Treatment of Preoperative UTI Before Spinal Cord Battery Replacement
This patient requires a full 7-day course of targeted antibiotic therapy completed before surgery, not just prophylactic dosing, because she has symptomatic bacteriuria (100,000 CFU/mL E. coli with moderate leukocytes) requiring treatment rather than asymptomatic bacteriuria requiring only prophylaxis. 1
Why Full Treatment Is Required
The IDSA guidelines strongly recommend screening for and treating bacteriuria prior to endoscopic urologic procedures with mucosal trauma to prevent the serious postoperative complication of sepsis, which occurred in 5.6% of untreated patients versus minimal rates in treated patients 1
Short-course therapy (1-2 doses) is only appropriate for asymptomatic bacteriuria immediately before the procedure, not for symptomatic bacteriuria or procedures scheduled days away 1
This patient has symptomatic bacteriuria (moderate leukocytes with 100,000 E. coli), which requires a full treatment course rather than prophylactic dosing 1
Recommended Antibiotic Regimen
First-line options for E. coli UTI treatment:
- Ciprofloxacin 500 mg PO every 12 hours for 7 days 1, 2, 3
- Trimethoprim-sulfamethoxazole 160/800 mg (1 double-strength tablet) PO every 12 hours for 7 days 1, 4, 3
- Amoxicillin-clavulanate 875 mg PO every 12 hours for 7 days 1, 5, 3
Alternative options if first-line agents cannot be used:
- Levofloxacin 500 mg PO daily for 7 days 1
- Nitrofurantoin 100 mg PO every 12 hours for 7 days (though less ideal for systemic infections) 6, 3
Timing Considerations for Surgery
Complete the full 7-day antibiotic course before surgery to ensure bacterial eradication 6
If surgery cannot be delayed, antimicrobial prophylaxis should be administered 30-60 minutes before the procedure using an agent active against the cultured organism 1
Obtain a repeat urine culture 24-48 hours before surgery if the catheter remains in place, as colonization likely occurred, and administer culture-directed therapy at catheter removal 1
Perioperative Prophylaxis Strategy
If the full treatment course is completed before surgery:
Standard surgical prophylaxis with cefazolin 1-2 g IV within 60 minutes of incision is appropriate for spinal surgery 1, 7
Redose cefazolin every 4 hours intraoperatively if the procedure extends beyond two half-lives 1
If surgery cannot be delayed and treatment is incomplete:
Administer targeted antimicrobial prophylaxis based on the E. coli susceptibility pattern 30-60 minutes before the procedure 1
Use an agent active against the cultured organism (e.g., ciprofloxacin 400 mg IV or ceftriaxone 1-2 g IV single dose) 1
Duration of Postoperative Antibiotics
Discontinue prophylactic antibiotics within 24 hours after wound closure for spinal surgery, as extended postoperative antibiotics do not reduce surgical site infection rates 1, 8, 9
Meta-analysis of 2,824 spinal surgery patients showed no significant difference in SSI rates between preoperative-only antibiotics (1.28%) versus extended postoperative antibiotics (1.38%) (RR 1.11,95% CI 0.53-2.36, p=0.78) 8, 9
Extended postoperative antibiotics increase costs, adverse drug effects, and antimicrobial resistance without improving outcomes 8, 9
Critical Pitfalls to Avoid
Do not confuse asymptomatic bacteriuria with symptomatic UTI - this patient has moderate leukocytes indicating inflammation requiring full treatment 1
Do not use single-dose prophylaxis for symptomatic bacteriuria - this is only appropriate for asymptomatic bacteriuria immediately before endoscopic urologic procedures 1
Do not extend prophylactic antibiotics beyond 24 hours postoperatively unless treating an active infection, as this increases resistance without reducing SSI 1, 8, 9
Ensure adequate nutritional status before surgery - 16 of 19 patients with postoperative spine infections were malnourished (total lymphocyte count <2,000) 10