Pre-op antibiotics sufficient to prevent UTI during stone Tx

Brian Howard Eisner, MD, examined antibiotic use in ureteroscopy and PCNL in two studies presented at the AUA annual meeting in New Orleans. He discusses the studies’ findings with Urology Times.   

What was the rationale for your study? 

The AUA best practice statement on antimicrobial prophylaxis before endoscopic surgery recommends ≤24 hours of antibiotics for ureteroscopic stone treatment. In the past, people have been more prone to give 3-7 days of postoperative antibiotics in addition to a single preoperative dose. 

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The reason we performed the study was to see if we complied with the AUA best practice statement. If we felt that the postoperative urinary tract infection rates were acceptable, we could encourage our colleagues in the community at large to adopt the best practice statement of ≤24 hours of antibiotics with ureteroscopic stone surgery.

Your research examined antibiotic use in both ureteroscopy and PCNL. What were the findings? 

We found in both the ureteroscopy study and the percutaneous nephrolithotomy (PCNL) study that in patients without a history of infection, compliance with the AUA guidelines of ≤24 hours of antibiotics does not appear to increase infection rates over giving antibiotics for 3-7 days post-op. 

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How commonly are urologists complying with the AUA guidelines?

There is some survey data from some of the sub-societies, which suggest that there is room for improvement. My general sense is that when these best practice statements are put into place, sometimes it takes a little time for everybody to adopt these best practice recommendations.

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What is the take-home message of both the ureteroscopy and PCNL study?

The reason we embarked on both the ureteroscopy study with my collaborators from the University of British Columbia and the PCNL study with collaborators from the University of Vermont is that one of the hot public health topics in general today is antibiotic stewardship and the responsible use of antibiotics. We’re finding more and more in urology and in medicine as a whole that antibiotic resistance is becoming a greater and greater public health problem. If we can use fewer antibiotics but still achieve our goals of having minimal infection rates post-op, I think that’s a great thing for our community.

READ: As stone risk falls, health status may rise

We hypothesized that compliance with the best practice statement would result in acceptable infection rates and we were satisfied to find out that in both of these studies that was true. We can now, based on these pilot data, confidently encourage our colleagues to comply with the AUA best practice statement for antimicrobial prophylactic for ureteroscopy and PCNL for patients without a history of infection.

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Did any data in particular stand out from your research?  

There are a lot of reports of antimicrobial resistance. One number that I site to my patients is that if you look in the state of Massachusetts, the resistance to fluoroquinolones for E. coli is anywhere from 15%-25% across the state. Those are valuable drugs that we can’t afford to lose to antimicrobial resistance. I think people feel that resistance to commonly used antibiotics such as fluoroquinolones or trimethoprim sulfamethoxazole is on the rise. Anything that we can do to preserve susceptibility to these antibiotics including responsible use of them is what I think should be a common goal of all urologic surgeons.   

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Can your study be a model for other states?

Resistance patterns are different by location. This study on ureteroscopy was done in my patient population in Boston and Vancouver. The PCNL study was also done in my population and in Burlington, VT. Based on the results, I think urologists everywhere performing these procedures can feel confident in adopting these practices. I think they can also monitor their results and if they seem to have a higher than expected infection rate or seem to be getting results that are worse than ours in terms of infection, then maybe they can look at their resistance patterns and rethink things.