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Perioperative Antibiotic Prophylaxis in Ureteroscopic Stone Removal
European Urology
European Urology 44 (2003) 115–118
Perioperative Antibiotic Prophylaxis in Ureteroscopic Stone Removal H.-J. Knopfa,*, H.-J. Graffb, H. Schulzea a
Department of Urology, Klinikum Dortmund gGmbH, Teaching Hospital of the University of Munster, Westfalendamm 403, D-44143 Dortmund, Germany b Department of Urology, Sta¨dtisches Klinikum Solingen, Solingen, Germany Accepted 1 April 2003
Abstract Objective: This study shall settle the question whether a perioperative single shot prophylaxis in connection with a ureteroscopic stone removal has an influence on the rate of postoperative urinary tract infections (UTIs) and inflammable complications or not. Methods: 113 patients were included in this prospective randomized study. In 57 patients 250 mg Levofloxacin p. o. was given approximately 60 prior ureteroscopy, 56 patients had no prophylaxis. The evaluation of all data which were processed electronically was carried out with the help of a standardised questionnaire. Results: Postoperatively symptomatic urinary tract infections or inflammable complications of the urogenital tract were found in neither of the two groups. In the group without prophylaxis, the rate of the postoperative significant bacteriurias was significantly higher than in the group with prophylaxis (7 patients [12.5%] vs. 1 patient [1.8%]) ( p ¼ 0:026). In six cases there was an E. coli bacteriuria additionally a Kl. pneumoniae and a not specified Staphylococcus bacteriuria were detected in further cases. Conclusion: Single shot prophylaxis using 250 mg Levofloxacin p. o. can be considered as cheap, the patient not burdened and regarding the missed selection pressure to nosocomial pathogens the preferred manner of perioperative antibiotic prophylaxis in ureteroscopic stone removal. In addition perioperative single shot prophylaxis may be beneficial in case of an unexpected intraoperative complication like e.g. ureter perforations. # 2003 Elsevier Science B.V. All rights reserved. Keywords: Antibiotic prophylaxis; Ureteroscopy; Stone removal; Urinary tract infection
1. Introduction Current options for the treatment of ureteral stones are based on either ‘‘push up’’ of the stone with consecutive extracorporeal shock wave lithotripsy (ESWL) or the ureteroscopic stone removal under view. Open surgical interventions are only required in selected cases. Symptomatic urinary tract infections (UTIs) are part of possible postoperative complications of ureteroscopic interventions with the risk of ascending pyelonephritis or other inflammable complications. No reliable data are available considering the use of perioperative antibiotic prophylaxis in ureterorenoscopic stone removal. *
Corresponding author. Tel. þ49-231-45090; Fax: þ49-231-4509-6406. E-mail address: [email protected] (H.-J. Knopf).
In cooperation with the study group ‘‘Infektiologie’’ of the German Society of Urology (DGU) the Paul Ehrlich Society has published recommendations for the perioperative antibiotic prophylaxis in the field of interventions in the urinary tract and the male genital system [1]. Using these recommendations we carried out a prospective randomised study with two arms to investigate whether a perioperative single shot prophylaxis in connection with ureterorenoscopic stone removal has a beneficial effect on the rate of postoperative UTIs and inflammable complications or not. 2. Material and methods 509 ureterorenoscopic interventions were carried out in our department between January and December 2000. 113 patients
0302-2838/03/$ – see front matter # 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S0302-2838(03)00189-1
116
H.-J. Knopf et al. / European Urology 44 (2003) 115–118
Table 1 Inclusion and exclusion criteria
Table 3 Location of ureteral stones
Inclusion criteria
Exclusion criteria
Prophylaxis
Indication for endoscopic stone removal
Clinical signs of infection (e.g. fever >38.0 8C) Laboratory signs of infection (leukocytes >15.000/ml) Antibiotic treatment one week before admission Allergies against quinolones Known cerebral cramp sufferings Known tendinitis Pregnancy, quiet time No informed consent
