Antibiotic use: Managing Pre and Post-Op Infections in ...

Antibiotic use: Managing Pre and Post-Op

Infections in Patients Undergoing Endoscopic Surgery

Matthew D Dunn MDEndourology and Stone Disease

UCLA Department of Urology

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Disclosures• Boston Scientific--Fellowship grant

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UTI associated with stone disease• Often a presenting sign• 20-30% of patients with stones have positive urine cultures• Often in face of obstruction

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UTI associated with stone disease• Often a presenting sign• 20-30% of patients with stones have positive urine cultures• Often in face of obstruction

• Need to deal with infection prior to treating the stone• Antibiotic treatment according to sensitivities and patient

factors

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Postop infections• Even more of an issue and often seen after endoscopic

procedures even when using antibiotic prophylaxis.

• How common is it?

• What are the risk factors?

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Conclusions:• 14.1% post op febrile UTI• Pseudomonas most common• Most resistant to quinolones

Recommendations:• Keep OR time low

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Postoperative infection Rates with negative preop cultureCROES URS Global Study

9Martov et al, J. Endourolgy 2015

Postoperative infection Rates with negative preop cultureCROES URS Global Study

10Martov et al, J. Endourolgy 2015

After PCNL?• Bacteremia has been reported up to 37% of patients

• 74% of patients have postoperative fever after PCNL

• Fulminant sepsis occurs in only 0.2-1.3% of patients

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Who is at risk?

12Martiv, et al, J Endourology 2015

Who is at risk?

13Martiv, et al, J Endourology 2015

Who is at risk?

14Martiv, et al, J Endourology 2015

Systemic antimicrobial usage is the primary driver of antimicrobial resistance

15Urologic Procedures and Antimicrobial Prophylaxis (2019)

Important to know:• Fewer antibiotics are being developed

16AUA core curriculum Botros-Brey, Liss

Important to know:• Fewer antibiotics are being developed

• Antibiotic stewardship is the responsibility of all clinicians

17AUA core curriculum Botros-Brey, Liss

Urologic Procedures and Antimicrobial Prophylaxis (2019)Periprocedural antimicrobial prophylaxis for the reduction of surgical site infections may be considered for all urologic procedures where a break in normal tissue barriers will occur.

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Urologic Procedures and Antimicrobial Prophylaxis (2019)• Always consider:

• patient’s medical risks• allergies• inherent risks associated with antimicrobial prophylaxis

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Preop URS• Preop infections should be treated

• Sterile urine should be assured prior to surgery

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Preop PCNL • All patients undergoing PCNL should have a urine

culture obtained preoperatively

• positive urine cultures should be treated with ≥ 1 week of culture-specific antibiotics before surgery.

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Preop PCNL • Broad-spectrum antibiotics should be administered at

time of PCNL

• maintain low intra-renal pressure with the use of a working sheath placement

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AUA Best Practice Policy on Urologic Surgery Antimicrobial Prophylaxis

• Does not endorse the use of antibiotics beyond 24 hours in patients without prosthetic material (orthopedic or cardiac)

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AUA Best Practice Policy on Urologic Surgery Antimicrobial Prophylaxis

• Does not endorse the use of antibiotics beyond 24 hours in patients without prosthetic material (orthopedic or cardiac)

• positive stone cultures or struvite stones reflect bacteria that were likely not adequately treated. In these cases, a course of antibiotics postoperatively, perhaps including prolonged suppressive antibiotics in the case of infection stones, should be given.

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Urologic Procedures and Antimicrobial Prophylaxis (2019)• Single-dose antimicrobial prophylaxis is appropriate in

the majority of uncomplicated urologic cases.

25Urologic Procedures and Antimicrobial Prophylaxis (2019)

• Routine cystoscopy and urodynamic studies do NOT require antimicrobial prophylaxis in healthy adults in the absence of infectious signs and symptoms.

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Urologic Procedures and Antimicrobial Prophylaxis (2019)

Wound ClassificationsClean Non-traumatic, elective. No break in aseptic

techniqueClean-Contaminated

Elective opening of GU tract; minor break in aseptic technique

Contaminated Gross contamination at surgical site without active infection; Spillage of GI tract; major break in aseptic technique

Dirty Active Infection at surgical site (purulent exudate)

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Wound ClassificationsClean Non-traumatic, elective. No break in aseptic

techniqueClean-Contaminated

Elective opening of GU tract; minor break in aseptic technique

Contaminated Gross contamination at surgical site without active infection; Spillage of GI tract; major break in aseptic technique

Dirty Active Infection at surgical site (purulent exudate)

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Class II/clean-contaminated procedures• Single-dose periprocedural antimicrobial prophylaxis is

currently recommended

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Class III/ contaminated procedures• Single-dose antimicrobial prophylaxis recommended as

the risk of a serious surgical site infection or systemic infection is high

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Class IV wounds• Infected—need full treatment; not single dose

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Urologic Procedures and Antimicrobial Prophylaxis (2019)• Parenteral antimicrobial prophylaxis agents should be

administered within one hour of an incision to establish an appropriate bactericidal concentration of the agents in the tissues at the time the incision is made.

