Original Paper Urol Int 1992;48:401-403
Department o f Urology, Marmara University, Medical School, Istanbul, T urkey
Keyw ords Gentamicin Antibiotic prophylaxis Endoscopic procedures of the urinary tract
Efficacy of Prophylactic Gentamicin Use in Postoperative Urinary Tract Infections after Endoscopic Procedures of the Urinary Tract
Abstract In this study, the efficacy of prophylactic antibiotic use was investigated. A total of 110 patients undergoing endoscopic procedures of the urinary tract were enrolled in the study. Fifty-five of the patients were treated with 8-hourly, 80 mg gentamicin sulfate of total three doses. The drug administration began just prior to the operation. Seven postoperative infections (12.7%) were detected, the same number as in the control group of 55 patients. The results confirm that there is no place for gentamicin prophylaxis in endoscopic proce dures of the urinary tract.
Introduction Endoscopic manipulations of the urinary tract have become a safe and well-tolerated procedure with the development of new endoscopic devices and more effica cious antiseptic solutions [1]. Although significant infec tious complications are not seen frequently in patients with preoperatively sterile urine, the incidence of urinary tract infection (UTI) after sterile urethral instrumentation was reported as high as 45% [2]. Antibiotic prophylaxis may prevent the possible inadvertent inoculation during surgery and the colonization of pathogen microorgansims. However, the efficacy of antibiotic prophylaxis in transurethral resection of the prostate (TUR-P) is still controversial [3], and there is not enough available data for the endoscopic procedures of the urinary tract to our knowledge.
Received: November 5, 1990 Accepted after revision: May 27. 1991
This study was conducted in order to figure out the efficacy of prophylactic gentamicin use in postoperative U TI after the endoscopic manipulations of the urinary tract.
Materials and Methods A total o f 110 patients undergoing various endoscopic procedures o f the urinary tract participated in the study (table 1). O f these, 55 were randomized as the antibiotic prophylaxis group while the remaining were assessed as the control group. The patients were investigated clinically and in terms o f postoperative urine cultures. In the former group, 80 mg gentamicin sulfate was administered via the intravenous route just prior to the operation. The doses were repeated twice, after 8 and 16 h, thus completing the prophylaxis pro tocol. N o treatment was applied in the control group. Exclusion criteria were indwelling urethral catheters or antibiotic therapy within 15 days preoperatively and elevated serum B U N or
Prof. A tif Akdas Chairman. Department o f Urology Marmara University Hospital Altunizadc - 81190. Istanbul (Turkey)
© 1992 S. Kargcr A G , Basel 0042-1138/92/0484-0401 $2.75/0
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 4:38:19 AM
D. Ersev Ö. Dillioglugil Y. Ilker F. $im$ek A. Akda$
Operation
Gentamicin
Control
T U R -P T U R -B T Cystoscopy + C P B Cystopanendoscopy Basket Optic urethrotomy RGP Pigtail Ureteroscopy
22 14 4 3 5 3 1 2 1
18 15 7 6 3 2 3 1 0
Total
55
55
T U R -B T = transurethral resection o f bladder tumor; C P B = cold punch biopsy; Basket = ureteral stone extraction; R G P = retrograde pyelography; Pigtail = ureteral double pigtail placement.
creatinine levels. None o f the patients in the study had U T I either clinically or bactcriologically preoperatively. Both groups were com parable in terms o f age, sex, history o f infection and the type o f oper ation. The age range for the gentamicin and control groups were 1486 (mean 61.6) and 15-80 (mean 61) respectively. There were 51 men and 4 women in each group. The genitalia were shaved on the night before operation. Povidonc-iodine solution o f 7.5% was used for surgical preparation. Eleven general and 44 spinal anesthesias were performed for the gen tamicin group. These figures were 9 and 46 respectively for the con trol group. General anesthesia was mostly preferred in endoscopic procedures o f the upper urinary tract. After T U R -P , continuous irri gation was performed routinely with physiological saline and discon tinued usually the next morning. Urine cultures were obtained from midstream urine specimens or withdrawn from the catheters o f patients after appropriate antiseptic preparation during the second postoperative day. 5 X 104 pure col ony count in 1 ml o f urine was categorized as bacteriological U T I. Cases with fever greater than 38 ° C orally or irritative voiding symp toms were accepted as clinical U T I. Postoperative infections were treated according to the sensitivity tests. The sensitivity testing was performed by 10-30 pg o f different antibiotic discs and the suscepti bility criterion was an area o f approximately 14-17 mm in diameter for each different antibiotic around the disc. The y } test was used for the statistical analysis.
