For example, while the risk of SSI with implantation of prosthetic materials and devices is intermediate, the consequences of an SSI in this setting are high. Ramos JA, Salinas DF, Osorio J, et al: Antibiotic prophylaxis and its appropriate timing for urological surgical procedures in patients with asymptomatic bacteriuria: a systematic review. The Joint Commission National Patient Safety Goals. 2012. https://www.rcpi.ie/news/publication/preventing-surgical-site-infections-key-recommendations-for-practice/. When indicated, a single oral dose given within an hour prior to the procedure, although dependent upon the agents oral pharmacokinetics, is sufficient and was the route chosen in nearly all reviewed studies. The least amount of antimicrobials needed to safely decrease the risk of infection to the patient should be used in order to minimize antimicrobial-related adverse effects and decrease the risk of drug-resistant organisms. There are a limited number of indications to treat asymptomatic candiduria. 24 AP in these higher-risk settings would be trimethoprim-sulfamethoxazole. Br J Surg 2017; 104: e134. However, AP in high-risk patient populations should be considered, as shown in a small study of renal transplant recipients. Nunez-Nunez M, Navarro MD, Palomo V, et al: The methodology of surveillance for antimicrobial resistance and healthcare-associated infections in Europe (SUSPIRE): a systematic review of publicly available information. Surgeon 2015;13:127. J Urol 2016; 195: 931. 112 Furthermore, there are risks of treating ASB. Colonization, as well as accompanying pyuria, is expected for those with long-term indwelling urinary catheters, or those who have had diversions or augmentative procedures involving bowel segments. Additionally, there has been a steady increase in resistance rates of Escherichia coli to fluoroquinolones. Mazur DJ, Fuchs DJ, Abicht TO, et al: Update on antibiotic prophylaxis for genitourinary procedures in patients with artificial joint replacement and artificial heart valves. J Endourol 2016; 30: 63. WebSCIP Antibiotics Selection Table *VANCOMYCIN DOCUMENTATION CRITERIA Use of Vancomycin for surgical prophylaxis requires MD, NP or PA documentation of one or more Antibiotic prophylaxis in surgery. You are Here: Stanford Medicine School of Medicine Departments Anesthesia Ether Anesthesia Resources Get Help COVID-19 AIRWAY COVERAGE Home DASHBOARD ETHER DASHBOARD PAGING Munday GS, Deveaux P, Roberts H, et al: Impact of implementation of the surgical care improvement project and future strategies for improving quality in surgery. For example, if the patient had recently taken a course of a cephalosporin, prophylaxis with a sulfonamide would be more appropriate than another cephalosporin. Clipboard, Search History, and several other advanced features are temporarily unavailable. While a complex topic, this BPS is intended to be a comprehensive and user-friendly reference for the clinicians and providers caring for patients undergoing urologic procedures. Two hours should be allowed in the case of vancomycin and fluoroquinolone use. Unfortunately, surgeons have been shown to often be inaccurate in the determination of a specific surgical wounds classification 91 despite the establishment of definitions almost 20 years ago. High-level evidence assessing SSI risks in the presence of a drain versus no drain with single dose AP is sorely needed. J Urol 2008; 179: 1379. Lawson KA, Rudzinski JK, Vicas I, et al: Assessment of antibiotic prophylaxis prescribing patterns for TURP: a need for Canadian guidelines? Ann Thorac Surg 2017; 104: 1349. Picchio M, De Angelis F, Zazza S, et al: Drain after elective laparoscopic cholecystectomy. Hernia 2017; 21: 833. J Med Microbiol 2017; 66: 927. It is unclear whether nail picks and brushes have an impact on the number of colony forming units remaining on the skin. Lytvyn L, Mertz D, Sadeghirad B, et al. In non-urologic cases where entry into the GU system has not occurred, there is no benefit accrued to the treatment of ASB. Springel EH, Wang X-Y, Sarfoh VM, et al: A randomized open-label controlled trial of chlorhexidine-alcohol vs povidone-iodine for cesarean antisepsis: the CAPICA trial. Wu X, Kubilay NZ, Ren J, et al: Antimicrobial-coated sutures to decrease surgical site infections: a systematic review and meta-analysis. Daum RS, Miller LG, Immergluck L, et al: A placebo-controlled trial of antibiotics for smaller skin abscesses. Global Guidelines for the Prevention of Surgical Site Infection. Carmichael JC, Keller DS, Baldini G, et al: Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. The more invasive the procedure, the more contaminated the operating field, the longer the procedure, the greater the risk of a post-procedural infection. Medical Microbiology 4th edition. 