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Prevention Of UTIs in
Endourological Surgery:
Regulation, Guideline,
Evidence, and Practice
In Taiwan
Stephen SD Yang, M.D., PhD.
Associate Professor of Department of Urology,
Tzu Chi Uninersity, Hualien, Taiwan
Chief of Department of Surgery
Tzu Chi General Hospital, Taipei Branch,Taipei, Taiwan
楊緒棣 副教授，外科部 主任
慈濟綜合醫院台北分院
2007/06/09
Welcome to Buddhist Tzu Chi General Hospital,
Xindian, Taipei,Taiwan:
The First Buddhist chain
hospital in the world
Fight for
Antibiotic
Abuse!
• In 1990s,
• 30% of URI cases used
antibiotics
• 6 days for SSI prophylaxis
1990 Active Surveillance
1995 NHI: strict regulations
TQIP 1999 Surveillance for SSI
Another field
is animal use
of antibiotics
2002 TMAC Medical students
2002 Public education
School Education
(junior high school)
2000 Control Yuan Involvement
2001 National
Surveillance Program
2003 Hospital Evaluation
In 2004
17% of URI cases used antibiotics.
3 days for SSI prophylaxis
Less use of 2nd line antibiotics
張上淳 感控
雜誌
200616:205
-18
Use and Abuse of Surgical Antibiotic
Prophylaxis in Hospitals in Taiwan
• Sep 1998 –March 1999, 629 patients in 14
hospitals.
• 499 (79%) for surgical prophylaxis (not
including GU) . 89% clean wound.
• Mean no. of antibiotics: 2 kinds.
• 1st Cepha 449 (90%) and Aminoglycosides
233 (50%)
• Mean duration of use: 6 days.
• More than 70 % use longer than 3 days.
• Mc Donald LC, et al: J Formos Med Assoc
2001;100:5-13.
Bacterial Infection:
War Between Host and Bacteria
Host
Defense
decrease
Impaired
Immune
system, or
anatomical
factors
Bacterial
Virulence
increase
Urological Abuse of
Intervention Antibiotics
Materials and Methods
• Regulations: the publications of the National Health
Insurance Bureau, Taiwan.
The Payer of medical fee. The Boss!!
• Guidelines: (1) Taiwanese Association of Infectious
Disease. (2) EAU UTI guideline 2006. (3) CampbellWalsh Urology 9th edition, 2007.
The academic consensus?
• Evidences: Published reports from Taiwan and around
the world. Retrospective or prospective data from
TCH, Taipei, Taiwan
• Practice: Email survey to 69 (17.3%) of 400
Urologists in Taiwan.
• The prescribers. The possible benefits/risks takers.
Practice of Urologists in Taiwan
Workplace distribution
N＝69
Age distribution
Clinic
3%
61-65 y/o
4%
56-60 y/o
1%
Area hosipital
12%
M edical center
49%
regional hosipital
36%
Years of practice
>65 y/o
0%
≦35 y/o
16%
51-55 y/o
16%
46-50 y/o
22%
36-40 y/o
25%
41-45 y/o
16%
Grades of academic position
25 years
3%
Associate Professor
13%
21-25 years
12%
≦5 years
25%
16-20 years
17%
11-15 years
17%
Professor
7%
6-10 years
26%
Nil
49%
Assistant Professor
7%
Lecturer
29%
Regulations (I) of Perioperative Antibiotics in
Surgery: Taiwan Health Insurance Bureau
• 4. Price of the agents should be
considered.
• 5. First line antibiotics should be used
first. (table)
• 6. The following conditions may use
second line antibiotics: (3) Confirmed by
infection men, (4) Apparent surgical
infections.
• Chap. 10. Antimicrobial agents. Pp 58-65. Regulations of the
payment for pharmaceutical agents. Central Health Insurance
Bureau. 2006/07. (WWW.nhi.gov.tw)
Regulations (II) of Perioperative Antibiotics
in Surgery: Taiwan Health Insurance Bureau
• 7. Conditions to use second line
antibiotics: (1) Culture proved that
second line antibiotics is required in
cases of using 1st line antibiotics
longer than 72 hours. (2) 7 days later
after using first line antibiotics for 72
hours and still not effective after
changing to another first line
antibiotics.
Regulations (III) of Perioperative Antibiotics
in Surgery: Taiwan Health Insurance Bureau
• 8. Prophylatic antibiotics for surgery.
• (1) Clean wound: -A) clean wound such as
herniorraphy, thyroidectomy: no antibiotics, or
at most one dose before op.
• (2) Clean contaminated wound: GU, GI, Chest,
Gyn, etc. First line medicine for 24 hours.