Results Two of 110 patients disqualified from the study be cause they were treated with antibiotics for pulmonary complications. One of them was in the gentamicin and the other was in the control group. The duration of operations was almost identical in both groups.
402
The bacteriological U TI rate was similar (13%). There were 7 postoperative infections in each group (table 2). The causative organsims are shown in table 3. O f these postoperative U TIs, one and two were clinically mani fested respectively in the gentamicin and control groups (p > 0.4). In the antibiotic prophylaxis group, two of the seven pathogens were gentamicin resistant.
Discussion The most important infectious complications of the endoscopic procedures of the urinary tract are U TI and sepsis. Although not confirmed universally, a UTI rate of 45%, even after sterile urethral instrumentation, was reported in 1976 by Korbel and Maher [4], but as men tioned previously, the endoscopic manipulations of the urinary tract have become a safe procedure by the devel opment of the endoscopic devices and antiseptic solu tions [1]. The risk of UTI in patients with preoperative sterile urine is very low and prophylaxis is not recom mended routinely [2, 5, 6], On the other hand, the high incidence of infection after T U R-P has been reported reaching a rate of 30-50% in cases without antibiotic pro phylaxis [1]. This high rate, in fact, is in contrast to some other clinical investigations which revealed a bacteriuria rate of 10-32% during the operation in patients with ster ile urine preoperatively [6], Some authors assume that uti lization of prophylactic antibiotics in all kinds of endo scopic procedures may decrease the chance of infection and prove to be effective [1, 7], Still there is controversy on the subject and those who resist the routine prophy laxis claim that this method raises the possibility o f creat ing resistant species and has no effect on postoperative UTI [2, 5], Not only the necessity of prophylactic antibiotic usage but also the antibiotics of choice and the administration schedule are still under debate. There are contradictory reports concerning the same antibiotics - either on behalf or opposing them as prophylactic agents [1,2, 8-10]. In this study the antibiotic of choice was gentamicin, which can be accepted as a prototype of aminoglycoside antibiotics, a group which has well-known and established effects on most of the uropathogens [11]. The optimal duration of prophylaxis has not been defined yet, but sin gle-dose administration is reported as effective as long term prophylaxis [1,3,12], Single-dose prophylaxis is also recommended because of its ease of application, low cost profiles and decreased chance of creating resistant mi croorganisms, and less disturbance of fecal flora [1], But
Ersev/Dillioglugil/Ilkcr/$im§ek/Akdas
Gentamicin Prophylaxis in Urinary Tract Endoscopic Procedures
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 4:38:19 AM
Table 1. Endoscopic procedures performed in gentamicin and control groups
Table 2. Postoperative U T Is
Gentamicin group
Control group
patients
UTI
%
patients
UTI
%
T U R -P Other procedures
22 33
5 2
22.7 6.1
18 37
4 3
22.2 8.1
Total
55
7
12.7
55
7
12.7
the probability of insufficient serum levels of the drug and possibility of necessitation of a new antibiotic course are the major drawbacks. Concerning these factors, gentami cin (3-5 mg/kg) was used in three divided doses. This current study revealed no significant difference between the prophylaxis and the control group as well as between the TUR-P and other endoscopic procedures and in terms of overall results. An interesting point emerging from this clinical trial was the high rate of postoperative U TI in the TU R-P group compared to other procedures (22.5 and 6-8%, respectively). One may assume that tech nical developments in manufacturing endoscopes, refine ment of operation techniques, utilization of inert cathe ters along with closed drainage systems and early removal of urethral catheters must decrease the chance of UTI after T U R -P , yet it is not the case. The most important factor for this unpleasant outcome may be the presence of microorganisms within the prostatic tissue, even though the urine is kept sterile [9, 12]. The high rate of infection in the T U R -P group in our study may be due to this factor
Table 3. Causative organisms in the postoperative U T Is
Organism
coli Klebsiella Enterobacter Proteus
E.
Gentamicin group
Control group
UTI
%
UTI
%
3 2 2 0
42.8 28.6 28.6 0
4 1 1 1
57.1 14.3 14.3 14.3
and other factors like postoperative continuous irrigation and improper handling of the irrigation fluids in unsatis factory containers during the operation. As a conclusion, prophylactic usage of gentamicin in endoscopic procedures of the urinary tract was not found to be effective in preventing U T I postoperatively and antibiotic prophylaxis should be restricted in selected cases that carry a high risk.