(22.2%) were included in this study under consideration of the inclusion and exclusion criteria (Table 1). Patients were prospectively randomised to receive 250 mg Levofloxacin p. o. approximately 60 minutes prior ureteroscopy (group I; n ¼ 57) or no antibiotic prophylaxis (group II; n ¼ 56). At admission a thorough case history evaluation was carried out to exclude clinical symptoms of existing infection of the urogenital tract as well as possible existing contraindications against fluorquinolones. The laboratory chemical examinations at admission included blood count, creatinine and electrolytes as well as a bacteriological examination of the mid-stream urine. Corresponding controls were carried out on the first or second postoperative day. All patients were examined daily for signs of inflammable complications and in the group of prophylaxis on possible side effects. All infections were documented according to the criteria of the Centers for Disease Control [2]. A significant bacteriuria was considered 105 cfu/ml urine or more. Interventions were carried out by four urologists with ureterorenoscopes of Olympus1 (diameter 9.5 Fr.). Fluorquinolon was given in agreement with the mentioned recommendations of the Paul Ehrlich Society [1]. Levofloxacin was chosen because of the long half-life of about 7 hours and the complete coverage of the pathogens spectrum to be expected. The evaluations of all data were processed electronically using a standardised questionnaire. For statistical analysis the w2-test was used.
3. Results 113 patients were included in this study considering the mentioned inclusion and exclusion criteria. Regarding age, gender (Table 2) and location of the ureteral stones (Table 3) both groups were comparable. Leading symptom at time of admission was the renal colic followed by micturation disorders and hematuria (Table 4). In 44 patients (77.2%) of group I and in 50 patients (89.3%) of group II respectively, dilatation of
Right Left Pelvic Sacral Lumbar No stone detectable
Age Gender
No prophylaxis
41.8 yrs (range 24–74 yrs) 31 male; 26 female
42.0 yrs (range 18–74 yrs) 35 male; 21 female
(47.4%) (52.6%) (78.9%) (3.5%) (10.5%) (7.0%)
Symptoms
Prophylaxis
Renal colic Micturation disorders Hematuria Asymptomatic
55 13 2 2
29 patients (51.8%) 27 patients (48.2%) 42 patients (75.0%) 1 patient (1.8%) 9 patients (16.1%) 4 patients (7.1%)
patients patients patients patients
No prophylaxis (96.5%) (22.8%) (3.5%) (3.5%)
55 patients (98.2%) 10 patients (17.9%) 8 patients (14.3%) 1 patient (1.8%)
the collecting system was detectable (Table 5). Regarding the dilatation of the collecting system either a ureteral catheter or a DJ stent was placed first in 50 patients (87.7%) in group I and in 45 patients (80.4%) in group II respectively on a average of 2 days before ureteroscopy. An i. v. pyelography was carried out in group I in 27 patients (47.4%) and in group II in 29 patients (51.8%), respectively (Table 5). In all other cases an i. v. pyelography was not obtained because of pain (colic) or known allergies (contrast media). In four patients (3.5%) a significant bacteriuria was proven preoperatively. In group I there was one bacteriuria (E. coli 106 cfu/ml), in group 2 three patients had a significant bacteriuria (E. coli, Kl. pneumoniae and Staphylococcus spp. 106 cfu/ml each). In the last case a contamination cannot be excluded. Length of the procedure was similar in both groups (group I: 21.5 min, range 7–65 min; group II: 19.6 min, range 5–60 min). Due to the size of the concrements in nine patients (2 ultrasound, 7 Lithoclast1) in group I and in six patients (6 Lithoclast1 in group II an intraureteral disintegration had to be carried out. ESWL followed immediately after ureteroscopic intervention Table 5 Results of ultrasound1 and urography at admission
No dilatation Dilatation 18 1 Dilatation 28 1 Dilatation 38 Urography: normal Urography: delayed elimination Urography: silent kidney Urography: no urography 1
Prophylaxis
patients patients patients patients patients patients
Table 4 Symptoms at admission
1
Table 2 Distribution of age and gender
27 30 45 2 6 4
No prophylaxis
Prophylaxis
No prophylaxis
13 18 19 7 7 28 2 20
6 23 25 2 3 32 4 17
H.-J. Knopf et al. / European Urology 44 (2003) 115–118
