GENERAL UROLOGY
REVIEW
An ibio ic p ophylaxis and i s app op ia e iming
o u ological su gical p ocedu es in pa ien s wi h
asymp oma ic bac e iu ia: A sys ema ic e iew
Jo ge A. Ramos
a,*
, Diego F. Salinas
b
, Johanna Oso io
c
, Albe o Ruano-Ra ina
d,e
a
Uni e sidad CES, Medellı´n, Colombia
b
Se ice o In ec ious Diseases, Hospi al Uni e si a io de Nei a, Colombia
c
School o Heal h Sciences, Fundacio
´n Uni e si a ia Na a a, Colombia
d
Depa men o P e en i e Medicine and Public Heal h, Uni e sidad de San iago de Compos ela, Spain
e
CIBER o Epidemiology and Public Heal h, CIBERESP, Mad id, Spain
Recei ed 20 Ma ch 2016, Recei ed in e ised o m 10 Ap il 2016, Accep ed 9 May 2016
A ailable online 10 June 2016
KEYWORDS
An ibio ic p ophylaxis;
Asymp oma ic bac e i-
u ia;
Su gical si e in ec ion;
U ological su ge y;
U ological su gical
p ocedu es
ABBREVIATIONS
AB, asymp oma ic
bac e iu ia
Abs ac Objec i e: To e iew he exis ing li e a u e on when and how o ea
pa ien s wi h asymp oma ic bac e iu ia (AB) who unde go u ological su ge y, as
unce ain y abou his issue pe sis s.
Me hods: A sys ema ic e iew was conduc ed o compa e he di e en iming o
adminis a ion o an ibio ic p ophylaxis in pa ien s wi h AB unde going u ological
su ge y. We used p edefined inclusion and exclusion c i e ia, and we also de eloped
a specific quali y scale o assess he quali y o he pape s included.
Resul s: Nine s udies me he inclusion c i e ia. O he nine s udies included, eigh
e alua ed an ibio ic p ophylaxis ega dless o he p esence o AB, as hei pu pose
was o e alua e he e ec i eness o an ibio ic p ophylaxis o u ological p ocedu es.
O hese, ou s udies showed a significan educ ion in he a e o in ec ions in he
in e en ion g oup compa ed wi h placebo, o wi h he same an ibio ic he apy bu
using di e en du a ions o he apy. Fou s udies ound no significan di e ences in
in ec ious complica ions be ween he in e en ion and compa ison a ms. Only one
s udy assessed he du a ion o an ibio ic p ophylaxis in pa ien s wi h AB.
*Co esponding au ho . Tel.: +57 301 6701077.
E-mail add ess: [email p o ec ed] (J.A. Ramos).
Pee e iew unde esponsibili y o A ab Associa ion o U ology.
P oduc ion and hos ing by Else ie
A ab Jou nal o U ology (2016) 14, 234–239
A ab Jou nal o U ology
(O ficial Jou nal o he A ab Associa ion o U ology)
www.sciencedi ec .com
h p://dx.doi.o g/10.1016/j.aju.2016.05.002
2090-598X Ó2016 A ab Associa ion o U ology. P oduc ion and hos ing by Else ie B.V.
This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
Conclusions: Wi h he a ailable e idence, an ibio ic he apy should be conside ed
only o p ocedu es in which s udies ha e shown a clinical benefi in he p e en ion
o in ec ion. I is impo an o es ablish he du a ion and ype o ea men o
an imic obial he apy o su gical p ophylaxis in pa ien s wi h AB who a e going
o ecei e u ological in asi e p ocedu es.
Ó2016 A ab Associa ion o U ology. P oduc ion and hos ing by Else ie B.V. This
is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.
o g/licenses/by-nc-nd/4.0/).
In oduc ion
Asymp oma ic bac e iu ia (AB) o u ina y ac coloni-
sa ion is defined as he isola ion o bac e ia in a u ine
sample collec ed p ope ly om a pe son who has no
signs o symp oms o a UTI [1]. This colonisa ion o
he u ina y ac is common in diabe ic women, wi h a
p e alence o 8–14% [2], in p egnan women (2–7%)
[3], in men aged >60 yea s (6–15%) [4], and in pa ien s
wi h spinal co d inju y, wi h a p e alence a e o >50%
[5].
