- Email: [email protected]
Randomized trial of antibiotic prophylaxis for combined urodynamics and cystourethroscopy
Randomized Trial of Antibiotic Prophylaxis for Combined Urodynamics and Cystourethroscopy GEOFFREY W. CUNDIFF, MD, MARY T. MCLENNAN, MD, AND ALFRED E. BENT, MD Objective: To determine the efficacy of prophylactic nitrofurantoin in preventing bacteriuria after urodynamics and cystourethroscopy. Methods: We assumed that nitrofurantoin prophylaxis would decrease the rate of infection after urodynamics and cystourethroscopy from 19% to 5%. All women presenting for urodynamics and cystourethroscopy during a 27-month period were offered enrollment, and 142 were randomly assigned to receive two doses of long-acting nitrofurantoin 100 mg (n 5 74), or two doses of placebo (n 5 68). Nitrofurantoin and placebo capsules were identical, and subjects and physicians were masked to group assignment. Differences were assessed using Student t test for continuous data and x2 analysis for dichotomous data. Results: There were no statistical differences in demographic characteristics or final diagnoses between groups. Seven women (5%) who had bacteriuria on initial urine culture were not included in the final analysis. The frequency of bacteriuria in the postinstrumentation urine cultures was 6% overall, 7% in the treatment group, and 5% in the controls, a nonsignificant difference ([relative risk] 1.49, [confidence interval] 0.37, 5.95). The power of the study was 33% to detect a significant difference. Conclusion: Bacteriuria after combined urodynamics and cystourethroscopy was not improved by a 1-day course of nitrofurantoin. (Obstet Gynecol 1999;93:749 –52. © 1999 by The American College of Obstetricians and Gynecologists.)
Infection is one of the leading causes of morbidity associated with urodynamics or cystourethroscopy, although the actual rate of procedure-related bacteriuria is not well defined for either procedure, with reported ranges of 3–19%.1–7 At our institution, most women evaluated for urinary incontinence have multichannel urodynamics and cystourethroscopy during the same visit to expedite evaluation. Combining urodynamics and cystourethroscopy could increase the rate of procedure-related bacteriuria. All patients who had urodynamics and cystourethroscopy were given antibiotic prophylaxis in the form of long-acting nitrofurantoin From the Greater Baltimore Medical Center, Baltimore, Maryland.
VOL. 93, NO. 5, PART 1, MAY 1999
100 mg in two doses over 1 day, as well as phenazopyridine 200 mg in two doses, following this investigation. The primary aim of this study was to determine the rate of clinically significant bacteriuria after combined urodynamics and cystourethroscopy and the efficacy of nitrofurantoin in preventing it. Based on previous findings,4 we assumed a postinstrumentation infection rate of 19%. Our hypothesis was that nitrofurantoin prophylaxis would decrease the infection rate to 5%. A second aim was to determine the rate of preexisting asymptomatic bacteriuria in women presenting for incontinence evaluations.