18. J Antimicrob Agents 2000; 15: 207. WebThe Antibiotic SCIP measures Click on Graphic to download file (318 KB) The images below are clickable. Additional anaerobic coverage provided by metronidazole and an antifungal such as fluconazole may also be considered for vaginal cases, particularly for high-risk patients. Hair removal has been traditionally performed to better visualize the operative area and potentially decrease infection. These risks include American Society of Anesthesiologists physical status classification greater than or equal to 2, and length of procedure >3 hours. As examples, patients undergoing urologic procedures often have associated host-related factors that increase the risk of an SSI and bacteremia; a recent TURP study found that ASB occurred during the case in 23% of patients. Uehara T, Takahashi S, Ichihara K, et al: Surgical site infection of scrotal and inguinal lesions after urologic surgery. Putnam LR, Chang CM, Rogers NB, et al: Adherence to surgical antibiotic prophylaxis remains a challenge despite multifaceted interventions. AP is only effective when the tissue concentrations of the appropriate antimicrobial are maintained above the minimal inhibitory concentration of the possible pathogens throughout the procedure. If the culture demonstrates infection, the patient should be prescribed appropriate antibiotic therapy; 62 however, stone cultures are often discordant with urine cultures. Eur Urol 2017; 72: 865. Product Information: BACTRIM(TM) otodst, sulfamethoxazole trimethoprim oral tablets oral double strength tablets. J Urol 2017; 198: 297. Shi D, Yao Y, and Yu W: Comparison of preoperative hair removal methods for the reduction of surgical site infections: a meta-analysis. Urol Pract 2017; 4: 383. Hence, for patients undergoing colorectal surgical procedures, coverage for both aerobic and anaerobic organisms is required; a first-generation cephalosporin and anaerobic coverage with metronidazole (which remains active against B. fragilis). Discussion will provide agreement across the surgical team as to the final wound class as well as a restatement and/or amplification of the AP required. Increased inspired FiO2 to optimize local tissue oxygenation, and adequate volume replacement are also important adjuncts to SSI risk reduction. Class II/clean-contaminated urologic procedures are not categorized by SSI risk but by broad wound class definitions. Kauffman CA, Vazquez JA, Sobel JD, et al: Prospective multicenter surveillance study of funguria in hospitalized patients. Henriksen NA, Deerenberg EB, Venclauskas L, et al: Triclosan-coated sutures and surgical site infection in abdominal surgery: the TRISTAN review, meta-analysis and trial sequential analysis. J Infect Chemother 2014; 20:186. 49 While no surgical study has evaluated the resultant MDR patterns emerging from single-dose AP compared with no antimicrobials, the use of prolonged antibiotic prophylaxis (>48 hours post-incision) has been significantly associated with an increased risk of acquiring antibiotic-resistance, while conferring no decrease in SSI. Surgical Infection Society 2020 Updated Guidelines on the Management of Complicated Skin and Soft Tissue Infections. Based on the AUA Guideline on the Surgical Management of Stones, 62,63 AP should be administered prior to stone intervention for ureteroscopic stone removal, PCNL, open and laparoscopic/robotic stone surgery, using a single dose. The indications for periprocedural AP coverage for asymptomatic colonization are dependent upon host-associated risks (Table I) and the procedural-associated risk probability of an SSI (Table II). AR Scientific, Inc. (per FDA), Philadelphia, PA, 2013. Ampicillin-sulbactam may also be used as second-line, which improves enterococcal coverage. Accordingly, this BPS included patient risk factors (who); diagnostic and treatment-associated urologic procedures, GU surgery, and prosthetics (what and where); as well as AP timing, re-dosing, and duration (when) in the search criteria. 