Study Need and Importance

There are many available guidelines based on high-quality data recommending only single dose or <1 day lower-spectrum antibiotic as prophylaxis.^1-4 Antibiotic usage during endourological procedures is believed to be highly discrepant from the guideline recommendations. Potential risks of urinary tract infections (UTIs) and antibiotic resistance are key concerns leading to lack of standardization among practicing urologists. This national level multicenter cross-sectional prospective audit was done with support from Urological Society of India and its collaborative research committee to assess the prevailing practice patterns and evaluate the factors for variation in usage of antibiotics along with its impact on perioperative infections.

What We Found

In this nationwide audit conducted across 20 centers in India, data were prospectively entered on a customized online portal for 1,538 patients undergoing various endourological procedures over 4 months. The procedures included cystoscopy (n=109), transurethral resection of prostate (n=239), transurethral resection of bladder tumor (n=183), ureteroscopy (n=473), and percutaneous nephrolithotomy (n=529). Overall, postoperative UTI/sepsis as defined by use of additional antibiotic(s) within 1 month of surgery, occurred in 98 (6.4%) cases. There was no difference in any comorbidities or predisposing factors between those who developed postoperative UTI vs those who did not, except chronic kidney disease, which was significantly associated with development of UTI. It was found that urine culture within 1 week of surgery showed significant (13%), insignificant (1.8%), or mixed growth (3.2%), or was not done before surgery (19.3%) in 37.3% cases. Of the cases 17.8% were given preoperative antibiotics within 1 week prior to surgery, of which only 9% had significant bacterial counts. Postoperative UTI rates were significantly higher in patients who received preoperative antibiotics (18.2% vs 3.8%, P = .000; Figure 1), and the rates still remained significantly higher after excluding patients who grew strongly uropathogenic bacteria.⁵ This trend was identified to be significant independently among all procedure types individually as well.

Single-dose perioperative antibiotic was used in only 20.7% patients, while the remainder received multiday prophylaxis including >3 days in 10.9% (Figure 2). Two different antibiotics were used as prophylaxis in 51.2% cases. This second antibiotic was also continued for >1 day in 35.8% of cases. High-end antibiotics were being used for primary prophylaxis in >62% cases, including beta-lactamase inhibitors and carbapenems. UTI rates were significantly better when patients received a short course of antibiotics than >3 days of prophylaxis (P = .583 single vs >3 days). Postoperative prophylaxis at discharge was prescribed for 88.2%, with 77.4% of these cases receiving such prophylaxis for >3 days (Figure 3). Surgeons were asked the reasons for using antibiotics if they varied from guideline recommendation of single dose or <1 day prophylaxis. Surgeon or institution protocol was the sole reason for such use in 75.4% of instances, while presence of stent or nephrostomy was considered as the reason in 12.4%, with multiple other factors in the remaining patients.

In this study, we found that antibiotics were overused in every 3 out of 4 patients, regardless of any scientific evidence to support such usage. Moreover, a trend toward an increase in postoperative UTIs was noted rather than the contrary belief that such extended use would prevent UTIs. More definitive focused studies are needed to confirm this finding. Overall, there is a large gap between the recommendations and the actual practice patterns of antibiotic use, with more than 75% of such decisions based only on surgeon or institute’s protocol.

Limitations

Data regarding repeat urine culture prior to procedure in those treated with antibiotics were not available. Further, side effects and cost of antibiotic use were not evaluated. Direct relation of postoperative UTI with antibiotic prophylaxis could not be established due to multiple factors, and the rates of such UTIs leading to sepsis and intensive care unit admission remains unknown.

Interpretation for Patient Care

This audit highlights the disparity between the evidence and actual practice patterns for usage of antibiotics in endourological procedures. Such overuse not only adds to the cost, but also poses a threat in terms of antibiotic resistance and possibly increased UTIs. Standardization of antibiotic regimen to the extent possible is the need of the hour. However, till then, there is considerable scope for reducing the overuse of antibiotics in these procedures.