tablet daily) or nitrofurantoin (50-100mg daily) 3, 6
• Continuous prophylaxis reduces UTI incidence by 48% (incidence rate ratio 0.52,95% CI 0.44-0.61, P<0.0001) 7
• Methenamine hippurate is an effective alternative for patients without urinary tract abnormalities (RR 0.24,95% CI 0.07-0.89) 3, 6

Monitoring During Long-Term Prophylaxis

• Obtain urine cultures every 3 months to monitor for emerging resistance 7
• Expect increased resistance to prophylactic agents (nitrofurantoin resistance increases from 9% to 24%, TMP resistance from 33% to 67% at 9-12 months) 7
• Reassess need for continued prophylaxis every 6 months 6

Critical Pitfalls to Avoid

What NOT to Do

• Do not treat asymptomatic bacteriuria, as this increases risk of symptomatic infection and resistance 3, 6
• Avoid beta-lactam antibiotics for prophylaxis due to collateral microbiota damage and increased recurrence rates 3
• Do not use fluoroquinolones for uncomplicated UTI treatment due to unfavorable risk-benefit ratio per FDA advisory 3
• Do not extend prophylaxis duration or increase antibiotic potency beyond recommended regimens, as this disrupts protective vaginal/periurethral microbiota and paradoxically increases recurrences 3, 6

Antibiotic Stewardship Principles

• Use short-duration therapy (3-5 days) for acute breakthrough UTIs with nitrofurantoin, TMP-SMX, or fosfomycin as first-line agents 3
• Culture all symptomatic UTIs before treatment to guide therapy 6
• Prophylaxis is only effective during active use; UTI rates return to baseline after cessation 6