in eight patients (15.1%) of group I and in four patients (7.7%) of group II, respectively. In five cases a perforation of the ureter occurred intraoperatively (group I: 3 patients; group II: 2 patients) which was radiologically documented. Follow up was uneventful after stenting in all cases. No additional antibiotic coverage was carried out in these cases. In 26 cases (45.6%) of group I and 29 cases (51.8%) of group II a stent was inserted postoperatively. The stents were removed on average after 11 days, in most cases in an outpatient setting. Primary stone free rates were 71.7% (group I) and 84.6% (group II), respectively which could be increased to 92.5% and 93.3% by auxiliary measures, respectively. The concrements were removed in all case with stone forceps. Postoperatively symptomatic urinary tract infections or inflammable complications of the urogenital tract were found in neither of the two groups. In the group without prophylaxis, the rate of the postoperative significant bacteriurias was significantly higher ( p ¼ 0:026) than in the group with prophylaxis (7 patients [12.5%] vs. 1 patient [1.8%]) (Table 6). In six cases E. coli was found, in the further two cases a Kl. pneumoniae and a not substratified Staphylococcus. If one takes into account that in two cases the bacteria (E. coli in group I, Kl. pneumoniae in group II) were preoperatively already provable, the rate of the nosocomial induced bacteriurias altogether for the complete study population was 5.3% (group I: 0%; group II: 10.7%). This difference between the groups was highly significant, too ( p ¼ 0:011). None of the proved pathogens showed a multiresistant pattern. No side effects of Levofloxacin could be recorded in the group of prophylaxis. Length of hospital stay was comparable in both groups (group I: 5.0 days versus group II: 5.1 days). 48 patients (group I: 25 patients, group II: 23 patients) could be re-examined in our clinic after an average of 15.3 days (6–84 days). Two patients of group II rejected a bacteriuria after 8 and 84 days (E. coli 105 cfu/ml, Staphylococcus spp. 105 cfu/ml). None of the patients complained of symptomatic UTIs or inflammatory complications. In additional 41 cases (24 patients of group I, 17 patients of group II) follow Table 6 Postoperative significant bacteriurias Prophylaxis E. coli
No prophylaxis 1 (preoperatively E. coli provable) Kl. pneumoniae Staphylococcus
5 1 (preoperatively provable) 1
117
up was obtained by telephone questionnaire and was uneventful in all.
4. Discussion Besides the ‘‘push up’’ with following ESWL the ureteroscopic removal is the standard therapy for ureteral calculi. By ureteroscopy the antirefluxive barrier of the intramural ureter is bridged so that pathogens of the lower urinary tract can be protracted into the upper tract. While the necessity of antibiotic therapy of preexisting symptomatic UTI in the case of urolithiasis is undisputed [3,4], the question of perioperative antibiotic prophylaxis in patients without symptoms of infection facing an endoscopic intervention for urolithiasis remains open. Furthermore, the importance of a postoperative bacteriuria at existing urine derivation is unknown till now and no reliable data are available regarding usefulness of perioperative antibiotic prophylaxis prior to ureteroscopic stone removal. Guidelines [5] concerning perioperative prophylaxis in urological interventions have been published by the Paul Ehrlich Society in cooperation with the ‘‘Study group Infektiologie’’ of the German Urological Association [1]. As recommended, a fluorquinolon was elected for this study. Levofloxacin in particular was used because of its high renal excretion and long halftime (7 hours), allowing a once per day oral medication. Based on preoperative clinical results and laboratory tests alone, a preselection of patients with regard to their risk of postoperative urinary tract infections is possible. The risk of a significant bacteriuria in absence of such findings is low. In our study this was the case in just 4 patients. Hence, if no hints for UTI are found preoperatively, the risk of postoperative symptomatic UTI due to ureteroscopic stone removal has to be considered low. In our study, this is the case independently whether a perioperative single shot prophylaxis was given or not. On the other hand, the rate of postoperative significant bacteriuria is increased significantly in the absence of a perioperative prophylaxis. However, the postoperative bacteriuria may not present a risk factor for symptomatic UTI in contrast to the preoperative one. Therefore the question arises whether there is at all an indication for a perioperative antibiotic prophylaxis in these selected patients. But based on our data, single shot prophylaxis can be considered as inexpensive, well tolerated and regarding the missed selection pressure to nosocomial pathogens the preferred manner of perioperative antibiotic
118
H.-J. Knopf et al. / European Urology 44 (2003) 115–118
prophylaxis in ureteroscopic stone removal. Furthermore a perioperative single shot prophylaxis may
provide additional safety in case of unexpected intraoperative complication like e.g. ureter perforation.