The e is clinical e idence ha AB should be ea ed in
p egnan women because i dec eases he isk o
pyeloneph i is by be ween 4% and 20% [6], and educes
he isk o p ema u e bi h [7]. An ibio ic he apy should
be used o pa ien s wi h AB who a e going o unde go
u ological su ge y due o a 60% isk o p esen ing wi h
in ec ious complica ions such as bac e aemia and a 10%
isk o sepsis [1].
Fo his condi ion, some clinical ials ha e shown
ha an ibio ic p ophylaxis in pa ien s wi h AB dec eases
he isk o bac e aemia and sepsis in he pos ope a i e
pe iod [1]; bu he e is no consensus on he ea men
ype o when o s a an ibio ic he apy. S udies ha e
s a ed p ophylaxis om 1 o 7 days be o e he p oce-
du e [8], wi hou de e mining he di e ences in he
esul s o each in e en ion.
Fo his eason i is impo an es ablish he app op i-
a e he apy and he ideal s a ing ime o an ibio ic p o-
phylaxis o p e en su gical in ec ions in u ological
p ocedu es in pa ien s wi h AB, wi h he aim o educing
he po en ial mo bidi y o hese pa ien s and also o
educe cos s. To answe his ques ion we pe o med a
sys ema ic e iew o he scien ific li e a u e.
Me hods
S udy design
We sys ema ically e iewed he scien ific li e a u e ol-
lowing he Pa ien , In e en ion, Compa ison, and Ou -
come (PICO) scheme. The pa ien s we e indi iduals wi h
AB wi h u ological su ge y scheduled. The in e en ion
was an ibio ic p ophylaxis, single-dose an ibio ic he -
apy o s a ing 3–5 days be o e he su gical p ocedu e.
The main ou come was pos ope a i e in ec ion. The
main objec i e was o de e mine i he e we e di e ences
in he esul s depending on he di e en iming o
adminis a ion o an ibio ic p ophylaxis.
The sea ch was conduc ed in PubMed, he Li e a u a
La ino-Ame icana e do Ca ibe em Cieˆ ncias da Sau´ de
da abase (LILACS), EBSCO, and Coch ane da abases
using he Medical Subjec Heading (MeSH) e ms ‘an-
ibio ic p ophylaxis’ AND ‘u ologic su gical p ocedu es’
AND ‘asymp oma ic bac e iu ia’. The sea ch was lim-
i ed o humans and he e we e no es ic ions on lan-
guage o sample size. S udies published up o Augus
2015 we e included wi h no da e es ic ion.
Inclusion c i e ia
Randomised clinical ials and obse a ional s udies
(coho s udies, case-con ol s udies) ha compa ed
he s a and ea men egimens o an ibio ic p ophy-
laxis in pa ien s wi h AB scheduled o a u ological su -
gical p ocedu e we e included. An addi ional inclusion
c i e ion was ha pa ien s had o be ollowed o a min-
imum o 7 days.
Ti les and abs ac s o he e ie ed s udies we e
e iewed o de e mine i hey me he inclusion c i e ia.
The ull ex was consul ed o de e mine defini i e inclu-
sion o no i he e we e doub s.
The mos equen easons o ejec ing in es iga ions
we e: (i) pa ien s had had a p e ious ansplan a ion; (ii)
pa ien s wi h ac i e UTIs; (iii) he p ima y ou come was
no in ec ion o he su gical si e; (i ) he ollow-up was
<7 days a e su ge y, and ( ) in o ma ion was
incomple e.
The main ou come a iable was pos -su gical in ec-
ious complica ions and seconda y ou comes we e ead-
missions and hospi al s ay. To conside a su gical si e
in ec ion we used he defini ion o he Cen e o Disease
Con ol o he USA: in ec ion has o occu wi hin
30 days a e he su gical p ocedu e, and i a ec s he
skin, subcu aneous issue, muscle o he manipula ed
o gan du ing su ge y.
S udy quali y assessmen
Two expe s independen ly assessed he quali y o all
pape s included. The me hodological quali y and he
An ibio ic p ophylaxis in pa ien s wi h asymp oma ic bac e iu ia 235
ex e nal alidi y o he included s udies we e e alua ed
using a specifically de eloped scale whe e fi e i ems we e
e alua ed wi h a sco e ange be ween 0 and 10 poin s.