References 5 Manson A L: Is antibiotic administration indi cated after outpatient cystoscopy? J Urol 1988; 140:316-317. 6 Grabe M: Antimicrobial agents in transure thral prostatic resection. J Urol 1987; 138:245252. 7 Prokocimer P. Quazza M , Lemoine JE , et al: Short-term prophylactic antibiotics in patients undergoing prostatectomy: Report o f a double blind randomized trial with two intravenous doses o f cefotaxime. J Urol 1986;135:60-64. 8 Larsen E H , Gasser T C , Madsen PO: Antim i crobial prophylaxis in urologic surgery. Urol C lin N Amer 1986; 13:591-597.
9
Morris M J, Golovsky D , Guiness M D G , et al: The value o f prophylactic antibiotics in trans urethral prostatic resection: A controlled trial with observations on the origin o f postopera tive infections. Br J Urol 1976;8:479-484. 10 Robinson M R G , Arudpragasam S J, Sahgal S M , et al: Bacteremia resulting from prostatic surgery: The source o f bacteria. Br J Urol 1982; 54:542-545. 11 Laurence D R , Bennett PN: Infection. II. Anti bacterial drugs; in Laurence D R , Bennet PN (eds): Clinical Pharmacology. Edingburgh, Churchill Livingstone, 1987, pp 211-236. 12 Kudinoff Z, Finegold SM , Kalmanson G M , et al: Use o f kanamycin or urinary acidification for prophylactic chemotherapy in transurethral prostatectomy. Am J Med Sei 1966;251:70— 74.
403
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 4:38:19 AM
1 Charton M , Vallencicn G , Vcillon B, et al: Antibiotic prophylaxis o f urinary tract infec tion after transurethral resection o f the pros tate: A randomized study. J Urol 1987; 138:87— 89. 2 Gibbons R P , Stark R A , Correa R J Jr, Cum mings K B . Mason JT : The prophylactic use or misuse - o f antibiotics in transurethral pros tatectomy. J Urol 1978;! 19:381-383. 3 Gold vasscr B, Bogokowsky B. Nativ O , et al: Pro' tylactic antimicrobial treatment in transure .irai prostatectomy. How long should it be instituted? Urology 1983;22:136-138. 4 Korbel E l, Maher PO: Use o f prophylactic anti biotics in urethral instrumentation. J Urol 1976:116:744-746.
Department o f Urology, Marmara University, Medical School, Istanbul, T urkey
Keyw ords Gentamicin Antibiotic prophylaxis Endoscopic procedures of the urinary tract
Efficacy of Prophylactic Gentamicin Use in Postoperative Urinary Tract Infections after Endoscopic Procedures of the Urinary Tract
Abstract In this study, the efficacy of prophylactic antibiotic use was investigated. A total of 110 patients undergoing endoscopic procedures of the urinary tract were enrolled in the study. Fifty-five of the patients were treated with 8-hourly, 80 mg gentamicin sulfate of total three doses. The drug administration began just prior to the operation. Seven postoperative infections (12.7%) were detected, the same number as in the control group of 55 patients. The results confirm that there is no place for gentamicin prophylaxis in endoscopic proce dures of the urinary tract.
Introduction Endoscopic manipulations of the urinary tract have become a safe and well-tolerated procedure with the development of new endoscopic devices and more effica cious antiseptic solutions [1]. Although significant infec tious complications are not seen frequently in patients with preoperatively sterile urine, the incidence of urinary tract infection (UTI) after sterile urethral instrumentation was reported as high as 45% [2]. Antibiotic prophylaxis may prevent the possible inadvertent inoculation during surgery and the colonization of pathogen microorgansims. However, the efficacy of antibiotic prophylaxis in transurethral resection of the prostate (TUR-P) is still controversial [3], and there is not enough available data for the endoscopic procedures of the urinary tract to our knowledge.
Received: November 5, 1990 Accepted after revision: May 27. 1991
This study was conducted in order to figure out the efficacy of prophylactic gentamicin use in postoperative U TI after the endoscopic manipulations of the urinary tract.