Specify indication of using antibiotics longer
than 48 hours or second line ABx.
List of First Line Antibiotics
Allowed in Taiwan
• Oral: amoxicillin, Cefalexin, Clindamycin,
doxycyclin, minocycline, nalidixic acid,
nitrofurantoin, trimethoprime/ sulf
methoxazole, etc.
• Parental: Cefazoline, cephalothin,
gentamicin, penicillin, etc.
• Table 1. p75. List of first line antibiotics. Central
Health Insurance Bureau. 2006/07. (WWW.nhi.gov.tw)
• BREAKING THE RULES, GETTING
NO PAY AND PENALTY!!!
Guidelines for the use of prophylatic antibiotics in
urological surgery in Taiwan (only 3 procedures)
Site/proc
edure
Likely
Recommend
pathoge ed
ns
antibiotics
Alternative
Durati
on
TRUSPBx
Enteric
GNB
Cefazoline
1gm IV at IA
GM 2mg/kg IV on call to
OR
or Ciproxacin 500mg
oral or 400mg IV on call
to OR
1
dose
TU-P-Bx
Enteric
GNB
Cefazoline
1gm IV at IA
GM 2mg/kg IV on call to
OR
or Ciproxacin 500mg
oral or 400mg IV on call
to OR
1
dose
TUR-BT
Enteric
GNB
Cefazoline
1gm IV at IA
GM 2mg/kg IV on call to
OR
1
dose
Microbiol Immunol Infect 2004;37:71-4
Prophylaxis for Cystoscopy
Regulations: 0-1 dose 1st line antibotics?
Guideline for Prophylaxis for Cystoscopy
• EAU 2006: no prophylaxis. (2nd gen
Cephalosporines or TMP +/- SMX for
patients at risk of UTI).
• Campbell-Walsh 2007: No absolute
indication for antimicromial prophylaxis
for cystoscopy, but indicated in patients
at risk of UTI.
Prophylaxis for UTI after single
catheterization or cystoscopy
• The risk of infection after one time
catheterization in healthy woman: 1-2%.
• Of patients with sterile urine, 2.2% -7.8%
reported culture-proven UTIs. While Rane, et
al, (2001) reported a high rate of 21% after
cystoscopy.
• Single dose prophylaxis reduced infections
to 1% to 5%. No significant systemic infection.
– Campbell –Walsh Urology, 2007, 9th ed.
UTI after Urodynamics and/or
cystoscopy
• After UDS, 19 (20%) of 97 pt with negative
culture developed a positive culture afterward.
No significant risk factor was detected Okorocha I,
et al: BJU International 2002;89:863-7
• Two doses nitrofurantoin (n=74) vs. placebo
(n=68) for women undergoing combined
urodynamics and cystourethroscopy: No
difference in rate of post exam UTI . Cundiff GW, et al:
Obstet Gynecol 1999;93(5 pt 1):749-52.
• One dose 400mg Norfloxacin: no significant
effect in cases received flexible cystoscopy.
Wilson L, et al: J Endourol 2005;19:1006-8.
Temporary Data for Single dose
Cephalexin prophylaxis for Cystoscopy
• Up to Apr. 30, 2007
• Placebo: 9 (M7, F2), one female with
carruncle had post exam UTI.
• Cephalexin : 7 (6M, 1F). Nil had UTI.
• Temporary conclusion: no prophylaxis is
required in case with no risk factor, e.g.
Bladder outlet obstruction.
Conclusions on prophylactic
antibiotics for cystoscopy
• UTI after UDS or cystoscopic examinations
varied from 2% to 21%.
• Symptoms of UTI after cystoscopy were
usually not severe, and spontaneous
resolution of UTI occurred.
• Pre-instrumentation prophylactic antibiotics
may be not necessary.
• Postmenopausal women and all men
undergoing cystoscopy may need prophylaxis.
Prophylaxis for Shock Wave Lithotripsy (SWL)
Regulations : 0-1 dose 1st line antibotics?
• EAU guideline: no prophylaxis for SWL
• Campbell-Wash: prophylaxis! (In patients
with stone and sterile urine, infection rate
after SWL reduced from 5.7% to 2.1%, Pearle
1997)
• A history of a recent UTI or of infectious
stones should warrant a full treatment
course of antimicrobial agents before SWL.
Prophylaxis for SWL:
a meta-analysis
• 8RCT, 885 patients.
• The incidence of UTIs after SWL
without prophylaxis: 0%-28%., with a
median of 5.7%.