Methods This was a double-masked randomized trial to compare the outcome of a two-dose regimen of long-acting nitrofurantoin prophylaxis to placebo for preventing colonization of the lower urinary tract during combined urodynamics and cystourethroscopy. The Institutional Review Board approved the study protocol. All women scheduled to undergo urodynamics and cystourethroscopy at a single institution over 27 months, beginning December 1, 1994, were screened for study entry. Women aged 21 to 75 years presenting for urinary incontinence who were willing to give informed consent were eligible. Exclusion criteria included a history of urinary tract infection within the preceding month, antibiotics within the preceding month, urethral instrumentation within the preceding month, pregnancy, allergy to nitrofurantoin, intermittent selfcatheterization, and risk of endocarditis. Those who gave informed consent were randomly assigned to treatment or placebo groups by using a computergenerated random numbers table with individual units of randomization, which was kept in a sealed envelope until the conclusion of the study. Allocation of study drug was by sequentially numbered opaque sealed envelopes prepared by the pharmacy department, concealed from the investigators who enrolled and as-
0029-7844/99/$20.00 PII S0029-7844(98)00521-3
749
signed subjects. Each envelope contained two capsules of long-acting nitrofurantoin 100 mg or placebo, which looked identical. Subjects were asked to take the two capsules in divided doses over 1 day after their urodynamic and cystourethroscopic evaluations. Both groups also received two doses of phenazopyridine 200 mg over 1 day. Compliance was not assessed, so analysis was on an intent-to-treat basis. Before entry, each subject was evaluated with a history and physical examination that included neurologic examination, pelvic examination, cotton-swab test, catheterization for residual urine determination, and urinalysis. Urodynamics and cystourethroscopy were done in strict adherence to a procedure protocol. Urodynamics were done with a Surgitek UDS1000 unit (Circon Corp., Surgitek Division, Racine, WI). After uroflowmetry, women were catheterized and urine specimens were collected and sent for culture. Fifty milliliters of sterile water was instilled before removing the catheter. Urethral closure pressure profiles and complex cystometry were done with sterilized solidstate-transducer catheters. A single-pressure transducer catheter was used in the vagina and a dual-pressure transducer catheter with filling lumen was used in the urethra and bladder. Profiles were done with women in the supine-empty and sitting-full positions. Cystometry was done with women in the sitting position. Cystourethroscopy followed urodynamics, using a no-touch technique with sterile instruments. Sterile water was the distending media. The endoscopic evaluation began with urethroscopy. A single pass was made with a 24-French or 15-French urethroscope to evaluate the urethral lumen, urethrovesical junction, trigone, and ureteral orifices. That was followed by a single pass of a 17-French, 30-degree cystoscope with a complete survey to evaluate the bladder. The primary outcome measure, bacteriuria, was assessed by culture of catheterized urine collected immediately before urodynamic and cystourethroscopic evaluation and a clean-catch midstream specimen collected 3 to 7 days after evaluation. The 3- to 7-day interval was chosen to increase enrollment. Many women referred to this practice traveled long distances, and we believed they would consider a narrower time frame for second cultures inconvenient. The microbiologic technique used for urine cultures was calibrated loop 1/100, with plating on blood agar for colony counts and MacConkey media for isolation. For purposes of this study, infection on both initial catheter specimen urine and follow-up clean-catch urine was defined as growth exceeding 105 colony-forming units per high-power field, and all organisms were considered pathogens. Sample-size analysis, with two-sided 95% significance, power of 80%, and a 1:1 ratio of placebo to
750 Cundiff et al
Antibiotic Prophylaxis
nitrofurantoin intervention, showed a necessary sample size of 196 subjects. To account for women who had bacteriuria on initial urine culture, we retrospectively analyzed 50 women who presented with urinary incontinence. We found a 3.6% rate of bacteriuria at presentation for urodynamics, which increased the sample size to 207 women needed to identify a statistical difference. We estimated enrollment time at 20 months. Although there were no predefined stopping rules, the study was terminated at 27 months with 142 subjects because of lower-than-expected enrollment. The additional 7 months of enrollment allowed us to surpass the number of women estimated by the power analysis (207); however, only 68% of those women were enrolled in the study, due in part to exclusions (23 women) and refusal to enroll (44 women). The primary reason for refusal was the inconvenience of returning the second urine specimen. The code was not broken until the study was terminated. Differences between treatment and control groups were assessed using Student t test for age and parity and x2 analysis for bacteriuria, hormonal status, and final diagnoses.
