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JU INSIGHT: AUA-recommended Antibiotic Prophylaxis for Primary Penile Implantation Results in a Higher, Not Lower, Risk for Postoperative Infection: A Multicenter Analysis

By: David W Barham, MD; Nikolaos Pyrgidis, MD, MSc; Martin S Gross, MD; Muhammed Hammad, MBBCh; Daniel Swerdloff, MD; Jake Miller, MD; Abdullah Alkhayal, MBBS; Khalid A Alrabeeah, MBBS; Robert Andrianne, MD, PhD; Arthur L Burnett, MD; Kelli Gross, MD; Georgios Hatzichirstodoulou, MD, PhD; James Hotaling, MD, MS; Tung-Chin Hsieh, MD; Adam Jones, BSC, MBBS, MD; James M Jones, BA; Aaron Lentz, MD; Jason Levy, DO; Vaibhav Modgil, BM, MSc; Daniar Osmonov, MD, PhD; Sung Hun Park, MD; Ian Pearce, BMedSci, BMBS; Paul Perito, MD; Hossein Sadeghi-Nejad, MD; Maxime Sempels, MD; Alfredo Suarez-Sarmiento Jr, MD; Jay Simhan, MD; Koenraad van Renterghem, MD, PhD; J. Nicholas Warner, MD; Matthew Ziegelmann, MD; Faysal A. Yafi, MD | Posted on: 16 Feb 2023

Barham DW, Pyrgidis N, Gross MS, et al. AUA-recommended antibiotic prophylaxis for primary penile implantation results in a higher, not lower, risk for postoperative infection: a multicenter analysis. J Urol. 2023;209(2):399-409.

Study Need and Importance

In 2008 the AUA published a Best Practice Statement on Urologic Surgery Antibiotic Prophylaxis that recommended an aminoglycoside and vancomycin or a first-/second-generation cephalosporin for penile prosthesis placement. This recommendation was based on orthopedic and general surgery literature due to a lack of high-level urological evidence. The combination of vancomycin and gentamicin has since become the most commonly used regimen for inflatable penile prosthesis (IPP) prophylaxis, as noted in a number of subsequent studies. Recent research has questioned the efficacy of these suggested regimens in high-risk patients. We sought to evaluate the efficacy of the most commonly used AUA-recommended regimen among all patients undergoing primary IPP placement.

What We Found

In a large multicenter study, we found vancomycin plus gentamicin was associated with an increased risk of implant infection in multivariable analysis (HR: 2.7, 95%CI: 1.4 to 5.4, P = .004; part A of Figure) compared to all other regimens. The addition of an antifungal to the antibacterial regimen decreased the risk of infection by 92%. In a subgroup analysis, there was no statistically significant difference between weight-based and low-dose (80 mg) gentamicin dosing (part B of Figure).

Figure. A, All patients undergoing primary inflatable penile prosthesis (IPP) placement. B, Patients receiving gentamicin as part of antibiotic prophylaxis. All asterisks indicate statistically significant findings.

Limitations

The main limitations of this study are its retrospective nature and inherent selection bias. A large portion of patients who received vancomycin plus gentamicin also received an antifungal, which may bias the hazards ratio. Additionally, we were not able to account for other infection reduction strategies.

Interpretation for Patient Care

Our findings provide a strong rationale for the addition of an antifungal to antibacterial coverage in all men undergoing IPP placement. Tailoring antimicrobial prophylaxis to local infection trends and antibiogram data may be the most effective and data driven option for IPP infection prevention.

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