Materials and Methods A total o f 110 patients undergoing various endoscopic procedures o f the urinary tract participated in the study (table 1). O f these, 55 were randomized as the antibiotic prophylaxis group while the remaining were assessed as the control group. The patients were investigated clinically and in terms o f postoperative urine cultures. In the former group, 80 mg gentamicin sulfate was administered via the intravenous route just prior to the operation. The doses were repeated twice, after 8 and 16 h, thus completing the prophylaxis pro tocol. N o treatment was applied in the control group. Exclusion criteria were indwelling urethral catheters or antibiotic therapy within 15 days preoperatively and elevated serum B U N or
Prof. A tif Akdas Chairman. Department o f Urology Marmara University Hospital Altunizadc - 81190. Istanbul (Turkey)
© 1992 S. Kargcr A G , Basel 0042-1138/92/0484-0401 $2.75/0
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 4:38:19 AM
D. Ersev Ö. Dillioglugil Y. Ilker F. $im$ek A. Akda$
Operation
Gentamicin
Control
T U R -P T U R -B T Cystoscopy + C P B Cystopanendoscopy Basket Optic urethrotomy RGP Pigtail Ureteroscopy
22 14 4 3 5 3 1 2 1
18 15 7 6 3 2 3 1 0
Total
55
55
T U R -B T = transurethral resection o f bladder tumor; C P B = cold punch biopsy; Basket = ureteral stone extraction; R G P = retrograde pyelography; Pigtail = ureteral double pigtail placement.
creatinine levels. None o f the patients in the study had U T I either clinically or bactcriologically preoperatively. Both groups were com parable in terms o f age, sex, history o f infection and the type o f oper ation. The age range for the gentamicin and control groups were 1486 (mean 61.6) and 15-80 (mean 61) respectively. There were 51 men and 4 women in each group. The genitalia were shaved on the night before operation. Povidonc-iodine solution o f 7.5% was used for surgical preparation. Eleven general and 44 spinal anesthesias were performed for the gen tamicin group. These figures were 9 and 46 respectively for the con trol group. General anesthesia was mostly preferred in endoscopic procedures o f the upper urinary tract. After T U R -P , continuous irri gation was performed routinely with physiological saline and discon tinued usually the next morning. Urine cultures were obtained from midstream urine specimens or withdrawn from the catheters o f patients after appropriate antiseptic preparation during the second postoperative day. 5 X 104 pure col ony count in 1 ml o f urine was categorized as bacteriological U T I. Cases with fever greater than 38 ° C orally or irritative voiding symp toms were accepted as clinical U T I. Postoperative infections were treated according to the sensitivity tests. The sensitivity testing was performed by 10-30 pg o f different antibiotic discs and the suscepti bility criterion was an area o f approximately 14-17 mm in diameter for each different antibiotic around the disc. The y } test was used for the statistical analysis.
Results Two of 110 patients disqualified from the study be cause they were treated with antibiotics for pulmonary complications. One of them was in the gentamicin and the other was in the control group. The duration of operations was almost identical in both groups.
402
The bacteriological U TI rate was similar (13%). There were 7 postoperative infections in each group (table 2). The causative organsims are shown in table 3. O f these postoperative U TIs, one and two were clinically mani fested respectively in the gentamicin and control groups (p > 0.4). In the antibiotic prophylaxis group, two of the seven pathogens were gentamicin resistant.
Discussion The most important infectious complications of the endoscopic procedures of the urinary tract are U TI and sepsis. Although not confirmed universally, a UTI rate of 45%, even after sterile urethral instrumentation, was reported in 1976 by Korbel and Maher [4], but as men tioned previously, the endoscopic manipulations of the urinary tract have become a safe procedure by the devel opment of the endoscopic devices and antiseptic solu tions [1]. The risk of UTI in patients with preoperative sterile urine is very low and prophylaxis is not recom mended routinely [2, 5, 6], On the other hand, the high incidence of infection after T U R-P has been reported reaching a rate of 30-50% in cases without antibiotic pro phylaxis [1]. This high rate, in fact, is in contrast to some other clinical investigations which revealed a bacteriuria rate of 10-32% during the operation in patients with ster ile urine preoperatively [6], Some authors assume that uti lization of prophylactic antibiotics in all kinds of endo scopic procedures may decrease the chance of infection and prove to be effective [1, 7], Still there is controversy on the subject and those who resist the routine prophy laxis claim that this method raises the possibility o f creat ing resistant species and has no effect on postoperative UTI [2, 5], Not only the necessity of prophylactic