Results The 142 women enrolled in the study had a mean age of 62 years (standard deviation [SD] 12.7, range 23– 86 years) and median parity of 2 (SD 0.7, range 0 – 8). Forty-three percent were postmenopausal and not taking hormone replacement. The final diagnoses were genuine stress incontinence (22%), detrusor instability (22%), mixed urinary incontinence (18%), intrinsic sphincteric deficiency (20%), intrinsic sphincteric deficiency with detrusor instability (15%), and normal studies (3%). The mean interval for return of the second urine culture was 5.5 days (SD 2.8, range 2–19 days). There were no statistical differences in these figures between the nitrofurantoin and placebo groups. Seventy-four women were assigned to nitrofurantoin and 68 to placebo (Table 1). One hundred forty-one women had initial urine cultures; the woman who did not was assigned to placebo. Seven enrolled women had bacteriuria on initial urine cultures, a prevalence of 5% for women presenting with urinary incontinence; those women were not included in the final analysis. Of the 134 remaining women, 70 were in the nitrofurantoin group and 64 in the placebo group. The incidence of bacteriuria in the postinstrumentation urine cultures was 6% (n 5 8) with an incidence of 7% (n 5 5) for the treatment group and 5% (n 5 3) for the control group, not a statistically significant difference, with relative risk of 1.49 (95% CI 0.37, 5.95). The power of the study was 33% to detect a significant difference.
Obstetrics & Gynecology
Table 1. Trial Profile of 142 Women Presenting for Combined Urodynamics and Cystourethroscopy*
Urine culture
Nitrofurantoin group (n 5 74)
Control group (n 5 68)
70 4 0
64 3 1
60 5 5
55 3 6
Initial Negative Positive None Final Negative Positive None
* Twenty-three patients were excluded, and 44 declined participation.
Discussion The rate of bacteriuria reported after urodynamic studies ranges from 4 –19%1– 4 and that after cystoscopy from 3–17%.5–7 The upper limits of those ranges represent significant potential morbidity, inducing many clinicians to give prophylactic antibiotics. Approaches vary considerably in choice of antimicrobial agents and routes of administration. The most common prophylactic regimen for urodynamics was oral nitrofurantoin. During cystoscopy, some practitioners use bladder irrigation in lieu of oral antibiotics. Previous attempts to determine efficacy of prophylactic antibiotics for urodynamic studies offered limited predictive value (Table 2).1,2,4 Even in the largest investigations, the differences in infection rates between the treated and untreated groups were not statistically significant. Some investigators concluded that prophylactic antibiotics were valuable, whereas others did not. Studies addressing questions of prophylactic antibiotics for cystoscopy are also inconsistent in interpretation, despite limited power (Table 2).5,7 For women presenting without bacteriuria, the incidence of bacteriuria after combined urodynamics and
cystourethroscopy was not significantly improved by two doses of long-acting nitrofurantoin, although the power of that observation was only 33%. It would require a sample size of 2250, 1125 in each arm, to determine the value of nitrofurantoin prophylaxis with a power of 80% and significance of 95%, based on the prevalence of bacteriuria in the present study. The need for such a large sample size reflects the minor differences observed in bacteriuria between intervention and placebo groups. The incidence of bacteriuria was considerably lower in this study than the 19% reported by Baker et al,4 but it is consistent with other investigators’ incidences of 3–11% (Table 2). Those differences were due in part to different delineations of a significant colony count in defining bacteriuria. Our relatively low incidence of bacteriuria was based on a colony count of 105, in contrast to the more stringent colony count of 108 used by Baker et al.4 Other factors that might have influenced the incidence of bacteriuria after urodynamics and cystourethroscopy included differences in technique, length of urodynamic and cystourethroscopic investigations, and differences in the interval between initial investigation and second urine culture. The no-touch technique uses sterile instruments and catheters with an emphasis on not contaminating the parts of the instruments in contact with the urethra and bladder mucosa. Although we did not time the investigations, the randomized design of the study should help to prevent differences in length of investigations between intervention and control groups. The length of the interval between the urodynamic and cystourethroscopic investigation and the second urine culture was not different between groups, which eliminated it as a potential bias. Because the overall rate of bacteriuria after combined urodynamics and cystourethroscopy was so low (7%), an argument could be made that antibiotic prophylaxis was not beneficial, and women should only be treated for symptomatic infections after urodynamics and cys-
Table 2. Comparison of Studies of Antibiotic Prophylaxis for Urodynamics and Cystourethroscopy
Reference
Procedure
Design
Bergman and McCarthy1 Copcoat et al2 Baker et al4 Manson5
Urodynamics Randomized
Richards and Bastable6
Cystoscopy
Urodynamics Randomized Urodynamics Randomized Cystoscopy Randomized
n
Antibiotic
96 Nitrofurantoin
Route Oral
82 Trimethoprim Oral 102 Nitrofurantoin Oral 138 TrimethoprimOral sulfamethoxazole or nitrofurantoin Nonrandomized 268 Chlorhexidine Intravesical
Dose (mg)
Duration (days)
Significant Incidence (%) growth (cfu/L) Initial Control
50 mg TID
3
. 105
200 mg QID 50 mg QID 160/800 mg BID or 100 mg QID Not given Not
1 1 3
given
0
11
Not given . 108 . 105
2.6 8.2 1.5
6.8 18.9 2.8
. 105
2.2
6.8
cfu 5 colony-forming units; TID 5 three times a day; QID 5 four times a day; BID 5 twice a day.