The i ems conside ed we e: ype o s udy, sample size,
ollow-up pe iod, compa able g oups a baseline, and
con ol co a ia es. Each i em was a ed be ween 0 and
2 poin s, and a s udy was conside ed as being o good
quali y i i had P7 poin s. S udies a ed a 5–6 poin s
we e conside ed as being o mode a e quali y and hose
o 64 poin s as low quali y. The scale used wi h i s i ems
is shown in Table 1.
Addi ionally, he quali y o he s udies was assessed
using he me hod ecommended by he Coch ane Col-
labo a ion o measu emen biases (domain-based
assessmen ) [9]. The possibili y o p esen ing selec ion
bias ( andomisa ion), de ec ion and con ol o bias
(masking), bias o losses, and epo ing biases was
sco ed as low, medium o high.
Resul s
The li e a u e sea ch e ie ed 14 in es iga ions, wi h
nine ulfilling he inclusion c i e ia. Fi e s udies analysed
an ibio ic p ophylaxis o ans ec al p os a e biopsy
[10–14], only one s udy e alua ed an ibio ic p ophylaxis
o u ological p ocedu es a a gene al le el [15], and he
emaining s udies analysed an ibio ic he apy o cys-
oscopy, ansu e h al p os a ic esec ion and u e h al
li ho ipsy [16]. The s udies we e published be ween
1998 and 2013, and we e ca ied ou in Chile, Colombia,
Taiwan, India, F ance, Tu key, and China. Mos o hem
we e w i en in English (77.8%). The cha ac e is ics o
he included s udies a e shown in Table 2.
O he nine s udies included, eigh e alua ed an ibi-
o ic p ophylaxis ega dless o he ime o ea men ini-
ia ion o he p esence o AB (Table 2); only one o hem
assessed he du a ion o an ibio ic p ophylaxis in
pa ien s wi h AB (Table 2).
Fou s udies showed a significan educ ion in he
a e o su gical in ec ion in he in e en ion g oup; o
hese, wo we e conduc ed in pa ien s scheduled o
ans ec al p os a e biopsy and hei compa ison g oup
ecei ed placebo [10,14]. They also had wo in e en ion
g oups each ha ing he same an ibio ics bu wi h di e -
en du a ions o ea men , wi hou significan di e -
ences be ween he in e en ion g oups.
The fi s s udy conduc ed in China, be ween 1998 and
2001, included 192 pa ien s. I concluded ha an o al
single dose o p ophylac ic an ibio ics (cip ofloxacin
500 mg and me onidazole 400 mg) is e ec i e and sa e
o p e en in ec ious complica ions in pa ien s unde go-
ing ans ec al p os a e biopsy [14]; he second, pe -
o med in India be ween 1996 and 1998 also concluded
ha an o al single dose (cip ofloxacin 500 mg and
inidazole 600 mg) was adequa e as p ophylaxis o
ans ec al p os a e biopsy [10]. Bo h s udies used pla-
cebo o compa ison and i s in e en ion g oups we e
di e en in an ibio ic and du a ion (Table 2).
Ano he s udy conduc ed in Chile, be ween 2001 and
2002, in pa ien s scheduled o ansu e h al esec ion
ound a lowe in ec ion a e in he in e en ion g oup
(ce azolin 1 g i. . e e y 8 h in 1 day and cip ofloxacin
e e y 12 h un il emo al o he bladde ca he e ) com-
pa ed wi h he compa ison g oup (ce azolin 1 g i. .
e e y 8 h by wo doses ollowed by ni o u an oin
100 mg o ally un il emo al o he u ina y ca he e );
howe e , he p esence o AB be o e he p ocedu e was
no de e mined [17]. The ou h s udy conduc ed in I aly
included 138 pa ien s and showed a lowe a e o in ec-
ion in he in e en ion g oup (pipe acillin azobac am
2250 mg i.m. e e y 12 h o 2 days) compa ed wi h he
compa ison g oup (cip ofloxacin 500 mg o ally e e
12 h o 7 days); howe e , again he p esence o AB
be o e he p ocedu e was no de e mined [11].
