Journal of Chemotherapy
ISSN: 1120-009X (Print) 1973-9478 (Online) Journal homepage: http://www.tandfonline.com/loi/yjoc20
Short-Term Antibiotic Prophylaxis in Open Urologic Surgery F. Pacelli, F. Ceriati, R. Bellantone & C. Cavicchioni To cite this article: F. Pacelli, F. Ceriati, R. Bellantone & C. Cavicchioni (1990) Short-Term Antibiotic Prophylaxis in Open Urologic Surgery, Journal of Chemotherapy, 2:4, 257-259, DOI: 10.1080/1120009X.1990.11739027 To link to this article: https://doi.org/10.1080/1120009X.1990.11739027
Published online: 14 Jul 2016.
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Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yjoc20
Journal of Chemotherapy
Short-Term Antibiotic Prophylaxis in Open Urologic Surgery F. PACELLI-F. CERIATI-R. BELLANTONE C. CAVICCHIONI
Summary - - - - - - - - - - - - - - - - The aim of the present study was to compare the efficacy of a single dose of ceftriaxone with a triple dose of gentamicin as prophylactic agents in patients undergoing open urologic surgery. Fifty-two patients were allocated into two groups which were well matched with respect to sex, age and surgical procedure: - 24 were given single-dose ceftriaxone (2 g i.v.) at the time of anesthesia (ceftriaxone group); - 28 received gentamicin (80 mg i.v.) nt the time of anesthesia and two additional doses of the same an tibiotic were subsequentely administrated every 8 hours (gentamicin group). The incidence of urinary tract infection (UTI) was 3.5% in the gentamicin group and 0 % in the ceftriaxone group (p = n .s. ); postoperative fever ( > 38 ° C) occurred in 28.3% and 8.3% in the gentamicin and ceftriaxone groups respectively (p = n.s.) . There was no clinical or hematological evidence of drug side effects in any patient. Results of the study show that short-term antibiotic regimens can improve UTI rates after open urologic surgery; moreover a single preoperative dose of ceftriaxone resulted to be as effective as three doses of gentamicin. Key words: antibiotic prophylaxis, urologic surgery.
Istituto di Patologia Chirurgica, Universitlt Cattolica del Sacra Cuore, Rome, Italy Author address: Fabio Pacelli , M .D ., I stituto di Patologia Chirurgica, Universitl1 Cattolica del Sacra Cuore, Largo A. Gemelli n . 8, 00168 · Roma, Italy. © Edizioni Ri viste Scientifiche · Firenze
Vol. 2 - n. 4 (257-259) - 1990
INTRODUCTION
The administration of antibiotic prophylaxis in patients with sterile urine undergoing open urologic surgery is still controversial 1 ; on the one hand some studies have shown that the prophylactic administration of antibiotic can reduce the risk of bacteriemia during surgery 2 and the postoperative infection rates 3 ; on the other hand some authors found no significant differences between the rates of infection in placebo and prophylactically treated patients who had sterile urine preoperatively 4 • However, as most open genitourinary operations on the kidney or the ureter could be classified as clean or possibly, clean-contaminated, and when considering that several studies have shown the presence of intraprostatic organisms even when urine is sterile u, antibiotic prophylaxis for open urologic surgery seems to be indicated . The aim of the present study was to compare the efficacy of a single dose of ceftriaxone with triple-dose gentamicin as prophylactic agents in patients undergoing open urologic surgery.