VOL. 93, NO. 5, PART 1, MAY 1999
Cundiff et al
Antibiotic Prophylaxis
751
tourethroscopy. That would only apply to women who presented for combined urodynamics and cystourethroscopy without bacteriuria. Women with evidence of bacteriuria before urodynamics and cystourethroscopy should be treated appropriately before proceeding with those investigations.
References 1. Bergman A, McCarthy TA. Antibiotic prophylaxis after instrumentation for urodynamic testing. Br J Urol 1983;55:568 –9. 2. Coptcoat MJ, Reed C, Cumming J, Shah PJ, Worth PH. Is antibiotic prophylaxis necessary for routine urodynamic investigations? A controlled study in 100 patients. Br J Urol 1988;61:302–3. 3. Payne SR, Timoney AG, McKenning ST, den Hollander D, Pead LJ, Maskell RM. Microbiologic look at urodynamic studies. Lancet 1988;2:1123– 6. 4. Baker KR, Drutz HP, Barnes MD. Effectiveness of antibiotic prophylaxis in preventing bacteriuria after multichannel urodynamic investigations: A blind, randomized study in 124 female patients. Am J Obstet Gynecol 1991;165:679 – 81. 5. Manson AL. Is antibiotic administration indicated after outpatient cystoscopy. J Urol 1988;140:316 –7.
752 Cundiff et al
Antibiotic Prophylaxis
6. Richards B, Bastable JR. Bacteriuria after out-patient cystoscopy. Br J Urol 1977;49:561– 4. 7. Hares MM. A double-blind trial of half-strength Polybactrin soluble GU bladder irrigation in cystoscopy. Br J Urol 1981;53:62–7.
Address reprint requests to:
Geoffrey W. Cundiff, MD Johns Hopkins Bayview Medical Center Department of Obstetrics and Gynecology Baltimore, MD 21224-2780 E-mail: [email protected]
Received July 1, 1998. Received in revised form October 19, 1998. Accepted November 5, 1998.
Copyright © 1999 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Obstetrics & Gynecology
Infection is one of the leading causes of morbidity associated with urodynamics or cystourethroscopy, although the actual rate of procedure-related bacteriuria is not well defined for either procedure, with reported ranges of 3–19%.1–7 At our institution, most women evaluated for urinary incontinence have multichannel urodynamics and cystourethroscopy during the same visit to expedite evaluation. Combining urodynamics and cystourethroscopy could increase the rate of procedure-related bacteriuria. All patients who had urodynamics and cystourethroscopy were given antibiotic prophylaxis in the form of long-acting nitrofurantoin From the Greater Baltimore Medical Center, Baltimore, Maryland.
VOL. 93, NO. 5, PART 1, MAY 1999
100 mg in two doses over 1 day, as well as phenazopyridine 200 mg in two doses, following this investigation. The primary aim of this study was to determine the rate of clinically significant bacteriuria after combined urodynamics and cystourethroscopy and the efficacy of nitrofurantoin in preventing it. Based on previous findings,4 we assumed a postinstrumentation infection rate of 19%. Our hypothesis was that nitrofurantoin prophylaxis would decrease the infection rate to 5%. A second aim was to determine the rate of preexisting asymptomatic bacteriuria in women presenting for incontinence evaluations.