• Prophylactic antibiotics in cases with
sterile urine decrease UTIs: 0-7.7%,
with a median of 2.1%. (Pearle MS and Roehrborn
CG, Urology 1997; 49:679-86)
SWL
100%
(A) No pyuria、APN or UTI
N＝69
Antibiotic use
91%
pr e-op Rat e
Post -op Rat e
90%
80%
65%
70%
60%
50%
40%
30%
16%
16%
20%
7%
0%
0%
10%
0%
1%
1% 0%
N o ant i bi ot i c
use
1 t h l i ne
cephal 1 . 0 gm
1 t h l i ne am i no
Com bi ne w i t h
cephal +
am i no
O t her s :
pr e-op Rat e
91%
7%
0%
1%
0%
Post -op Rat e
65%
16%
0%
1%
16%
20%
20%
Antibiotic dose
18%
16%
14%
12%
10%
8%
7%
7%
6%
3%
4%
1%
2%
1%
3%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
3 days
5 days
7 days
1 4 days
m i ssi ng
answ er
0%
0%
0%
0%
0%
0%
3%
20%
0%
0%
0%
7%
1 dose
1 day
2 days
pr e-op Rat e
7%
1%
Post -op Rat e
1%
3%
Discussion: Prophylactic Antibiotics in SWL
without UTIs
• 91% did not use preop ABx. 65% did not use
post op. ABx.
• 23% use post op. ABx for >1 days.!
•  But preoperative oral antibiotics is more
important and postop antibiotics may be not
necessary in cases without postop fever!
• Stone size and location may have an impact
on post SWL infection rate. Further study is
required.
• Our impression: stone less than 10mm may
not need prophylaxis.
• Recent pain attack and no fever  no
prophylaxis?
Prophylaxis for Ureteroscopoic lithotripsy (USL)
Regulations: Clean contaminated wound. First
line medicine for 24 hours.
• EAU 2006: uncomplicated distal ureteral
stone  no prophylaxis.
Proximal or impacted stone, or PCNL
 all patients need prophlaxis with 2nd or 3rd
cepha or TMP +/- SMX or Aminopenicillin/BLI
or fluoroquinolones. Short course (1-3days) is
recommended.
• Campbell-Walsh 2007: recommended
prophylaxis.
Prophylaxis for USL
• Incidence of UTI after USL is 1.3% in a large
series. (Sosa RE, 159-68.)
• Knopf et al, 2003: RCT to prove that
prophylactic fluoroquinolone administration
significantly reduced postop UTIs in a healthy
population (n=113) with ureteral stone and
uninfected preop urine (12.5%  1.8%). (F-Q
not allowed in Tw)
• Taylor AL, et al, 2002: 63 URS in 56 cases,
including URSL in 54 sides. Perioperative use
of antibiotics: 3 (7%) UTIs (pyrexia, PN,
pyonephrosis).  recommend perioperative
antibiotics. (BJU International 89:181-5)
Antimicrobial prophylaxis for URSL in
TCH, Taipei: A Retrospective Study
• Between Sep. 2006 and Apr. 2007, 168 patients
underwent URSL. Of them 127 had single ureteral
stone.
• Preoperative no signs of UTI in 62 patients
(Prophylaxis Group), 57 patients had signs of UTI
(Therapeutic groups), and 8 patients did not check
urinalysis.
• Preop urine culture: 0/2 positive in the prophylaxis
group ; 7/10 (70%) positive in the therapeutic group (2
E coli, 2 P mirabilis, 2 mixed growth, 1 Group B
streptoccous
• Cefazoline 1.0 gm IV at induction was used
preoperatively in all. 10% add GM.
• DJ was inserted as the clinician’s decision.
Stone Size and Postoperative Infection
Size N
(mm)
Post Pyuria
Back to ER
+
-
?
Pain
UTI*
Others
7 (44%)
9
9
0
0
1
5-10 44
11 (52%)
10
23
3
<5
17 (50%) 17
24
Total 127 35 (49%) 36
56
>10
25
58
1
(2.3%)
2
3
(5.2%)
5
4
(3.9%) (3.1%)
1
0
2
(1.6%)
Stone fragmentation rate: 99.2%. ER rate: 8.6%
* Febrile UTI
Antimicrobial prophylaxis for USL
in TCH, Taipei: Stone Size
Groups
Prophylactic
Therapeutic
Antibiotics
N
Mean stone size
(mm)
Stone location
Up
Mid
Low
Post Op ABx (-)
32
6.7 ± 4.4
14
8
10
Post Op ABx (+)
26
6.2 ± 5.3
9
2
13
Subtotal
58
6.5 ± 4.7
23
10
23
Post Op ABx (-)
7
11.2 ± 5.1
2
4
1
Post Op ABx (+)
39
7.4 ± 5.5
16
9
14
subtotal
46
8.0 ± 5.4
18
13
15
Total
104
7.2 ± 5.0
41
23
38
* Patients without preoperative antibiotics were excluded.