PATIENTS AND METHODS
Fifty-two patients undergoing open urologic surgery were included in the study. Subjects with known allergy to betalactams or aminoglycosides and those with chronic indwelling Foley catheters were excluded from the study. The other exclusion criteria regarded patients with preoperative urine culture positive for any bacteria within 48 h before surgery, those scheduled to undergo large bowel operation and ISSN 11 20-009X
258
F. PACELLI - F. CERIATI - R. BELLANTONE - C . CAVICCHIONI
those considered at high risk because of severely debilitating diseases (such as uncontrolled diabetes or terminal cancer). Patients were allocated into two groups: - Twenty-four patients received single dose ceftriaxone (Roche) (2g i. v .) at the time of anesthesia (ceftriaxone group); - Twenty-eight were given gentamicin (Essex) (80 mg i.v .) at induction of anesthesia, two additional doses of the same antibiotic were subsequently administered every 8 hours (genta-
- urinary tract infection: finding of bacteria in colony counts > 100,000 / ml; - respiratory infection: as judged both clinically and by chest x-ray; - wound infections: purulent discharge with or without culture of pathogenic microorganism; - septicemia. The Fisher's exact test was used for statistical analysis.
micin group). The groups were well matched with respect to sex, age and operative procedure (Table 1). Table 2 shows the underlying pathology. There were also no significant differences in terms of average operation time, number of subjects transfused during or after the operation, and duration of postoperative catheterization. Postoperative septic morbidity was defined as follows:
TA BL E
1 - Characteristics of the 52 patients included in the study. Ceftriaxone G roup
Mean age (years - range) Total M/F
Gentamicin Group
64.1 {34-75 ) 66 .9 (28-69) 20/4
26/2
12 1 3
8 4 2 2 6 2 4
Opera tive procedure Transvesical pros tatec tomy Total cystec tomy Ureterolithoto my Pyelolithotomy Nephroureterec tomy Ureteral reimpl antation Bladder resecti on Papilloma resection O peration time media n (min .) Ca theteriza tion time median (days)
T ABLE
3 2 1 2 127.2 4.3
11 8.6 4.9
2 · Underlying pathology of 52 patients included in the study.
Benign prostatic hyperplasia Bladder carcinoma Ureteral stone Renal (pyelic) stone Renal cell carcinoma Ureteropelvic junction obstruction Bladder papillomatos is Ureteral papillomatosis
Ceftri axone G roup
Gentamicin Group
12 1 3
8
RESULTS
Overall, urinary tract infection (UTI) was observed in 3.5% (1/28) of patients in the gentamicin group and 0% in ceftriaxone group (p = n.s.) . Pathogens isolated were Streptococcus faecalis and Klebsiella pneumoniae; the same patient displayed symptoms related to septicemia (S. faecalis), successfully treated by antibiotic administration (cefoxitin 4 g a day plus gentamicin 240 mg a day). No UTis were observed in the ceftriaxone group; in one patient (4.1%) who had undergone left nephrectomy for renal cell carcinoma a respiratory tract infection was observed. It was successfully treated by administration of ceftriaxone (2g i. v. twice a day plus netilmicin 250 mg i.v. twice a day) . The postoperative mean stay in hospital was comparable: 11.4 days in the ceftriaxone group and 12.6 days in the gentamicin group. Differences were found between the two treatment groups in the occurrence of postoperative fever, and related antibiotic administration: the number of patients with postoperative body temperature > 38°C was 8 (28.3%) in gentamicin group and 2 (8.3%) in ceftriaxone group . (p = n.s.). There was no clinical evidence of drug side effects in any patient. We observed no pain at the site of infection nor maculopapular rash or flushing. No hematological abnormalities were noted .