The emaining ou s udies ound no significan di -
e ences in educing in ec ious complica ions. One was
conduc ed in Colombia in 138 pa ien s wi h nega i e
u ine cul u es wi h an indica ion o cys oscopy, whe e
hey compa ed single-dose le ofloxacin 500 mg as a p o-
phylac ic an ibio ic wi h placebo and ound no di e -
ence in in ec ious complica ions [18]. Ano he s udy in
F ance wi h 288 men scheduled o ans ec al p os a e
biopsy, ound no di e ence be ween he du a ion o
an ibio ic he apy (single dose s 3 days) wi h cip oflox-
acin 500 mg o ally, wi hou checking o he p esence o
AB [12]. The hi d s udy, conduc ed in Taiwan be ween
2009 and 2012 in 206 pa ien s wi h nega i e u ine cul-
u es scheduled o u e e o enoscopic li ho ipsy ound
no di e ences in in ec ious complica ions in he h ee
Table 1 Quali y scale used o sco e he included s udies.
I em assessed Cha ac e is ic Weigh
S udy design O he designs 0
Coho s udy 1
Con olled clinical
ial
2
To al sample size, n6100 0
101–200 1
>200 2
Co- a iables adjus men
(numbe )
62
*
0
>2 2
Compa able g oups He e ogeneous 0
Homogeneous 2
Follow-up pe iod, days 7–9 0
10–20 1
>20 2
To al 10
*
Age and sex.
236 Ramos e al.
in e en ion g oups compa ed wi h he con ol g oup
ha ecei ed no an ibio ic [19]. Finally, a s udy con-
duc ed in Benin in 87 pa ien s unde going ans ec al
p os a e biopsy ound no significan di e ences
compa ing bo h g oups, wi h no moni o ing o he
p esence o AB [13].
Only he s udy by Sayin Ku lu e al. [15] conduc ed in
Tu key be ween 2005 and 2008 in 59 pa ien s scheduled
Table 2 Desc ip ion o he nine included s udies.
Re s. S udy
loca ion
Pa icipan s,
n
In e en ion Compa ison Main esul s Sco e
Ga cia-
Pe domo
e al. [18]
Colombia G oup I: 138
G oup C:
138
Le ofloxacin 500 mg single
dose
Placebo 500 mg single dose The incidence o UTI
was 0.7% G oup I) and
3% (G oup C)
P= 0.17
7
Valde eni o
Sepu´ l eda
[17]
Chile G oup I: 45
G oup C: 45
Ce azolin 1 g i. .
p eope a i ely and e e y 8 h
du ing he fi s day (3 doses).
Followed by cip ofloxacin
250 mg o ally e e y 12 h un il
emo al o he bladde
ca he e
Ce azolin 1 g i. .
p eope a i ely and 8 h la e (2
doses). Ni o u an oin
ollowed by 1000 mg o ally
daily un il emo al o he
bladde ca he e
Pos -su gical UTI
occu ed in 2% o
G oup I and 16% o
G oup C
P= 0.026
6
Co mio
e al. [11]
I aly G oup I: 72
G oup C: 66
Pipe acilin azobac am
2250 mg i.m. e e y 12 h o
2 days
Cip ofloxacin 500 mg o ally
e e y 12 h o 7 days
Pos -su gical UTI
occu ed in 0% in
G oup I and in 3.03% in
G oup C
P= 0.026
6
B iffaux
e al. [12]
F ance G oup I: 139
G oup C:
149
Cip ofloxacina 500 mg o ally
2 h be o e he p ocedu e
Cip ofloxacin o 3 days One pa ien in each
g oup p esen ed wi h
p os a i is
8
Hsieh e al.
[19]
Taiwan G oup I1: 53
G oup I2: 52
G oup I3: 50
G oup C: 51
1. Ce azolin 1 g 60 min be o e
he p ocedu e
2. Ce iazone 1 g 60 min
be o e he p ocedu e
3. Le ofloxacin 500 mg 2 h
be o e he p ocedu e
No an ibio ics The a e o in ec ion
a e he p ocedu e was
1.3% in G oup I and
5.9% in G oup C
P= 0.09
3
Agbugui
e al. [13]
Benin G oup I: 42
G oup C: 45
Cip ofloxacin 500 mg o ally
and me onidazole 400 mg
e e y 8 h o 1 day
Cip ofloxacin 500 mg o ally
and me onidazole 400 mg
e e y 8 h o 5 days
The a e o in ec ion
a e he p ocedu e was
19% in G oup I and
15.6% in G oup C
4
Yang e al.