Methods This was a double-masked randomized trial to compare the outcome of a two-dose regimen of long-acting nitrofurantoin prophylaxis to placebo for preventing colonization of the lower urinary tract during combined urodynamics and cystourethroscopy. The Institutional Review Board approved the study protocol. All women scheduled to undergo urodynamics and cystourethroscopy at a single institution over 27 months, beginning December 1, 1994, were screened for study entry. Women aged 21 to 75 years presenting for urinary incontinence who were willing to give informed consent were eligible. Exclusion criteria included a history of urinary tract infection within the preceding month, antibiotics within the preceding month, urethral instrumentation within the preceding month, pregnancy, allergy to nitrofurantoin, intermittent selfcatheterization, and risk of endocarditis. Those who gave informed consent were randomly assigned to treatment or placebo groups by using a computergenerated random numbers table with individual units of randomization, which was kept in a sealed envelope until the conclusion of the study. Allocation of study drug was by sequentially numbered opaque sealed envelopes prepared by the pharmacy department, concealed from the investigators who enrolled and as-
0029-7844/99/$20.00 PII S0029-7844(98)00521-3
749
signed subjects. Each envelope contained two capsules of long-acting nitrofurantoin 100 mg or placebo, which looked identical. Subjects were asked to take the two capsules in divided doses over 1 day after their urodynamic and cystourethroscopic evaluations. Both groups also received two doses of phenazopyridine 200 mg over 1 day. Compliance was not assessed, so analysis was on an intent-to-treat basis. Before entry, each subject was evaluated with a history and physical examination that included neurologic examination, pelvic examination, cotton-swab test, catheterization for residual urine determination, and urinalysis. Urodynamics and cystourethroscopy were done in strict adherence to a procedure protocol. Urodynamics were done with a Surgitek UDS1000 unit (Circon Corp., Surgitek Division, Racine, WI). After uroflowmetry, women were catheterized and urine specimens were collected and sent for culture. Fifty milliliters of sterile water was instilled before removing the catheter. Urethral closure pressure profiles and complex cystometry were done with sterilized solidstate-transducer catheters. A single-pressure transducer catheter was used in the vagina and a dual-pressure transducer catheter with filling lumen was used in the urethra and bladder. Profiles were done with women in the supine-empty and sitting-full positions. Cystometry was done with women in the sitting position. Cystourethroscopy followed urodynamics, using a no-touch technique with sterile instruments. Sterile water was the distending media. The endoscopic evaluation began with urethroscopy. A single pass was made with a 24-French or 15-French urethroscope to evaluate the urethral lumen, urethrovesical junction, trigone, and ureteral orifices. That was followed by a single pass of a 17-French, 30-degree cystoscope with a complete survey to evaluate the bladder. The primary outcome measure, bacteriuria, was assessed by culture of catheterized urine collected immediately before urodynamic and cystourethroscopic evaluation and a clean-catch midstream specimen collected 3 to 7 days after evaluation. The 3- to 7-day interval was chosen to increase enrollment. Many women referred to this practice traveled long distances, and we believed they would consider a narrower time frame for second cultures inconvenient. The microbiologic technique used for urine cultures was calibrated loop 1/100, with plating on blood agar for colony counts and MacConkey media for isolation. For purposes of this study, infection on both initial catheter specimen urine and follow-up clean-catch urine was defined as growth exceeding 105 colony-forming units per high-power field, and all organisms were considered pathogens. Sample-size analysis, with two-sided 95% significance, power of 80%, and a 1:1 ratio of placebo to
750 Cundiff et al
Antibiotic Prophylaxis
nitrofurantoin intervention, showed a necessary sample size of 196 subjects. To account for women who had bacteriuria on initial urine culture, we retrospectively analyzed 50 women who presented with urinary incontinence. We found a 3.6% rate of bacteriuria at presentation for urodynamics, which increased the sample size to 207 women needed to identify a statistical difference. We estimated enrollment time at 20 months. Although there were no predefined stopping rules, the study was terminated at 27 months with 142 subjects because of lower-than-expected enrollment. The additional 7 months of enrollment allowed us to surpass the number of women estimated by the power analysis (207); however, only 68% of those women were enrolled in the study, due in part to exclusions (23 women) and refusal to enroll (44 women). The primary reason for refusal was the inconvenience of returning the second urine specimen. The code was not broken until the study was terminated. Differences between treatment and control groups were assessed using Student t test for age and parity and x2 analysis for bacteriuria, hormonal status, and final diagnoses.