References [1] Naber KG, Hofstetter AG, Bru¨ hl P, Bichler KH, Lebert C und die Arbeitsgemeinschaft Harnwegsinfektionen der Sektion Chemotherapie der Paul-Ehrlich-Gesellschaft fu¨ r Chemotherapie und Arbeitskreis Urologische Infektionen der Deutschen Gesellschaft fu¨ r Urologie. Leitlinien zur perioperative Prophylaxe bei Eingriffen an den Harnwegen und im ma¨ nnlichen Genitalbereich. Chemother J 2000;9:165–70. [2] Wong ES, Hooten TM. Guideline for prevention of catheter-associated
urinary tract infections. Infection control 1981;2:125–30. [3] Hofstetter A. Die perioperative Antibiotikaprophylaxe in der Urologie. Urologe B 2000;40:226–32. [4] De Torres WR, Carson III CC. Antibiotic prophylaxis in urologic surgery. Curr Opinion Urol 1995;5:48–54. [5] EAU Guidelines for the Management of Urinary and Male Genital Tract Infections. Eur Urol 2001;40:576–88.
European Urology 44 (2003) 115–118
Perioperative Antibiotic Prophylaxis in Ureteroscopic Stone Removal H.-J. Knopfa,*, H.-J. Graffb, H. Schulzea a
Department of Urology, Klinikum Dortmund gGmbH, Teaching Hospital of the University of Munster, Westfalendamm 403, D-44143 Dortmund, Germany b Department of Urology, Sta¨dtisches Klinikum Solingen, Solingen, Germany Accepted 1 April 2003
Abstract Objective: This study shall settle the question whether a perioperative single shot prophylaxis in connection with a ureteroscopic stone removal has an influence on the rate of postoperative urinary tract infections (UTIs) and inflammable complications or not. Methods: 113 patients were included in this prospective randomized study. In 57 patients 250 mg Levofloxacin p. o. was given approximately 60 prior ureteroscopy, 56 patients had no prophylaxis. The evaluation of all data which were processed electronically was carried out with the help of a standardised questionnaire. Results: Postoperatively symptomatic urinary tract infections or inflammable complications of the urogenital tract were found in neither of the two groups. In the group without prophylaxis, the rate of the postoperative significant bacteriurias was significantly higher than in the group with prophylaxis (7 patients [12.5%] vs. 1 patient [1.8%]) ( p ¼ 0:026). In six cases there was an E. coli bacteriuria additionally a Kl. pneumoniae and a not specified Staphylococcus bacteriuria were detected in further cases. Conclusion: Single shot prophylaxis using 250 mg Levofloxacin p. o. can be considered as cheap, the patient not burdened and regarding the missed selection pressure to nosocomial pathogens the preferred manner of perioperative antibiotic prophylaxis in ureteroscopic stone removal. In addition perioperative single shot prophylaxis may be beneficial in case of an unexpected intraoperative complication like e.g. ureter perforations. # 2003 Elsevier Science B.V. All rights reserved. Keywords: Antibiotic prophylaxis; Ureteroscopy; Stone removal; Urinary tract infection
1. Introduction Current options for the treatment of ureteral stones are based on either ‘‘push up’’ of the stone with consecutive extracorporeal shock wave lithotripsy (ESWL) or the ureteroscopic stone removal under view. Open surgical interventions are only required in selected cases. Symptomatic urinary tract infections (UTIs) are part of possible postoperative complications of ureteroscopic interventions with the risk of ascending pyelonephritis or other inflammable complications. No reliable data are available considering the use of perioperative antibiotic prophylaxis in ureterorenoscopic stone removal. *
Corresponding author. Tel. þ49-231-45090; Fax: þ49-231-4509-6406. E-mail address: [email protected] (H.-J. Knopf).
