Do healthy adult living kidney donors (age 18‑65) receive prophylactic antibiotics for urinary tract infection before the donor nephrectomy?

Prophylactic Antibiotics for Living Kidney Donors Before Nephrectomy

A single dose of prophylactic antibiotic (typically cefazolin 1-2g IV) administered within 60 minutes before surgical incision is sufficient for healthy living kidney donors undergoing donor nephrectomy, with no need for extended postoperative courses. 1, 2

Evidence-Based Rationale

Single-Dose Prophylaxis is Adequate for Clean Surgery

• Donor nephrectomy is classified as a Class I/clean procedure (uninfected incision without entry into the gastrointestinal or genitourinary tract), where single-dose antibiotic prophylaxis targeting skin flora may not even be necessary according to recent evidence 1

• A prospective study of 100 kidney donors demonstrated that cefazolin 1g IV before anesthesia continued for only 24 hours resulted in wound infection rates identical to 7-day extended courses (2% vs 2%, p>0.5) 2

• The 2020 American Urological Association Best Practice Statement indicates that for clean outpatient urologic procedures including minimally invasive renal surgery, single-dose prophylaxis coverage for usual skin flora may not be necessary, though groin and perineal incisions may warrant consideration 1

Timing and Dosing Principles

• Infusion must begin within 60 minutes of surgical incision to achieve optimal tissue concentrations 1

• Dosing should be adjusted for patient body weight or body mass index, with additional intraoperative doses required if the procedure extends beyond two half-lives of the initial dose 1

• Prophylaxis should be discontinued within 24 hours of procedure completion in the absence of preexisting infection 1

Specific Antibiotic Recommendations

First-Line Agent

• Cefazolin (first-generation cephalosporin) is the preferred agent for donor nephrectomy, providing coverage against skin flora including staphylococci 3, 4, 2

• Dosing: 1-2g IV as a single dose before incision 3, 2

Alternative Considerations

• In kidney transplant recipients (not donors), single-dose ceftriaxone has demonstrated effectiveness with SSI rates of only 2% 4

• For patients with beta-lactam allergies, alternative agents should follow institutional protocols for clean surgical procedures 1

Critical Distinctions: Donors vs Recipients

Donors Are Lower Risk

• Healthy living donors have fundamentally different infection risk compared to immunosuppressed transplant recipients 5, 6

• A retrospective study of 448 renal transplant recipients without routine prophylaxis showed only 3.4% early postoperative infections, suggesting even recipients may not require extended courses 6

• Transplant recipients receiving single-dose cefazolin had equivalent SSI rates (2%) compared to multiple-dose regimens extending 7-10 days postoperatively 3

Recipients May Require Extended Prophylaxis

• For transplant recipients (not applicable to donors), some centers use prophylaxis until postoperative day 7-10, though evidence increasingly supports single-dose regimens 3, 5

• A 2019 study comparing single-dose versus multiple-dose prophylaxis in 212 kidney transplant recipients found no difference in SSI rates (1.9% vs 3.8%, p=0.40) 3

Common Pitfalls to Avoid

Do Not Extend Prophylaxis Beyond 24 Hours

• Extended antibiotic courses in healthy donors are therapeutic rather than prophylactic and lack evidence of benefit 1

• Prolonged prophylaxis contributes to antimicrobial resistance, Clostridioides difficile infection risk, and increased healthcare costs without reducing infection rates 5, 6

• The literature offers little guidance supporting prophylaxis beyond 24 hours after wound closure for clean procedures 1

Do Not Confuse with Recipient Protocols

• Many transplant centers worldwide (89%) use perioperative prophylaxis for recipients, but this practice is increasingly questioned even for immunosuppressed patients 6

• Healthy donors should not receive the same extended prophylaxis regimens designed for immunosuppressed recipients 5, 6

Catheter Management

• If a urinary catheter is placed, do not extend antibiotics for catheter duration 1

• In cases of prolonged catheterization (48-72 hours), colonization has likely occurred, and empiric treatment at catheter removal is therapeutic rather than prophylactic 1

• The optimal approach (culture-directed vs empiric treatment at catheter removal) remains unclear and depends on host factors and catheterization duration 1

Surgical Site Infection Risk Factors

Modifiable Factors

• Proper surgical technique and minimizing operative time reduce SSI risk more effectively than extended antibiotic courses 2, 6

• Adequate coupling technique and operator experience are critical for minimizing tissue trauma 1

Patient-Specific Considerations

• Female gender was identified as the only independent risk factor for urinary tract infections in transplant recipients (not SSIs), but this does not justify extended prophylaxis in healthy female donors 3

• Urine leak (15.38% SSI rate) and immunosuppression are recipient-specific risk factors not applicable to healthy donors 4

Practical Algorithm for Donor Nephrectomy

1. Verify sterile preoperative urine - if bacteriuria present, treat before surgery 1

2. Administer cefazolin 1-2g IV within 60 minutes before incision 1, 2

3. Redose intraoperatively if procedure exceeds 4 hours (two half-lives of cefazolin) 1

4. Discontinue prophylaxis within 24 hours of surgery completion 1, 2

5. Do not prescribe postoperative antibiotics unless clinical signs of infection develop 1, 2, 5