• If used, vancomycin and fluoroquinolones may be administered within two hours of the procedure.

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Urologic Procedures and Antimicrobial Prophylaxis (2019)• Fluoroquinolone resistance is increasing in incidence

• No longer recommended as 1st line for prophylaxis for:• Cystoscopy• Ureteroscopy• Percutaneous Nephrolithotomy• Urodynamics • Catheter removal with risk factors

• Preferred Choice: Bactrim (clinic procedures) or Cephalosporin

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Change in GuidelinesFrom 2012 to 2019

Urologic Procedures and Antimicrobial Prophylaxis (2019)• Antimicrobial prophylaxis should target the likely local

organisms. Test urine ahead of time

• Use antimicrobials that cover the most recent local antibiogram for genitourinary organisms.

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Urologic Procedures and Antimicrobial Prophylaxis (2019)

• Elective procedures should be deferred in the presence of symptoms consistent with an active infection until an antimicrobial course is complete and associated symptoms have improved.

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Urologic Procedures and Antimicrobial Prophylaxis (2019)• Antimicrobial prophylaxis solely for the prevention of

infectious endocarditis is not required for genitourinary procedures, even in the setting of a high-risk cardiac condition.

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Urologic Procedures and Antimicrobial Prophylaxis (2019)• Antimicrobial prophylaxis solely for the prevention of

infectious endocarditis is not required for genitourinary procedures, even in the setting of a high-risk cardiac condition.

• Antimicrobial prophylaxis for the prevention of prosthetic hip or knee prostheses is recommended, particularly for genitourinary procedures at high risk of bacteremia, within two years of prosthetic joint placement and for high-risk populations.

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Antimicrobial prophylaxis• Clinic/office procedures• When patient and procedural risk factors are present:

• voiding trials• removal of catheters or drains• stent or nephrostomy tube removal

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Antimicrobial prophylaxis• Shock wave lithotripsy does not require antimicrobial

prophylaxis

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What about fungal infections?• Antifungal treatment, rather than single-dose

prophylaxis, is recommended for patients with symptomatic fungal urinary tract infections at the time of exchange of any permanent drainage tube or stent once fungicidal levels are present.

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What about fungal infections?• Antifungal treatment, rather than single-dose

prophylaxis, is recommended for patients with symptomatic fungal urinary tract infections at the time of exchange of any permanent drainage tube or stent once fungicidal levels are present.

• Antifungal prophylaxis may not be necessary for those with asymptomatic funguria undergoing routine urinary catheter, nephrostomy or stent placement or exchange.

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What about fungal infections?• Single-dose antifungal prophylaxis is recommended for

patients with asymptomatic funguria undergoing endoscopic, robotic, or open surgery on the urinary tract.

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What about fungal infections?• A longer course of periprocedural antifungal treatment

is strongly recommended in neutropenic patients with funguria who have a urinary tract obstruction and are undergoing surgery on the genitourinary tract.

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Case Presentation

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31F with dysuria, left flank pain, nausea/vomiting, and chills, treated on 2 prior occasions for dysuria/urgency with 2 courses of ciprofloxacin, then Macrobid.

Clinical Course • Left ureteral stent placement due to infection and

hydronephrosis

• Discharged on 3 days ciprofloxacin.

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Clinical Course • Week later, came to ED for fever (102F), tachycardic to 140s,

WBC 27, hypotensive requiring pressors• CT scan revealed pancolitis• Started empirically for C.Diff (resulted positive 9/5/20)• Remained hypotensive on Levophed.

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Fulminant C Diff Colitis

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Conclusion• Ensure sterile urine prior to endourologic procedures

• Single dose prophylaxis appropriate for most procedures

• Office based: catheter/stent manipulation• Class II/III procedures

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Conclusion• Tailor antibiotic prophylaxis according to:

• Patient risk factors• most likely bacteria• procedure performed

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Conclusions• ESWL, UDS, cystoscopy—no need for antibiotic

prophylaxis if healthy

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Conclusions• ESWL, UDS, cystoscopy—no need for antibiotic

prophylaxis if healthy

• URS, PCNL--- check urine culture,pretreat UTIsingle dose prophylaxistreat longer if infection stone

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Conclusions• Understanding the most common bacteria to cause

UTIs and choosing antibiotics wisely will likely improve outcomes, reduce resistance, and preserve antibiotics needed for special situations and populations.

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Urologic Procedures and Antimicrobial Prophylaxis (2019)