What antibiotics are recommended for a patient undergoing suprapubic cystostomy?

Antibiotic Prophylaxis for Suprapubic Cystostomy

A single dose of cefazolin, cefuroxime, or cefamandole administered within 60 minutes before the procedure is the recommended first-line antibiotic prophylaxis for suprapubic cystostomy placement. 1

First-Line Antibiotic Regimens

• Cefazolin 1-2 g IV is the preferred agent for most urological procedures involving the lower urinary tract, including suprapubic cystostomy 1
• Cefuroxime 1.5 g IV or cefamandole 1 g IV are acceptable alternatives with similar efficacy 1
• The antibiotic should be infused within 60 minutes before the surgical incision to achieve adequate tissue levels 1

Alternative Regimens for Beta-Lactam Allergy

• Gentamicin 1.5 mg/kg IV (maximum 120 mg) can be used in patients with penicillin or cephalosporin allergy 1
• Fluoroquinolones (levofloxacin 500 mg oral or IV) are alternatives, though should be reserved for cases where cephalosporins cannot be used due to increasing resistance patterns 1, 2, 3
• Avoid aminoglycosides if concurrent nephrotoxic drugs are being used or if renal dysfunction is present 1

Duration of Prophylaxis

• Single-dose prophylaxis is sufficient for the procedure itself and should not extend beyond 24 hours after wound closure 1
• Antimicrobial prophylaxis discontinued within 24 hours minimizes the risk of multidrug-resistant organisms and adverse events 1
• Extended antibiotic courses beyond 24 hours are not indicated unless treating an established infection rather than providing prophylaxis 2, 3

Special Considerations for Indwelling Catheters

• Duration of catheterization is the leading risk factor for urinary tract infection, with bacteriuria rates reaching 24% at 15 days and 98% at 30 days after suprapubic cystostomy placement 4
• Most catheter-associated bacteriuria is asymptomatic and does not require treatment 4
• Prophylactic antibiotics do not prevent catheter-associated bacteriuria during prolonged catheterization and should not be continued for this purpose 4

Management of Pre-existing Bacteriuria

• If preoperative urine culture shows bacteriuria, treat with targeted antibiotics for 2-5 days before the procedure based on culture sensitivities 5
• Obtain a repeat urine culture to confirm clearance before proceeding with elective suprapubic cystostomy 5
• If purulent urine is encountered during the procedure, abort if possible and initiate broad-spectrum antibiotics pending culture results 2

Critical Pitfalls to Avoid

• Do not continue prophylactic antibiotics beyond 24 hours in an attempt to prevent catheter-associated bacteriuria—this violates antimicrobial stewardship principles and increases resistance without reducing infection rates 1, 4
• Do not use fluoroquinolones as first-line agents given increasing resistance patterns; reserve them for patients with documented beta-lactam allergies 1
• Do not treat asymptomatic bacteriuria in patients with indwelling suprapubic catheters, as this is expected and treatment does not improve outcomes 4
• Ensure proper timing of antibiotic administration—giving antibiotics too early (>60 minutes before incision) or too late (after incision) reduces efficacy 1

Redosing During Prolonged Procedures

• Redose the antibiotic intraoperatively if the procedure duration exceeds two half-lives of the initial dose 1
• For cefazolin (half-life ~2 hours), redose if the procedure extends beyond 4 hours 1