4 2 2
DISCUSSION
3
5
2
2 4 1
In recent years, since the 1979 critical re view of the literature by Chodak and Plaut\ a number of studies have been conducted with short courses of antibiotics in urologic sur-
259
SHORT-TERM ANTIBIOTIC PROPHYLAXIS IN OPEN UROLOGIC SURGERY
gery 6 • 8 • Recently three randomized, controlled double-blind trials have shed light on the real efficacy of antibiotic prophylaxis 3 • 9 • 10 ; nevertheless the ideal duration of prophylactic treatment remains debatable 11 • For this reason we evaluated the bacteriological and clinical efficacy of prophylactic antibiotics consisting of a single preoperative dose of ceftriaxone compared to triple-dose gentamicin. Ceftriaxone was chosen because of its broad spectrum and long (8 hours) half-life. Rapid i. v. infusion was adopted in order to obtain the peak serum concentration and the best tissue penetration during the contamination period. Our results demonstrate that a single 2 g preoperative ceftriaxone injection can reduce the incidence of postoperative UTI in patients undergoing open urologic surgery: none of our 24 ceftriaxone-treated patients had any evidence of UTI, whereas one out of 28 gentami~ cin-treated patients experienced UTI and subsequently septicemia. Moreover the occurrence of postoperative fever was lower in ceftriaxone treated patients, even if one of them developed a respiratory tract infection during the postoperative course. However, antibiotic prophylaxis is unlikely to prevent later postoperative bacterial complications such as pneumonia. Regarding the potential for development of resistant organisms and superinfection, the prophylactic use of single-dose or short-term prophylaxis did not produce any tendency toward resistant organisms. In conclusion, results of the study show that short-term antibiotic regimens can improve UTI rates after open urologic surgery (overall incidence of UTI 1.9% - 1/52). In particular it must be stressed that the incidence of UTI after 20 transvesical prostatectomies was equal to 0, whereas the reported incidence of postoperative UTI infection in patients with sterile preoperative urine undergoing prostatic surgery and not receiving any antibiotic prophylaxis varies
between 30 and 50% according to various studies s •8 • 12 • Therefore antibiotic prophylaxis in urologic surgery has to be recommended. Regarding the duration of treatment, the use of a single dose of a broad spectrum, non-toxic antibiotic such as ceftriaxone, seems to be suggested.
REFERENCES 1 Madsen P, Larsen E, Dorflinger T . The role of antibacterial prophylaxis in urologic surgery. Urology 1985; 26 (Suppl. 1) : 38-42. ' Haverkorn MJ. Prophylactic trimethoprin for prostatectomy. Urology 1984; 24: 414-419. 'Childs SJ, Veils WG, Mirelman T . Antibiotic prophylaxis for genitourinary surgery in community hospitals. J Urol, 1983; 130: 305-308. 4 Marshall A. Prophylactic antimicrobial therapy in retropubic prostatectomy. Br J Urol 1960; 31: 431 -43 7. 'Morris MJ, Golovsky D , Guinness MDG, Mahler PO. The value of prophylactic antibiotics in transurethral prostatic resection: a controlled trial with observation of the origin of postoperative infections. Br J Urol 1976; 48 : 479-483. 'Robinson MRG, Arudpragasam SJ, Sahgal SM, Cross R, Akdas J, Pitta! B, Sibbald R. Bacteraemia resulting from prostatic surgery: the source of bacteria . Br J Urol 1982; 54: 542-547. 'Chodak GW, Plaut ME . Systemic antibiotics for pro· phylaxis in urologic surgery: a critical review. J Urol 1979; 121: 695-699. 'Botto H, Richard F, Mathieu F, Perreau AM, Carney M. Short-term prophylaxis with cefotaxime in prostatic surgery. J Antimicrob Chemother 1984 ; 14 (Suppl. B) 14: 231234. ' Prokocimer P, Quazza M, Gibert C, et al. Short-term prophylactic antibiotics in patients undergoing prostatectomy : report of a double-blind randomi zed tri al with 2 intravenous doses of cefotaxime. J Urol 1986; 135: 60-64 . 10 Nielsen OS, Maigaard S, Frimodt-Moller N, Madsen PO . Prophylactic antibiotics in transurethral prostatectomy . J Urol 1981 ; 126: 60-63. 11 Charron M, Vallancien B, VeilJon B, Brisset JM. Antibiotic prophylaxis of urinary tract infection after transurethral resection of the prostate: a randomized study. J Urol 1987; 138: 87-89. " Ramsey EW, Sheth NK Antibiotic prophylaxis in patients undergoing prostatectomy. Urology 1983; 21: 376-379. " Shah PJR, Gordon W, Chaudary M. Short-term antibiotic prophylaxis and prostatectomy. Br J Urol 1981; 53: 339-343 .