Results The 142 women enrolled in the study had a mean age of 62 years (standard deviation [SD] 12.7, range 23– 86 years) and median parity of 2 (SD 0.7, range 0 – 8). Forty-three percent were postmenopausal and not taking hormone replacement. The final diagnoses were genuine stress incontinence (22%), detrusor instability (22%), mixed urinary incontinence (18%), intrinsic sphincteric deficiency (20%), intrinsic sphincteric deficiency with detrusor instability (15%), and normal studies (3%). The mean interval for return of the second urine culture was 5.5 days (SD 2.8, range 2–19 days). There were no statistical differences in these figures between the nitrofurantoin and placebo groups. Seventy-four women were assigned to nitrofurantoin and 68 to placebo (Table 1). One hundred forty-one women had initial urine cultures; the woman who did not was assigned to placebo. Seven enrolled women had bacteriuria on initial urine cultures, a prevalence of 5% for women presenting with urinary incontinence; those women were not included in the final analysis. Of the 134 remaining women, 70 were in the nitrofurantoin group and 64 in the placebo group. The incidence of bacteriuria in the postinstrumentation urine cultures was 6% (n 5 8) with an incidence of 7% (n 5 5) for the treatment group and 5% (n 5 3) for the control group, not a statistically significant difference, with relative risk of 1.49 (95% CI 0.37, 5.95). The power of the study was 33% to detect a significant difference.
Obstetrics & Gynecology
Table 1. Trial Profile of 142 Women Presenting for Combined Urodynamics and Cystourethroscopy*
Urine culture
Nitrofurantoin group (n 5 74)
Control group (n 5 68)
70 4 0
64 3 1
60 5 5
55 3 6
Initial Negative Positive None Final Negative Positive None
* Twenty-three patients were excluded, and 44 declined participation.
Discussion The rate of bacteriuria reported after urodynamic studies ranges from 4 –19%1– 4 and that after cystoscopy from 3–17%.5–7 The upper limits of those ranges represent significant potential morbidity, inducing many clinicians to give prophylactic antibiotics. Approaches vary considerably in choice of antimicrobial agents and routes of administration. The most common prophylactic regimen for urodynamics was oral nitrofurantoin. During cystoscopy, some practitioners use bladder irrigation in lieu of oral antibiotics. Previous attempts to determine efficacy of prophylactic antibiotics for urodynamic studies offered limited predictive value (Table 2).1,2,4 Even in the largest investigations, the differences in infection rates between the treated and untreated groups were not statistically significant. Some investigators concluded that prophylactic antibiotics were valuable, whereas others did not. Studies addressing questions of prophylactic antibiotics for cystoscopy are also inconsistent in interpretation, despite limited power (Table 2).5,7 For women presenting without bacteriuria, the incidence of bacteriuria after combined urodynamics and
cystourethroscopy was not significantly improved by two doses of long-acting nitrofurantoin, although the power of that observation was only 33%. It would require a sample size of 2250, 1125 in each arm, to determine the value of nitrofurantoin prophylaxis with a power of 80% and significance of 95%, based on the prevalence of bacteriuria in the present study. The need for such a large sample size reflects the minor differences observed in bacteriuria between intervention and placebo groups. The incidence of bacteriuria was considerably lower in this study than the 19% reported by Baker et al,4 but it is consistent with other investigators’ incidences of 3–11% (Table 2). Those differences were due in part to different delineations of a significant colony count in defining bacteriuria. Our relatively low incidence of bacteriuria was