1 RCT evidence suggests uncertain trade-offs between the benefits and harms regarding the optimal timing of the preoperative shower or bath, the total number of soap or antiseptic agent applications, or the use of chlorhexidine gluconate washcloths for the prevention of SSI. Emerg Med J 2014; 7: 576. Class II wound classification requires further investigation into improved subclassifications by case-specific periprocedural risks; this would be inclusive not only of SSI and bacteremic events but of other periprocedural risks, such as hemorrhage with resumption of anticoagulants and antiplatelet therapy. In the absence of neutropenia or other high-risk patient characteristics, nephrostomy exchanges and ureteral stenting procedures alone do not require antifungal prophylaxis for asymptomatic funguria. The duration of treatment in the neutropenic individual or the patient with mycetoma cannot be specified given the lack of data to support the course duration. When applicable, the side of surgery is identified. Unfortunately, as the urologic procedure-associated risks of an SSI do not align with these traditional wound classifications (Table IV), these classifications should not be used to determine the need for AP. For this reason, nitrofurantoin is a poor agent for AP due to low tissue concentrations, although it is highly concentrated in the urine. Gross MS, Phillips EA, Carrasquillo RJ, et al: Multicenter investigation of the micro-organisms involved in penile prosthesis infection: an analysis of the efficacy of the AUA and EAU guidelines for penile prosthesis prophylaxis. Mangram AJ, Horan TC, Pearson ML, et al: Guideline for prevention of surgical site infection, 1999. Leukocyte esterase has poor positive predictive value due to chronic pyuria frequently seen in poorly emptying bladders or those on clean intermittent catheterization. Accessibility Correct prophylactic antibiotic selection based on the procedure type (see Antibiotics Table for specific requirements) ABX 3. 16 Further, there are differences between the classifications of surgical complications with the Clavien-Dindo classification scoring a complication differently than the Centers for Disease Control and Prevention (CDC) recommendations. Surgeon 2018; 16: 176. Document categories: Publications Download files: J Am Coll Surg 2017; 224: 59. For cutaneous incisions where a prosthetic device is planned, coverage for skin flora including streptococci is warranted. To cite this best practice statement:Lightner DJ, Wymer K, Sanchez J et al: Best practice statement on urologic procedures and antimicrobial prophylaxis. This site needs JavaScript to work properly. As nephrotoxicity is common in patients receiving amphotericin beyond a single dose of prophylaxis, creatinine, potassium, and magnesium need to be closely monitored for those requiring repeated dosing. We recommend use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis. While the need for AP for urologic Class II procedures is based on the specific procedure, the AP agent choice requires knowledge of the prior urine culture results, the local antibiogram, and the patients associated risks. Sands K, Vineyard G, and Platt R: Surgical site infections occurring after hospital discharge. Scottish Intercollegiate Guidelines Network (SIGN). In lower-risk Class II/clean-contaminated procedures such as office cystoscopy, AP does not provide a risk/benefit ratio supporting routine AP use. WebABX 1. Reduction of SSI may occur if drains are brought through a separate stab wound. As such, further research is required incorporating community and hospital antimicrobial resistance patterns. Takemoto RC, Lonner B, Andres T, et al: Appropriateness of twenty-four-hour antibiotic prophylaxis after spinal surgery in which a drain is utilized: a prospective randomized study. Alternatives include first- or second-generation cephalosporins, amoxicillin/clavulanate, or an aminoglycoside ampicillin. 42,43. 55 Recent modifications to the NNIS risk index include a history of preoperative chemotherapy (OR=1.94), or groin incisions (OR=4.65). 