Introduction

Perioperative antibiotic administration remains an unstandardized practice in management of urethral stricture disease (USD).¹ Practice patterns vary among urologists in the pre-, intra-, and postoperative periods, especially as it relates to catheter use.² An understanding of antibiotic use patterns can improve postoperative wound healing as well as mitigate the incidence of multidrug resistant organisms (MDRO). Here we outline the available evidence on antimicrobial use in the perioperative and postoperative settings in management of USD, including at time of catheter removal.

Perioperative Management

A recent survey found that 8.8% of urologists do not routinely order a urine culture (UCx) prior to urethroplasty,² while some urologists order a urinalysis (UA) and based on the result proceed to UCx. The AUA guidelines recommend preoperative UCx prior to surgical management of USD and treatment of active UTIs as well as asymptomatic bacteriuria in patients planned for urethral surgery.³ Similarly, the European Association of Urology (EAU) recommends obtaining a UCx prior to surgery and treatment of asymptomatic bacteriuria,⁴ and further recommend omission of a UA and proceeding directly to UCx. Both EAU and AUA guidelines recommend treatment based on local antibiograms and resistance patterns.

Neither guideline mentions duration of treatment nor timing of obtaining or how to interpret a UCx in the preoperative setting. Over 41% of urologists use a threshold of 10,000 colony forming units (CFU)/mL, and 35% of urologists believe 7 days is an appropriate duration of treatment.² One randomized controlled trial established a protocol where > 100,000 CFU/mL in patients without catheters and > 50,000 CFU/mL in those with catheters were treated preoperatively regardless of patient symptomatology.⁵ Oral treatment was 3 to 5 days preoperatively and for MDRO patients with only intravenous options, treatment was 24 to 48 hours.

There is no available evidence to recommend rechecking a UCx in treated patients, and AUA guidelines recommend against obtaining UCx in asymptomatic patients.

Intraoperative Antibiotic Management

According to the AUA best practice policy statement on antibiotics, surgical prophylaxis should be a single perioperative dose and discontinued within 24 hours. The most likely pathogens in urethroplasty cases include gram-negative rods, enterococci, and Staphylococcus aureus. The AUA recommends a single dose of cephalosporins as first-line therapy, with cefoxitin, cefotetan, and ampicillin/sulbactam as second-line therapies.⁶ For patients with positive preoperative cultures, prophylaxis should be directed at the pathogen in question with specific attention to ensure the above-mentioned organisms are sufficiently covered by the antibiotic choice. As per surgical literature, regardless of choice of antibiotic, it should be administered < 60 minutes prior to incision.⁷ For patients with allergies to cephalosporins, fluoroquinolones present an acceptable alternative.⁵ There are no established data on choice of surgical site preparation for minimization of wound infection.

Postoperative Antibiotic Use

In comparing prolonged antibiotic use for urethroplasty patients to postprostatectomy patients without any routine prolonged antibiotic use, the UTI rates were similar, around 6.7%.⁵ This was backed by another study where all patients were given 30 days of postoperative antibiotics, or longer if catheter removal was beyond 30 days, found no difference in wound complications or stricture recurrence⁸ and therefore recommended no role for postoperative antibiotics.

The AUA recommends pericatheter removal antibiotics in selected patients with risk factors.³ The EAU states that they do not have sufficient evidence to support continued antibiotic use postoperatively and they do not recommend their use during the pericatheter removal period.⁴ Further, even for patients with positive preoperative treated urine cultures, there are no data to support longer antibiotic use in the postoperative period. These recommendations are based in part on studies which have consistently demonstrated a lack of described benefit in use of prolonged postoperative antibiotics after treatment of USD.^1,5,9

The strongest evidence to date was a prospective multicenter study of over 900 patients.¹ Patients in the prolonged antibiotic cohort took nitrofurantoin twice daily through catheter removal along with a separate dose of fluroquinolone or trimethoprim-sulfamethoxazole double strength at time of Foley removal. This was compared to patients who only received 2 doses of pericatheter removal fluroquinolone or trimethoprim-sulfamethoxazole double strength. The study found no difference in either postoperative UTI rates or wound complication rates. An additional single center study had a similar conclusion which supported the elimination of prolonged prophylactic antibiotic use while the urethral catheter is in place.⁹

Discussion and Conclusion

Historically, antibiotic use in urethral surgery was quite liberal both in the number of antibiotics given and their prolonged use. Recent publications have shown the harm and cost of extensive antibiotic overuse with the rising occurrence of MDROs, side effects, and cost for patients. Current USD studies that followed the AUA/EAU guidelines have shown standardized and protocol-driven practices both direct and limit antibiotic use in urethral reconstruction which we all should be following. The Table is included to provide an algorithm to follow in all phases of the operative management of USD.

Table. A Guideline-Based Algorithm for Antibiotics in Urethroplasty

Standardized, evidence-based practices, can improve postoperative wound healing, minimize preventable burdens on the health care system in both cost and utilization, and maximize antibiotic stewardship practices to reduce the risk of new MDROs.