ISSN: 1120-009X (Print) 1973-9478 (Online) Journal homepage: http://www.tandfonline.com/loi/yjoc20
Short-Term Antibiotic Prophylaxis in Open Urologic Surgery F. Pacelli, F. Ceriati, R. Bellantone & C. Cavicchioni To cite this article: F. Pacelli, F. Ceriati, R. Bellantone & C. Cavicchioni (1990) Short-Term Antibiotic Prophylaxis in Open Urologic Surgery, Journal of Chemotherapy, 2:4, 257-259, DOI: 10.1080/1120009X.1990.11739027 To link to this article: https://doi.org/10.1080/1120009X.1990.11739027
Published online: 14 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yjoc20
Journal of Chemotherapy
Short-Term Antibiotic Prophylaxis in Open Urologic Surgery F. PACELLI-F. CERIATI-R. BELLANTONE C. CAVICCHIONI
Summary - - - - - - - - - - - - - - - - The aim of the present study was to compare the efficacy of a single dose of ceftriaxone with a triple dose of gentamicin as prophylactic agents in patients undergoing open urologic surgery. Fifty-two patients were allocated into two groups which were well matched with respect to sex, age and surgical procedure: - 24 were given single-dose ceftriaxone (2 g i.v.) at the time of anesthesia (ceftriaxone group); - 28 received gentamicin (80 mg i.v.) nt the time of anesthesia and two additional doses of the same an tibiotic were subsequentely administrated every 8 hours (gentamicin group). The incidence of urinary tract infection (UTI) was 3.5% in the gentamicin group and 0 % in the ceftriaxone group (p = n .s. ); postoperative fever ( > 38 ° C) occurred in 28.3% and 8.3% in the gentamicin and ceftriaxone groups respectively (p = n.s.) . There was no clinical or hematological evidence of drug side effects in any patient. Results of the study show that short-term antibiotic regimens can improve UTI rates after open urologic surgery; moreover a single preoperative dose of ceftriaxone resulted to be as effective as three doses of gentamicin. Key words: antibiotic prophylaxis, urologic surgery.
Istituto di Patologia Chirurgica, Universitlt Cattolica del Sacra Cuore, Rome, Italy Author address: Fabio Pacelli , M .D ., I stituto di Patologia Chirurgica, Universitl1 Cattolica del Sacra Cuore, Largo A. Gemelli n . 8, 00168 · Roma, Italy. © Edizioni Ri viste Scientifiche · Firenze
Vol. 2 - n. 4 (257-259) - 1990
INTRODUCTION
The administration of antibiotic prophylaxis in patients with sterile urine undergoing open urologic surgery is still controversial 1 ; on the one hand some studies have shown that the prophylactic administration of antibiotic can reduce the risk of bacteriemia during surgery 2 and the postoperative infection rates 3 ; on the other hand some authors found no significant differences between the rates of infection in placebo and prophylactically treated patients who had sterile urine preoperatively 4 • However, as most open genitourinary operations on the kidney or the ureter could be classified as clean or possibly, clean-contaminated, and when considering that several studies have shown the presence of intraprostatic organisms even when urine is sterile u, antibiotic prophylaxis for open urologic surgery seems to be indicated . The aim of the present study was to compare the efficacy of a single dose of ceftriaxone with triple-dose gentamicin as prophylactic agents in patients undergoing open urologic surgery.