50 Hence, in the absence of high-quality research to suggest a benefit to continued AP beyond wound closure and literature to suggest specific harms, this BPS recommends that AP be limited to the duration of the procedure itself with no subsequent dosing after wound closure. Am J Infect Control 1991; 19: 19. PMC 40,41 The concerns regarding limiting AP doses beyond wound closure is not unique to urologic practice. Furthermore, there is moderate-quality evidence from multiple RCTs that do not show a benefit of prolonging AP beyond the case completion, 41 and, according to a World Health Organization (WHO) systematic review, the benefit of intraoperative coverage is undetermined at this time. Anderson DJ, Podgorny K, Berrios-Torres SI, et al: Strategies to prevent surgical site infections in acute care hospitals: 2014 update. FOIA No recommendation has been provided by guidelines for these unresolved issues. Where institutional gram-negative enteric resistance patterns to first- and second-generation cephalosporins is high, the use of a single dose of ceftriaxone, (a third-generation cephalosporin) plus metronidazole may be preferred over routine use of carbapenems (e.g., imipenem, ertapenem), which are more specifically reserved for targeting MDR organisms. Consequently, their use as first-line treatment of uncomplicated cystitis is discouraged; use of such agents should be reserved for serious bacterial infections where the benefits outweigh the risks. Chapter 95. Arch Esp Urol 2012; 65: 542. 33 Those urologic cases that might forgo AP include all Class I procedures and many Class II procedures (see Table II). An SSI associated with a vaginal hysterectomy is often polymicrobial; without antimicrobial coverage, SSI incidence ranges widely from 14% to 57%. Marschall J, Carpenter CR, Fowler S, et al: Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis. Cameron AP, Campeau L, Brucker BM, et al: Best practice policy statement on urodynamic antibiotic prophylaxis in the non-index patient. Due to the low level of clinical evidence for many of these statements, more studies are needed to assess patient-associated risk for lowrisk procedures. 76,77. AP agent choice is based on prior urine culture results and/or the local antibiogram. Kwaan MR, Weight CJ, Carda SJ, et al: Abdominal closure protocol in colorectal, gynecologic oncology, and urology procedures: a randomized quality improvement trial. Bratzler DW: The surgical infection prevention and surgical care improvement projects: promises and pitfalls. Urol Oncol 2016; 34: 532.e13. The current evidence strength regarding successful strategies to reduce periprocedural C. difficile infections is weak. Eur Urol 2016; 69: 276. Kitagawa K, Shigemura K, Yamamichi F, et al: International comparison of causative bacteria and antimicrobial susceptibilities of urinary tract infections between Kobe, Japan and Surabaya, Indonesia. However, single-dose treatment of ASB is recommended in pregnant females since they are a high-risk population. Testing for true allergy is appropriate with this class of antimicrobials considering it is likely to be required for current and future care. Br Med Bull 2018; 125: 25. We recommend a maximum of four days of antibiotic agents, and perhaps a shorter duration in patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis. Chen SC, Tong ZS, Lee OC, et al: Clinician response to candida organisms in the urine of patients attending hospital. Gupta A, Osmon DR, Hanssen AD, et al: Genitourinary procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study. 136 No recommendations in numerous SSI guidelines addressed stapled versus sutured closures, nor routine wound irrigation. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). The .gov means its official. We laud the institutions and researchers now producing such comparative trials, which are rapidly appearing and changing the perceived need for and duration of AP. The documentation of SSI associated with outpatient and short-stay procedures is inadequate as illustrated by an older study that reported that 84% of SSI occurred after discharge and, therefore, were underreported. Singer AJ and Thode HC Jr.: Systemic antibiotics after incision and drainage of simple abscesses: a meta-analysis. The WHO publication recently performed a systematic review on whether screening for infection with potentially harmful organisms or surgical AP should be modified in areas with high (>10%) extended-spectrum -lactamase producing Enterobacteriaceae prevalence. Multiple questions remain unanswered, admittedly because of the low incidence of measurable events: registries would allow for risk calculation of orthopedic joint infection