based on a colony count of 105, in contrast to the more stringent colony count of 108 used by Baker et al.4 Other factors that might have influenced the incidence of bacteriuria after urodynamics and cystourethroscopy included differences in technique, length of urodynamic and cystourethroscopic investigations, and differences in the interval between initial investigation and second urine culture. The no-touch technique uses sterile instruments and catheters with an emphasis on not contaminating the parts of the instruments in contact with the urethra and bladder mucosa. Although we did not time the investigations, the randomized design of the study should help to prevent differences in length of investigations between intervention and control groups. The length of the interval between the urodynamic and cystourethroscopic investigation and the second urine culture was not different between groups, which eliminated it as a potential bias. Because the overall rate of bacteriuria after combined urodynamics and cystourethroscopy was so low (7%), an argument could be made that antibiotic prophylaxis was not beneficial, and women should only be treated for symptomatic infections after urodynamics and cys-
Table 2. Comparison of Studies of Antibiotic Prophylaxis for Urodynamics and Cystourethroscopy
Reference
Procedure
Design
Bergman and McCarthy1 Copcoat et al2 Baker et al4 Manson5
Urodynamics Randomized
Richards and Bastable6
Cystoscopy
Urodynamics Randomized Urodynamics Randomized Cystoscopy Randomized
n
Antibiotic
96 Nitrofurantoin
Route Oral
82 Trimethoprim Oral 102 Nitrofurantoin Oral 138 TrimethoprimOral sulfamethoxazole or nitrofurantoin Nonrandomized 268 Chlorhexidine Intravesical
Dose (mg)
Duration (days)
Significant Incidence (%) growth (cfu/L) Initial Control
50 mg TID
3
. 105
200 mg QID 50 mg QID 160/800 mg BID or 100 mg QID Not given Not
1 1 3
given
0
11
Not given . 108 . 105
2.6 8.2 1.5
6.8 18.9 2.8
. 105
2.2
6.8
cfu 5 colony-forming units; TID 5 three times a day; QID 5 four times a day; BID 5 twice a day.
VOL. 93, NO. 5, PART 1, MAY 1999
Cundiff et al
Antibiotic Prophylaxis
751
tourethroscopy. That would only apply to women who presented for combined urodynamics and cystourethroscopy without bacteriuria. Women with evidence of bacteriuria before urodynamics and cystourethroscopy should be treated appropriately before proceeding with those investigations.
References 1. Bergman A, McCarthy TA. Antibiotic prophylaxis after instrumentation for urodynamic testing. Br J Urol 1983;55:568 –9. 2. Coptcoat MJ, Reed C, Cumming J, Shah PJ, Worth PH. Is antibiotic prophylaxis necessary for routine urodynamic investigations? A controlled study in 100 patients. Br J Urol 1988;61:302–3. 3. Payne SR, Timoney AG, McKenning ST, den Hollander D, Pead LJ, Maskell RM. Microbiologic look at urodynamic studies. Lancet 1988;2:1123– 6. 4. Baker KR, Drutz HP, Barnes MD. Effectiveness of antibiotic prophylaxis in preventing bacteriuria after multichannel urodynamic investigations: A blind, randomized study in 124 female patients. Am J Obstet Gynecol 1991;165:679 – 81. 5. Manson AL. Is antibiotic administration indicated after outpatient cystoscopy. J Urol 1988;140:316 –7.
752 Cundiff et al
Antibiotic Prophylaxis
6. Richards B, Bastable JR. Bacteriuria after out-patient cystoscopy. Br J Urol 1977;49:561– 4. 7. Hares MM. A double-blind trial of half-strength Polybactrin soluble GU bladder irrigation in cystoscopy. Br J Urol 1981;53:62–7.
Address reprint requests to:
Geoffrey W. Cundiff, MD Johns Hopkins Bayview Medical Center Department of Obstetrics and Gynecology Baltimore, MD 21224-2780 E-mail: [email protected]
Received July 1, 1998. Received in revised form October 19, 1998. Accepted November 5, 1998.
Copyright © 1999 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Obstetrics & Gynecology