antibiotic usage but also the antibiotics of choice and the administration schedule are still under debate. There are contradictory reports concerning the same antibiotics - either on behalf or opposing them as prophylactic agents [1,2, 8-10]. In this study the antibiotic of choice was gentamicin, which can be accepted as a prototype of aminoglycoside antibiotics, a group which has well-known and established effects on most of the uropathogens [11]. The optimal duration of prophylaxis has not been defined yet, but sin gle-dose administration is reported as effective as long term prophylaxis [1,3,12], Single-dose prophylaxis is also recommended because of its ease of application, low cost profiles and decreased chance of creating resistant mi croorganisms, and less disturbance of fecal flora [1], But
Ersev/Dillioglugil/Ilkcr/$im§ek/Akdas
Gentamicin Prophylaxis in Urinary Tract Endoscopic Procedures
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 4:38:19 AM
Table 1. Endoscopic procedures performed in gentamicin and control groups
Table 2. Postoperative U T Is
Gentamicin group
Control group
patients
UTI
%
patients
UTI
%
T U R -P Other procedures
22 33
5 2
22.7 6.1
18 37
4 3
22.2 8.1
Total
55
7
12.7
55
7
12.7
the probability of insufficient serum levels of the drug and possibility of necessitation of a new antibiotic course are the major drawbacks. Concerning these factors, gentami cin (3-5 mg/kg) was used in three divided doses. This current study revealed no significant difference between the prophylaxis and the control group as well as between the TUR-P and other endoscopic procedures and in terms of overall results. An interesting point emerging from this clinical trial was the high rate of postoperative U TI in the TU R-P group compared to other procedures (22.5 and 6-8%, respectively). One may assume that tech nical developments in manufacturing endoscopes, refine ment of operation techniques, utilization of inert cathe ters along with closed drainage systems and early removal of urethral catheters must decrease the chance of UTI after T U R -P , yet it is not the case. The most important factor for this unpleasant outcome may be the presence of microorganisms within the prostatic tissue, even though the urine is kept sterile [9, 12]. The high rate of infection in the T U R -P group in our study may be due to this factor
Table 3. Causative organisms in the postoperative U T Is
Organism
coli Klebsiella Enterobacter Proteus
E.
Gentamicin group
Control group
UTI
%
UTI
%
3 2 2 0
42.8 28.6 28.6 0
4 1 1 1
57.1 14.3 14.3 14.3
and other factors like postoperative continuous irrigation and improper handling of the irrigation fluids in unsatis factory containers during the operation. As a conclusion, prophylactic usage of gentamicin in endoscopic procedures of the urinary tract was not found to be effective in preventing U T I postoperatively and antibiotic prophylaxis should be restricted in selected cases that carry a high risk.
References 5 Manson A L: Is antibiotic administration indi cated after outpatient cystoscopy? J Urol 1988; 140:316-317. 6 Grabe M: Antimicrobial agents in transure thral prostatic resection. J Urol 1987; 138:245252. 7 Prokocimer P. Quazza M , Lemoine JE , et al: Short-term prophylactic antibiotics in patients undergoing prostatectomy: Report o f a double blind randomized trial with two intravenous doses o f cefotaxime. J Urol 1986;135:60-64. 8 Larsen E H , Gasser T C , Madsen PO: Antim i crobial prophylaxis in urologic surgery. Urol C lin N Amer 1986; 13:591-597.
9
Morris M J, Golovsky D , Guiness M D G , et al: The value o f prophylactic antibiotics in trans urethral prostatic resection: A controlled trial with observations on the origin o f postopera tive infections. Br J Urol 1976;8:479-484. 10 Robinson M R G , Arudpragasam S J, Sahgal S M , et al: Bacteremia resulting from prostatic surgery: The source o f bacteria. Br J Urol 1982; 54:542-545. 11 Laurence D R , Bennett PN: Infection. II. Anti bacterial drugs; in Laurence D R , Bennet PN (eds): Clinical Pharmacology. Edingburgh, Churchill Livingstone, 1987, pp 211-236. 12 Kudinoff Z, Finegold SM , Kalmanson G M , et al: Use o f kanamycin or urinary acidification for prophylactic chemotherapy in transurethral prostatectomy. Am J Med Sei 1966;251:70— 74.
403
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 4:38:19 AM
1 Charton M , Vallencicn G , Vcillon B, et al: Antibiotic prophylaxis o f urinary tract infec tion after transurethral resection o f the pros tate: A randomized study. J Urol 1987; 138:87— 89. 2 Gibbons R P , Stark R A , Correa R J Jr, Cum mings K B . Mason JT : The prophylactic use or misuse - o f antibiotics in transurethral pros tatectomy. J Urol 1978;! 19:381-383. 3 Gold vasscr B, Bogokowsky B. Nativ O , et al: Pro' tylactic antimicrobial treatment in transure .irai prostatectomy. How long should it be instituted? Urology 1983;22:136-138. 4 Korbel E l, Maher PO: Use o f prophylactic anti biotics in urethral instrumentation. J Urol 1976:116:744-746.