In cooperation with the study group ‘‘Infektiologie’’ of the German Society of Urology (DGU) the Paul Ehrlich Society has published recommendations for the perioperative antibiotic prophylaxis in the field of interventions in the urinary tract and the male genital system [1]. Using these recommendations we carried out a prospective randomised study with two arms to investigate whether a perioperative single shot prophylaxis in connection with ureterorenoscopic stone removal has a beneficial effect on the rate of postoperative UTIs and inflammable complications or not. 2. Material and methods 509 ureterorenoscopic interventions were carried out in our department between January and December 2000. 113 patients
0302-2838/03/$ – see front matter # 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S0302-2838(03)00189-1
116
H.-J. Knopf et al. / European Urology 44 (2003) 115–118
Table 1 Inclusion and exclusion criteria
Table 3 Location of ureteral stones
Inclusion criteria
Exclusion criteria
Prophylaxis
Indication for endoscopic stone removal
Clinical signs of infection (e.g. fever >38.0 8C) Laboratory signs of infection (leukocytes >15.000/ml) Antibiotic treatment one week before admission Allergies against quinolones Known cerebral cramp sufferings Known tendinitis Pregnancy, quiet time No informed consent
(22.2%) were included in this study under consideration of the inclusion and exclusion criteria (Table 1). Patients were prospectively randomised to receive 250 mg Levofloxacin p. o. approximately 60 minutes prior ureteroscopy (group I; n ¼ 57) or no antibiotic prophylaxis (group II; n ¼ 56). At admission a thorough case history evaluation was carried out to exclude clinical symptoms of existing infection of the urogenital tract as well as possible existing contraindications against fluorquinolones. The laboratory chemical examinations at admission included blood count, creatinine and electrolytes as well as a bacteriological examination of the mid-stream urine. Corresponding controls were carried out on the first or second postoperative day. All patients were examined daily for signs of inflammable complications and in the group of prophylaxis on possible side effects. All infections were documented according to the criteria of the Centers for Disease Control [2]. A significant bacteriuria was considered 105 cfu/ml urine or more. Interventions were carried out by four urologists with ureterorenoscopes of Olympus1 (diameter 9.5 Fr.). Fluorquinolon was given in agreement with the mentioned recommendations of the Paul Ehrlich Society [1]. Levofloxacin was chosen because of the long half-life of about 7 hours and the complete coverage of the pathogens spectrum to be expected. The evaluations of all data were processed electronically using a standardised questionnaire. For statistical analysis the w2-test was used.