[14]
China G oup I1: 64
G oup I2: 66
G oup C: 62
1. Cip ofloxacin 500 mg and
me onidazole 400 mg
2. Cip ofloxacin 500 mg and
me onidazole 400 mg o
3 days
Placebo (no an ibio ics) The incidence o
in ec ious complica ions
in he G oup C was
highe han in G oup I
P< 0.01)
The e we e no
significan diffe ences in
in ec ious complica ions
be ween he G oup I
g oups
P> 0.05
5
A on e al.
[10]
India G oup I1: 79
G oup I2: 77
G oup C: 75
1. Single dose o cip ofloxacin
500 mg and 600 mg
inidazole
2. Single dose o cip ofloxacin
500 mg and inidazole
600 mg e e y 12 h o
3 days
Placebo able wice a day o
3 days (no an ibio ics)
The incidence o
in ec ious complica ions
in G oup C was highe
(19%) han in he G oup
I g oups (6% and 8%)
P< 0.01
5
Sayin Ku lu
e al. [15]
Tu key G oup I: 31
G oup C: 28
Single dose o an app op ia e
an ibio ic, de e mined by
an imic obial sensi i i y
es ing, 30–60 min be o e
su ge y
An ibio ic ea men be o e
su ge y un il nega i e cul u e
None o he pa ien s
p esen ed in ec ious
complica ions
Diffe ences in leng h o
s ay and cos s o
an ibio ic he apy we e
ound
4
G oup I, in e en ion g oup; G oup C, compa ison g oup.
An ibio ic p ophylaxis in pa ien s wi h asymp oma ic bac e iu ia 237
o a u ological p ocedu e assessed he du a ion o
an ibio ic p ophylaxis in pa ien s wi h AB, indica ing
ha he e we e no significan di e ences be ween
single-dose he apy (30–60 min be o e he p ocedu e)
wi h an an ibio ic ea men las ing 3–15 days un il he
u ine was s e ile be o e su ge y. Tha s udy also ound
significan di e ences in he educ ion o hospi al s ay
and cos s o an imic obials in he single-dose g oup
(P< 0.001).
Quali y o he included s udies
The quali y o he included s udies was no high. Only
wo had >7 poin s in he ad hoc scale and ou had a
sco e o 5–6 poin s. The a e age sco e was 5.3 poin s.
Discussion
This is he fi s sys ema ic e iew o analyse he ype o
an ibio ic p ophylaxis and i s adequa e du a ion o
pa ien s wi h AB scheduled o in asi e u ological p o-
cedu es. The use o an ibio ic p ophylaxis o u ological
su gical p ocedu es has su ficien clinical e idence o
educing pos -su gical u ina y in ec ions and i is ecom-
mended in he 2015 Canadian U ological Associa ion
an ibio ic p ophylaxis guideline o u ological p oce-
du es [8].
F om he s udies e iewed, no one was ca ied ou in
pa ien s wi h AB, as he a iable was no con olled o
o because hey we e ca ied ou in pa ien s wi h nega-
i e u ine cul u es. The pu pose o he s udies e alua ed
was o iden i y he e ec i eness o an ibio ic p ophylaxis
o u ological p ocedu es, wi hou e alua ing he ade-
qua e scheduling o his he apy. A u he limi a ion
o he s udies was he small sample size, which made i
di ficul o ha e s a is ically significan esul s due o
he low in ec ion a e bo h in he in e en ion and in
he con ol/placebo g oups.
Schemes o an ibio ic p ophylaxis
The included s udies had mul iple schemes o an ibio ic
p ophylaxis, wi h a ia ions in he an ibio ics used,
dosage, and du a ion o ea men . Fo example, he
mos used an ibio ic was cip ofloxacin in he s udies o
Aa on e al. [10], Yang e al. [14], Agbugui e al. [13],
B i aux e al. [12], Valde eni o and Co mio [17], as sin-
gle o combined he apy. The s udy schemes we e all di -
e en and he mos u ilised du a ion o he apy was
1 day o single-doses, wi hou significan di e ences in
he in e en ion g oups. The di e ence obse ed in he
included s udies was a dec ease in he isk o pos -
su gical in ec ions in pa ien s unde going an ibio ic p o-
phylaxis compa ed wi h hose o he placebo g oup. The
abo e eflec s he guideline ecommenda ions, whe e
an ibio ic p ophylaxis o AB is ecommended, al hough
he e is no specific ecommenda ion on he du a ion o
he apy [1,5,8].