PATIENTS AND METHODS
Fifty-two patients undergoing open urologic surgery were included in the study. Subjects with known allergy to betalactams or aminoglycosides and those with chronic indwelling Foley catheters were excluded from the study. The other exclusion criteria regarded patients with preoperative urine culture positive for any bacteria within 48 h before surgery, those scheduled to undergo large bowel operation and ISSN 11 20-009X
258
F. PACELLI - F. CERIATI - R. BELLANTONE - C . CAVICCHIONI
those considered at high risk because of severely debilitating diseases (such as uncontrolled diabetes or terminal cancer). Patients were allocated into two groups: - Twenty-four patients received single dose ceftriaxone (Roche) (2g i. v .) at the time of anesthesia (ceftriaxone group); - Twenty-eight were given gentamicin (Essex) (80 mg i.v .) at induction of anesthesia, two additional doses of the same antibiotic were subsequently administered every 8 hours (genta-
- urinary tract infection: finding of bacteria in colony counts > 100,000 / ml; - respiratory infection: as judged both clinically and by chest x-ray; - wound infections: purulent discharge with or without culture of pathogenic microorganism; - septicemia. The Fisher's exact test was used for statistical analysis.
micin group). The groups were well matched with respect to sex, age and operative procedure (Table 1). Table 2 shows the underlying pathology. There were also no significant differences in terms of average operation time, number of subjects transfused during or after the operation, and duration of postoperative catheterization. Postoperative septic morbidity was defined as follows:
TA BL E
1 - Characteristics of the 52 patients included in the study. Ceftriaxone G roup
Mean age (years - range) Total M/F
Gentamicin Group
64.1 {34-75 ) 66 .9 (28-69) 20/4
26/2
12 1 3
8 4 2 2 6 2 4
Opera tive procedure Transvesical pros tatec tomy Total cystec tomy Ureterolithoto my Pyelolithotomy Nephroureterec tomy Ureteral reimpl antation Bladder resecti on Papilloma resection O peration time media n (min .) Ca theteriza tion time median (days)
T ABLE
3 2 1 2 127.2 4.3
11 8.6 4.9
2 · Underlying pathology of 52 patients included in the study.
Benign prostatic hyperplasia Bladder carcinoma Ureteral stone Renal (pyelic) stone Renal cell carcinoma Ureteropelvic junction obstruction Bladder papillomatos is Ureteral papillomatosis
Ceftri axone G roup
Gentamicin Group
12 1 3
8
RESULTS
Overall, urinary tract infection (UTI) was observed in 3.5% (1/28) of patients in the gentamicin group and 0% in ceftriaxone group (p = n.s.) . Pathogens isolated were Streptococcus faecalis and Klebsiella pneumoniae; the same patient displayed symptoms related to septicemia (S. faecalis), successfully treated by antibiotic administration (cefoxitin 4 g a day plus gentamicin 240 mg a day). No UTis were observed in the ceftriaxone group; in one patient (4.1%) who had undergone left nephrectomy for renal cell carcinoma a respiratory tract infection was observed. It was successfully treated by administration of ceftriaxone (2g i. v. twice a day plus netilmicin 250 mg i.v. twice a day) . The postoperative mean stay in hospital was comparable: 11.4 days in the ceftriaxone group and 12.6 days in the gentamicin group. Differences were found between the two treatment groups in the occurrence of postoperative fever, and related antibiotic administration: the number of patients with postoperative body temperature > 38°C was 8 (28.3%) in gentamicin group and 2 (8.3%) in ceftriaxone group . (p = n.s.). There was no clinical evidence of drug side effects in any patient. We observed no pain at the site of infection nor maculopapular rash or flushing. No hematological abnormalities were noted .