3. Results 113 patients were included in this study considering the mentioned inclusion and exclusion criteria. Regarding age, gender (Table 2) and location of the ureteral stones (Table 3) both groups were comparable. Leading symptom at time of admission was the renal colic followed by micturation disorders and hematuria (Table 4). In 44 patients (77.2%) of group I and in 50 patients (89.3%) of group II respectively, dilatation of
Right Left Pelvic Sacral Lumbar No stone detectable
Age Gender
No prophylaxis
41.8 yrs (range 24–74 yrs) 31 male; 26 female
42.0 yrs (range 18–74 yrs) 35 male; 21 female
(47.4%) (52.6%) (78.9%) (3.5%) (10.5%) (7.0%)
Symptoms
Prophylaxis
Renal colic Micturation disorders Hematuria Asymptomatic
55 13 2 2
29 patients (51.8%) 27 patients (48.2%) 42 patients (75.0%) 1 patient (1.8%) 9 patients (16.1%) 4 patients (7.1%)
patients patients patients patients
No prophylaxis (96.5%) (22.8%) (3.5%) (3.5%)
55 patients (98.2%) 10 patients (17.9%) 8 patients (14.3%) 1 patient (1.8%)
the collecting system was detectable (Table 5). Regarding the dilatation of the collecting system either a ureteral catheter or a DJ stent was placed first in 50 patients (87.7%) in group I and in 45 patients (80.4%) in group II respectively on a average of 2 days before ureteroscopy. An i. v. pyelography was carried out in group I in 27 patients (47.4%) and in group II in 29 patients (51.8%), respectively (Table 5). In all other cases an i. v. pyelography was not obtained because of pain (colic) or known allergies (contrast media). In four patients (3.5%) a significant bacteriuria was proven preoperatively. In group I there was one bacteriuria (E. coli 106 cfu/ml), in group 2 three patients had a significant bacteriuria (E. coli, Kl. pneumoniae and Staphylococcus spp. 106 cfu/ml each). In the last case a contamination cannot be excluded. Length of the procedure was similar in both groups (group I: 21.5 min, range 7–65 min; group II: 19.6 min, range 5–60 min). Due to the size of the concrements in nine patients (2 ultrasound, 7 Lithoclast1) in group I and in six patients (6 Lithoclast1 in group II an intraureteral disintegration had to be carried out. ESWL followed immediately after ureteroscopic intervention Table 5 Results of ultrasound1 and urography at admission
No dilatation Dilatation 18 1 Dilatation 28 1 Dilatation 38 Urography: normal Urography: delayed elimination Urography: silent kidney Urography: no urography 1
Prophylaxis
patients patients patients patients patients patients
Table 4 Symptoms at admission
1
Table 2 Distribution of age and gender
27 30 45 2 6 4
No prophylaxis
Prophylaxis
No prophylaxis
13 18 19 7 7 28 2 20
6 23 25 2 3 32 4 17
H.-J. Knopf et al. / European Urology 44 (2003) 115–118
in eight patients (15.1%) of group I and in four patients (7.7%) of group II, respectively. In five cases a perforation of the ureter occurred intraoperatively (group I: 3 patients; group II: 2 patients) which was radiologically documented. Follow up was uneventful after stenting in all cases. No additional antibiotic coverage was carried out in these cases. In 26 cases (45.6%) of group I and 29 cases (51.8%) of group II a stent was inserted postoperatively. The stents were removed on average after 11 days, in most cases in an outpatient setting. Primary stone free rates were 71.7% (group I) and 84.6% (group II), respectively which could be increased to 92.5% and 93.3% by auxiliary measures, respectively. The concrements were removed in all case with stone forceps. Postoperatively symptomatic urinary tract infections or inflammable complications of the urogenital tract were found in neither of the two groups. In the group without prophylaxis, the rate of the postoperative significant bacteriurias was significantly higher ( p ¼ 0:026) than in the group with prophylaxis (7 patients [12.5%] vs. 1 patient [1.8%]) (Table 6). In six cases E. coli was found, in the further two cases a Kl. pneumoniae and a not substratified Staphylococcus. If one takes into account that in two cases the bacteria (E. coli in group I, Kl. pneumoniae in group II) were preoperatively already provable, the rate of the nosocomial induced bacteriurias altogether for the complete study population was 5.3% (group I: 0%; group II: 10.7%). This difference between the groups was highly significant, too ( p ¼ 0:011). None of the proved pathogens showed a multiresistant pattern. No side effects of Levofloxacin could be recorded in the group of prophylaxis. Length of hospital stay was comparable in both groups (group I: 5.0 days versus group II: 5.1 days). 48 patients (group I: 25 patients, group II: 23 patients) could be re-examined in our clinic after an average of 15.3 days (6–84 days). Two patients of group II rejected a bacteriuria after 8 and 84 days (E. coli 105 cfu/ml, Staphylococcus spp. 105 cfu/ml). None of the patients complained of symptomatic UTIs or inflammatory complications. In additional 41 cases (24 patients of group I, 17 patients of group II) follow Table 6 Postoperative significant bacteriurias Prophylaxis E. coli
No prophylaxis 1 (preoperatively E. coli provable) Kl. pneumoniae Staphylococcus
5 1 (preoperatively provable) 1
117
up was obtained by telephone questionnaire and was uneventful in all.