All s udies employed wide-spec um an ibio ics, wi h
cip ofloxacin and le ofloxacin he mos common, so
may gene a e mul i- esis an bac e ia by selec i e p es-
su e [20]. Rega ding he ollow-up o assess pos -
su gical in ec ious complica ions, he maximum leng h
was 5 weeks in he Chilean s udy [17] wi h an a e age
o 10 days a e he u ological in e en ion.
I is no ewo hy ha in wo s udies by Ga cia-
Pe domo e al. [18] and Hsieh e al. [19], he in e en ion
g oup was compa ed wi h he placebo g oup and hey
did no find significan di e ences, which sugges s ha
an ibio ic p ophylaxis does no educe he isk o in ec-
ious complica ions. Howe e , hese s udies had a low
s a is ical powe due o hei small sample size, which
makes i di ficul o iden i y significan di e ences.
Me hodological aspec s
The sample size o he included s udies was e y he e o-
geneous, om 59 pa ien s o >200. This sample size is
insu ficien o show an e ec o an ibio ic ea men
and he e o e canno ei he asce ain i i is mo e o less
e ec i e o specific subg oups (i.e. age, gende o di e -
en u ological p ocedu es).
One o he mos key p oblems o he s udies included
is ha mos o he s udies (89%) did no con ol o he
a iable o AB be o e he in e en ion, whils in o he s i
was done in pa ien s wi h nega i e u ine cul u es. Only
he s udy o Sayin Ku lu e al. [15] con olled o AB,
bu his s udy had a low sample size (31 pa ien s in he
in e en ion g oup and 28 in he compa ison g oup)
and did no con ol o con ounding a iables such as
pe manen esicle ca he e o immunosupp ession. In
addi ion, mos o he u ological p ocedu es we e inse -
ion o change o JJ ca he e s.
Limi a ions and ad an ages
The main limi a ion o he p esen e iew is ha i does
no p o ide e idence abou he esea ch ques ion ( he -
apy and s a ing ime o an ibio ic p ophylaxis o p e-
en in ec ion in u ological p ocedu es in pa ien s wi h
AB). Ano he limi a ion is he impossibili y o applying
me a-analy ic echniques due o he high he e ogenei y
o he included s udies (di e en sample sizes, di e en
g oups o compa ison, including placebo, di e en su -
gical indica ions, e c.) ha does no make hem compa-
able. Ano he impo an limi a ion is ha mos o he
s udies did no con ol o a iables such as AB, su gical
p ocedu es, and p ophylaxis du a ion. A las limi a ion
is ha only wo s udies had a quali y sco e o >7 poin s
in he ad hoc quali y scale.
The main ad an age o he s udy is he use o a sys-
ema ic e iew, as his me hodology analyses he a ail-
238 Ramos e al.
able e idence using a consis en and cohe en p ocedu e.
In his same way, he quali y scale de eloped o his
e iew helps o g ade he quali y o s udies included
using a homogeneous app oach.
The guide diagnosis and ea men o AB in adul s
ecommended clinical ials o de e mine he du a ion
o he apy o he ea men o AB in pa ien s scheduled
o u ological su ge y.
To conclude, i is impo an o es ablish he du a ion
and ype o ea men o an imic obial he apy o su -
gical p ophylaxis in pa ien s wi h AB ha a e going o
ecei e u ological in asi e p ocedu es. I we can show
ha a sho du a ion o an ibio ic he apy is equally
e ec i e and sa e his would dec ease hospi al s ay, he
delay in ime o su ge y, he cos s in p o iding se ices,
and mos impo an ly, he isk would be con olled
in ec ion selec ion o mul i- esis an bac e ia, which
could lead o gene a ing a heal h policy impac in his
g oup o pa ien s.
Con lic s o in e es
The au ho s decla e no o ha e any conflic s o in e es .
Sou ce o unding
None.
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