What is the antibiotic of choice for urologic injuries and infections?

From the Guidelines

For urologic injuries and infections, the antibiotic choice should be guided by the most recent European Association of Urology guidelines, which recommend specific regimens based on the causative pathogen, as outlined in Table 13 of the 2024 guidelines 1. When considering the treatment of urologic infections, it is essential to identify the causative pathogen to guide antibiotic selection.

• For gonococcal infections, ceftriaxone (1 g i.m. or i.v. as a single dose) is the recommended first-line treatment, with alternative regimens including cefixime (400 mg p.o. as a single dose) plus azithromycin (1 g p.o. as a single dose) 1.
• For non-gonococcal infections, doxycycline (100 mg b.i.d. p.o. for 7 days) is the preferred treatment, with azithromycin (500 mg p.o. on day 1,250 mg p.o. for 4 days) as an alternative 1.
• The choice of antibiotic should also consider local resistance patterns, patient allergies, and renal function, as emphasized in the European Association of Urology guidelines on urological infections 1. Key considerations in selecting an antibiotic regimen include:
• The specific pathogen involved
• Local resistance patterns
• Patient allergies and renal function
• The severity of the infection and the need for broader coverage in cases of urologic trauma or potential contamination. In cases where the pathogen is unidentified, empirical treatment should be guided by the most likely causative organisms and local resistance patterns, with adjustment of the treatment regimen based on subsequent culture and sensitivity results. The use of fluoroquinolones, such as ciprofloxacin, should be reserved for cases where the local resistance rate is <10% and the patient does not require hospitalization, as recommended in the European Association of Urology guidelines 1.

From the FDA Drug Label

1.8 Chronic Bacterial Prostatitis Levofloxacin tablets are indicated for the treatment of chronic bacterial prostatitis due to Escherichia coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis [see Clinical Studies (14.6)]. 1.9 Complicated Urinary Tract Infections: 5 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis [see Clinical Studies (14.7)]. 1.11 Acute Pyelonephritis: 5 or 10 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia [see Clinical Studies (14.7,14.8)].

For urologic injury and infection, the recommended antibiotic choice is levofloxacin. The following conditions are approved for treatment with levofloxacin:

• Chronic bacterial prostatitis due to Escherichia coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis
• Complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis
• Acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia 2

From the Research

Urologic Injury and Infection Antibiotic Choice

• The choice of antibiotic for urologic injuries and infections depends on various factors, including the type of infection, patient-specific factors, and local resistance patterns 3.
• For uncomplicated urinary tract infections (UTIs), trimethoprim-sulfamethoxazole is often the preferred first-line agent, but fluoroquinolones such as ciprofloxacin may be used in areas with high resistance rates 3.
• Ciprofloxacin extended release (ER) has been shown to be effective in treating UTIs, with a once-daily dosing regimen that can improve patient compliance and reduce the development of antimicrobial resistance 3.
• In cases of urologic interventions, antibiotic prophylaxis (AP) may be necessary to reduce the risk of infectious complications, but the choice of antibiotic and duration of prophylaxis depend on the specific procedure and patient characteristics 4.
• For transrectal ultrasound-guided prostate biopsy, a single dose of levofloxacin combined with an aminoglycoside has been shown to be superior to ciprofloxacin in preventing severe infections 5.
• The use of postoperative antibiotics after ureteroscopy may not be necessary in patients with a negative preoperative urine culture, and antibiotic stewardship can help reduce the risk of antimicrobial resistance 6.

Antibiotic Prophylaxis in Urologic Interventions

• AP is not routinely recommended for urodynamic exams, diagnostic cystoscopy, and extracorporeal shock-wave lithotripsy 4.
• AP is mandatory for transrectal prostate biopsy, and a tailored strategy based on the specific procedure and patient characteristics is essential 4.
• The choice of antibiotic for AP depends on the specific procedure, patient characteristics, and local resistance patterns, and a one-size-fits-all approach may not be suitable 4.

Specific Antibiotic Regimens

• Ciprofloxacin ER has been shown to be effective in treating UTIs, with a once-daily dosing regimen that can improve patient compliance and reduce the development of antimicrobial resistance 3.
• Levofloxacin combined with an aminoglycoside has been shown to be superior to ciprofloxacin in preventing severe infections after transrectal ultrasound-guided prostate biopsy 5.
• The use of postoperative antibiotics after ureteroscopy may not be necessary in patients with a negative preoperative urine culture, and antibiotic stewardship can help reduce the risk of antimicrobial resistance 6.