4. Discussion Besides the ‘‘push up’’ with following ESWL the ureteroscopic removal is the standard therapy for ureteral calculi. By ureteroscopy the antirefluxive barrier of the intramural ureter is bridged so that pathogens of the lower urinary tract can be protracted into the upper tract. While the necessity of antibiotic therapy of preexisting symptomatic UTI in the case of urolithiasis is undisputed [3,4], the question of perioperative antibiotic prophylaxis in patients without symptoms of infection facing an endoscopic intervention for urolithiasis remains open. Furthermore, the importance of a postoperative bacteriuria at existing urine derivation is unknown till now and no reliable data are available regarding usefulness of perioperative antibiotic prophylaxis prior to ureteroscopic stone removal. Guidelines [5] concerning perioperative prophylaxis in urological interventions have been published by the Paul Ehrlich Society in cooperation with the ‘‘Study group Infektiologie’’ of the German Urological Association [1]. As recommended, a fluorquinolon was elected for this study. Levofloxacin in particular was used because of its high renal excretion and long halftime (7 hours), allowing a once per day oral medication. Based on preoperative clinical results and laboratory tests alone, a preselection of patients with regard to their risk of postoperative urinary tract infections is possible. The risk of a significant bacteriuria in absence of such findings is low. In our study this was the case in just 4 patients. Hence, if no hints for UTI are found preoperatively, the risk of postoperative symptomatic UTI due to ureteroscopic stone removal has to be considered low. In our study, this is the case independently whether a perioperative single shot prophylaxis was given or not. On the other hand, the rate of postoperative significant bacteriuria is increased significantly in the absence of a perioperative prophylaxis. However, the postoperative bacteriuria may not present a risk factor for symptomatic UTI in contrast to the preoperative one. Therefore the question arises whether there is at all an indication for a perioperative antibiotic prophylaxis in these selected patients. But based on our data, single shot prophylaxis can be considered as inexpensive, well tolerated and regarding the missed selection pressure to nosocomial pathogens the preferred manner of perioperative antibiotic
118
H.-J. Knopf et al. / European Urology 44 (2003) 115–118
prophylaxis in ureteroscopic stone removal. Furthermore a perioperative single shot prophylaxis may
provide additional safety in case of unexpected intraoperative complication like e.g. ureter perforation.
References [1] Naber KG, Hofstetter AG, Bru¨ hl P, Bichler KH, Lebert C und die Arbeitsgemeinschaft Harnwegsinfektionen der Sektion Chemotherapie der Paul-Ehrlich-Gesellschaft fu¨ r Chemotherapie und Arbeitskreis Urologische Infektionen der Deutschen Gesellschaft fu¨ r Urologie. Leitlinien zur perioperative Prophylaxe bei Eingriffen an den Harnwegen und im ma¨ nnlichen Genitalbereich. Chemother J 2000;9:165–70. [2] Wong ES, Hooten TM. Guideline for prevention of catheter-associated
urinary tract infections. Infection control 1981;2:125–30. [3] Hofstetter A. Die perioperative Antibiotikaprophylaxe in der Urologie. Urologe B 2000;40:226–32. [4] De Torres WR, Carson III CC. Antibiotic prophylaxis in urologic surgery. Curr Opinion Urol 1995;5:48–54. [5] EAU Guidelines for the Management of Urinary and Male Genital Tract Infections. Eur Urol 2001;40:576–88.