4 2 2
DISCUSSION
3
5
2
2 4 1
In recent years, since the 1979 critical re view of the literature by Chodak and Plaut\ a number of studies have been conducted with short courses of antibiotics in urologic sur-
259
SHORT-TERM ANTIBIOTIC PROPHYLAXIS IN OPEN UROLOGIC SURGERY
gery 6 • 8 • Recently three randomized, controlled double-blind trials have shed light on the real efficacy of antibiotic prophylaxis 3 • 9 • 10 ; nevertheless the ideal duration of prophylactic treatment remains debatable 11 • For this reason we evaluated the bacteriological and clinical efficacy of prophylactic antibiotics consisting of a single preoperative dose of ceftriaxone compared to triple-dose gentamicin. Ceftriaxone was chosen because of its broad spectrum and long (8 hours) half-life. Rapid i. v. infusion was adopted in order to obtain the peak serum concentration and the best tissue penetration during the contamination period. Our results demonstrate that a single 2 g preoperative ceftriaxone injection can reduce the incidence of postoperative UTI in patients undergoing open urologic surgery: none of our 24 ceftriaxone-treated patients had any evidence of UTI, whereas one out of 28 gentami~ cin-treated patients experienced UTI and subsequently septicemia. Moreover the occurrence of postoperative fever was lower in ceftriaxone treated patients, even if one of them developed a respiratory tract infection during the postoperative course. However, antibiotic prophylaxis is unlikely to prevent later postoperative bacterial complications such as pneumonia. Regarding the potential for development of resistant organisms and superinfection, the prophylactic use of single-dose or short-term prophylaxis did not produce any tendency toward resistant organisms. In conclusion, results of the study show that short-term antibiotic regimens can improve UTI rates after open urologic surgery (overall incidence of UTI 1.9% - 1/52). In particular it must be stressed that the incidence of UTI after 20 transvesical prostatectomies was equal to 0, whereas the reported incidence of postoperative UTI infection in patients with sterile preoperative urine undergoing prostatic surgery and not receiving any antibiotic prophylaxis varies
between 30 and 50% according to various studies s •8 • 12 • Therefore antibiotic prophylaxis in urologic surgery has to be recommended. Regarding the duration of treatment, the use of a single dose of a broad spectrum, non-toxic antibiotic such as ceftriaxone, seems to be suggested.
REFERENCES 1 Madsen P, Larsen E, Dorflinger T . The role of antibacterial prophylaxis in urologic surgery. Urology 1985; 26 (Suppl. 1) : 38-42. ' Haverkorn MJ. Prophylactic trimethoprin for prostatectomy. Urology 1984; 24: 414-419. 'Childs SJ, Veils WG, Mirelman T . Antibiotic prophylaxis for genitourinary surgery in community hospitals. J Urol, 1983; 130: 305-308. 4 Marshall A. Prophylactic antimicrobial therapy in retropubic prostatectomy. Br J Urol 1960; 31: 431 -43 7. 'Morris MJ, Golovsky D , Guinness MDG, Mahler PO. The value of prophylactic antibiotics in transurethral prostatic resection: a controlled trial with observation of the origin of postoperative infections. Br J Urol 1976; 48 : 479-483. 'Robinson MRG, Arudpragasam SJ, Sahgal SM, Cross R, Akdas J, Pitta! B, Sibbald R. Bacteraemia resulting from prostatic surgery: the source of bacteria . Br J Urol 1982; 54: 542-547. 'Chodak GW, Plaut ME . Systemic antibiotics for pro· phylaxis in urologic surgery: a critical review. J Urol 1979; 121: 695-699. 'Botto H, Richard F, Mathieu F, Perreau AM, Carney M. Short-term prophylaxis with cefotaxime in prostatic surgery. J Antimicrob Chemother 1984 ; 14 (Suppl. B) 14: 231234. ' Prokocimer P, Quazza M, Gibert C, et al. Short-term prophylactic antibiotics in patients undergoing prostatectomy : report of a double-blind randomi zed tri al with 2 intravenous doses of cefotaxime. J Urol 1986; 135: 60-64 . 10 Nielsen OS, Maigaard S, Frimodt-Moller N, Madsen PO . Prophylactic antibiotics in transurethral prostatectomy . J Urol 1981 ; 126: 60-63. 11 Charron M, Vallancien B, VeilJon B, Brisset JM. Antibiotic prophylaxis of urinary tract infection after transurethral resection of the prostate: a randomized study. J Urol 1987; 138: 87-89. " Ramsey EW, Sheth NK Antibiotic prophylaxis in patients undergoing prostatectomy. Urology 1983; 21: 376-379. " Shah PJR, Gordon W, Chaudary M. Short-term antibiotic prophylaxis and prostatectomy. Br J Urol 1981; 53: 339-343 .
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