subsequent to GU procedures, and would appropriately assess blood cultures correlated with concurrent periprosthetic joint cultures, perhaps using advanced microbiologic techniques 158 to enhance source localization. Singh A, Bartsch SM, Muder RR, et al: An economic model: value of antimicrobial-coated sutures to society, hospitals, and third-party payers in preventing abdominal surgical site infections. Health UDo. 17 Lastly, it is unlikely that high volume data on SSI and the impact of AP will be available in the near term for most urologic procedures; SSI are currently reported for inpatient hospital procedures, and most urology cases are increasingly performed as 23-hour stays or less. What Urologists Need to Know about Telehealth, Urologic Procedures and Antimicrobial Prophylaxis (2019), Volunteer Opportunities for Residents and Young Urologists, Residents and Fellows Committee Activities, Residents and Fellows Committee Essay Contest, Frequently Asked Questions about the Residents Forum, The AUA Residents and Fellows Committee Teaching Award, Young Urologists of the Year Award Winners, Young Urologists Podcasts & Webcast Series, Practice Guideline for Urologic Ultrasound, Urologic Ultrasound Practice Accreditation, Training Guidelines for Urologic Ultrasound, Request a Hands-on Urologic Ultrasound Course, Transgender and Gender Diverse Patient Care, Accredited Listing of U.S. Urology Residency Programs, Additional Fellowships for Internationals, Continuing Medical Education & Accreditation, AUA Continuing Education (CE) Mission Statement, Section Meeting Request for Course of Choice, Confidentiality Statement for Online Education, Sexual Activity and Cardiovascular Disease, Engage with Quality Improvement and Patient Safety (E-QIPS), Clinical Consensus Statement and Quality Improvement Issue Brief (CCS & QIIB), Improving Advanced Prostate Cancer Patient Management and Care Coordination, Activities for the AUA Leadership Program, Urology Scientific Mentoring and Research Training (USMART), Brandeis Universitys Executive MBA for Physicians, Resources for Coding and Reimbursement Process, Holtgrewe Legislative Fellowship Program Application, 2023-2024 AUA Science & Quality Fellow Program Application, 2020-2021 AUA Science & Quality Fellow Program Application, Quality Payment Program Improvement Activities, Boston Scientific Medical Student Innovation Fellowship, Physician Scientist Residency Training Awards, Table I: Hostrelated factors affecting SSI risk, Table II: Proposed Procedureassociated Risk Probabilty of SSI, Table III: Recommended Definitions for a Surgical Site Infection (SSI), Hospital Acquired Infection (HAI), and Periprocedural Urinary Tract Infections (UTI), Table V: Recommended antimicrobial prophylaxis for urologic procedures, Table VI: End of Case Assesment of Wound Class, American College of Cardiology/ American Heart Association, Catheter-associated urinary tract infection, Generation, as in first generation cephalosporin, Methicillin-resistant Staphylococcus aureus, National Nosocomial Infectious Surveillance, Scored Patient-Generated Subjective Global Assessment. It must be emphasized that for oral administration, the achievement of adequate tissue levels of the selected antimicrobial may not occur within the one-hour time frame given for parenteral administration. The first step is to create as clean an environment as possible. Evaluation thereafter may also include a simple dipstick, laboratory performed microscopy, and/or formal culture, with assessed risks requiring higher levels of antimicrobial specificity and sensitivity. For example, a cystoscopic examination, defined as a Class II procedure, has an extremely low risk of SSI compared with transurethral resection of the prostate (TURP), another Class II procedure. Cochrane Database of Syst Rev 2016; 4: cd011621. If large bowel spillage occurs at the time of a reconstruction, then anaerobic antibiotic coverage is now indicated. Richards D, Toop L, Chambers S, et al: Response to antibiotics of women with symptoms of urinary tract infection but negative dipstick urine test results: double blind randomised controlled trial. Am J Infect Control 2016; 44: 283. 61. Within urologic practice, transrectal prostate biopsy may still require consideration of fluoroquinolone AP in some centers and in some clinical conditions.
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