Antibiotic Prophylaxis for Urological Surgery and Procedures

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Timing of Antibiotic Administration

  • Single dose, IV prophylaxis up to 60 minutes prior to skin incision/ intervention.
  • Single dose, oral ciprofloxacin 1 hour prior to procedure.

See table below for choice of antibiotic

For gentamicin

  • See appendix 1 for prophylactic dosing
  • Doses of up to 400mg gentamicin can be given by slow IV injection over 3 – 5 minutes
  • If subsequent treatment using gentamicin is required, measure gentamicin concentration 6-14 hours post theatre gentamicin dose, and follow GGC guidance on staffnet for gentamicin dosing. Calculate the gentamicin dose using the online calculator. Discuss with pharmacy if further advice is required ( or if out of hours, the on call pharmacist)
  • Teicoplanin and gentamicin are incompatible when mixed directly and must not be mixed before injection.

Teicoplanin

  • If patients weight is less than or equal to 40 kg give teicoplanin 400mg.
  • Give 400 - 800 mg teicoplanin by slow intravenous injection over 3-5 minutes.
  • Teicoplanin and gentamicin are incompatible when mixed directly and must not be mixed before injection.

If >1.5L blood loss

  • replace fluid
  • repeat antibiotic (full dose): amoxicillin, cefuroxime, co-amoxiclav, flucloxacillin, metronidazole,
  • for oral ciprofloxacin give single dose IV gentamicin
  • gentamicin at half dose
  • give half the original teicoplanin dose if ≥ 1.5L blood loss within the first hour of operation. If this blood loss occurs after the first hour of operation no further dosing of teicoplanin required.

If surgery continues for >4hrs from first antibiotic dose

  • repeat at full prophylactic dose: amoxicillin, cefuroxime, co-amoxiclav, flucloxacillin.

If surgery continues for >8hrs from first antibiotic dose

  • repeat at full prophylactic dose: amoxicillin, cefuroxime, co-amoxiclav, flucloxacillin, and metronidazole.
  • for oral ciprofloxacin give single dose IV gentamicin
  • If eGFR > 60 ml/min repeat gentamicin at full treatment dose. If eGFR ≦ 60 ml/min no repeat dosing of gentamicin.
  • No repeat dosing of teicoplanin is required if surgery prolonged.

If MRSA positive:

decolonise prior to procedure as per NHS GGC infection control guidelines and discuss with microbiology re antibiotic choice.

CPE carriers:

If identified as Carbapenamase producing Enterobacterales carriers contact microbiology.

^Ciprofloxacin

see BNF warning re the restrictions and precautions for use, due to very rare reports of disabling and potentially long-lasting or irreversible side effects of quinolones. If high C. difficile risk (e.g. previous C. difficile infection, Age >65 AND ≥ 1 of: frailty, severe underlying disease, prolonged hospital stay, extensive prior antibiotic exposure) avoid ciprofloxacin and discuss alternative with microbiology.

Table: Procedure; Recommended antibiotic / comments

ALWAYS review previous microbiology results- Ensure that prophylaxis covers recent urinary tract isolates etc. 
If patient colonised or infected with resistant pathogens please contact on-call Microbiologist for further guidance.

Procedure Recommended antibiotic/comment
Endo-Urological procedure:
Endoscopic ureteric stone fragmentation/ removal
Ureteric Stent insertion/change
TURP
IV Gentamicin*#
OR
^Ciprofloxacin 750mg orally 1 hr prior to procedure
TURBT
Cystoscopy,
Urodynamic examination
Cystoscopic Stent removal
Urethral Catheter Change
Not routinely recommended
For TURBT if patient is considered high risk (based on burden of tumour, i.e. size, necrosis) consider IV Gentamicin*#
Percutaneous procedure:
Percutaneous nephrolithotomy (PCNL)
Extracorporeal shock wave lithotripsy (ESWL)
Removal of
IV Gentamicin*#
OR
^Ciprofloxacin 750 mg orally 1 hr prior to procedure
Open, laparoscopic & robotic assisted operations):
Open operation or laparoscopic surgery involving opening the urinary tract with bowel segments:
Prostatectomy
Cystectomy
IV Amoxicillin 1 g
+
IV Metronidazole 500 mg
+
IV Gentamicin*#
If true penicillin/ beta-lactam allergy
Replace IV Amoxicillin with
IV Teicoplanin~ 800 mg
Clean, open operation or
laparoscopic surgery:
Nephrectomy/Partial Neprectomy
Retroperitoneal lymph node dissection
Nephroureterectomy
Pyleoplasty
IV Cefuroxime 1.5 g
If true penicillin/ beta-lactam allergy or MRSA risk:
IV Teicoplanin 800 mg
Other procedures:
Urethroplasty (with or without free flap, buccal mucosal graft)
IV Co-amoxiclav 1.2 g
+
IV Gentamicin*#
If true penicillin/ beta-lactam allergy or high MRSA risk replace IV Co-amoxiclav with
IV Teicoplanin 800 mg +
IV Metronidazole 500 mg
Other procedures:
Implantation of prosthetic device
Penile amputation/glans resurfacing with or without lymph node dissection
IV Flucloxacillin 2 g
+
IV Gentamicin*#
If true penicillin/ beta-lactam allergy or high MRSA risk Replace IV Flucloxacillin with
IV Teicoplanin 800 mg
Transrectal prostate biopsy IV Gentamicin*#
OR
^Ciprofloxacin 750 mg orally 1 hr prior to procedure

Last reviewed: 30 November 2019

Next review: 30 November 2022

Author(s): Ysobel Gourlay

Version: 4

Author Email(s): [email protected]

Approved By: Antimicrobial Utilisation Committee