Antimicrobial prophylaxis for URSL
in TCH, Taipei: Prophylactic Group
N
Post op Pyuria
Back to ER
Positive
Negative
NA
UTI
Pain *
Post
Op ABx
(+)
26
6 (37.5%)
10
10
1
3
Post
Op ABx
(-)
32
7 (64%)
4
21
1
1
DJ (+) 46
11 (85%)
2
26 2 (4%)
DJ (-)
2 (40%)
3
5
10
DJ + in 22/26 of post anti +
in 24/32 of post anti -
0
3
(6.5%)
1
Post op use of antibiotics tended to
reduce pyuria rate (p=0.18), but
not febrile UTI rate.
Antimicrobial prophylaxis for URSL
in TCH, Taipei: Therapeutic Group
N
Post op Pyuria
Back to ER
Positive
Negative
NA
UTI
Pain *
1
(2.6%)
0
1
1
(2.6%)
0
1
Post Op
ABx (+)
39
13 (54%)
11
15
Post Op
ABx (-)
7
0
5
2
13 (52%)
12
14
0
4
3
DJ (+) 39
DJ (-)
7
DJ + in x/39 of post anti +
in y/7 of post anti -
0
0
Post op use of antibiotics did not reduce
pyuria rate, nor febrile UTI rate.
Postoperative Use of Antibiotics
Did not Reduce Pyuria
post op
Pyuria*
Antibiotic
s
Yes
19/40
(47.5%)
Febrile
UTI
Pain
2/65
(3.1%)
4/65
(6.2%)
Nil
1/39
(2.6%)
1/39
(2.6%)
7/16
(43.8%)
* P=0.80
DJ insertion: a strong impact on
postoperative outcome
DJ
Positive
Pyuria*
Febrile
UTI
Pain
24/38
(63%)
3/85
(3.5%)
4/85
(4.7%)
0
1/17
(5.9%)
DJ
2/9
negative (22%)
* P=0.026 <0.05
Discussion : Antimicrobial prophylaxis
for URSL in TCH, Taipei
• Preoperative pyuria usually meant bacteriuria.
(70% + predictive rate).
• Totally, febrile UTI occurred in 4/127 (3.1%) and
All the 4 patients with UTI had DJ inserted.
• Stone size does not matter!!
• Postop antibiotics were used more frequently
in patients with preop pyuria, while it was
resulted in no gain.
• DJ insertion had a strong impact on postop.
Pyuria (63%), and febrile UTI (3.5%).
USL
(A) No pyuria、nor APN
No post
fever
Antibiotic use
59%
60%
51%
pr e-op Rat e
Post -op Rat e
50%
40%
30%
26%
23%
20%
3%
10%
10%
10%
13%
0%
1%
0%
N o ant i bi ot i c
use
1 t h l i ne
cephal 1 . 0 gm
1 t h l i ne am i no
Com bi ne w i t h
cephal +
am i no
pr e-op Rat e
26%
59%
3%
10%
1%
Post -op Rat e
23%
51%
0%
10%
13%
O t her s :
70%
64%
Antibiotic dose
60%
50%
40%
29%
30%
20%
26%
23%
23%
16%
6%
10%
6%
0%
1%
0%
0%
0%
0
1%
4%
0
0%
0%
1 dose
1 day
2 days
3 days
5 days
7 days
1 4 days
mi ssi ng
answ er
no
request
pre-op Rat e
64%
6%
0%
0%
0%
0
0
4%
26%
Post -op Rat e
16%
29%
1%
23%
0%
1%
0%
6%
23%
Discussion: Practice of Prophylactic
Antibiotics in USL without signs of UTI
• 26% did not use pre-op antibiotics. (Not
complying to the rules!)
• 23% did not use post op antibiotics.
Follow our results.
• 10% use two kinds of antibiotics. (Break
the rule!)
• 23% use postop. antibiotics for 3 days.
(Break the rule!)
USL
(B) With pyuia, no fever, no APN
58
%
60%
52 %
pr e-o p Rat e
Po st -o p Rat e
50%
33
40%
%
Antibiotic
30%
20%
23 %
6%
13 %
10 %
10%
0%
3%
0%
0%
N o ant i bi ot i c
use
1 t h l i ne
cephal 1 . 0 gm
1 t h l i ne
am i no
Com bi ne w i t h
cephal +
am i no
6%
58%
0%
33%
3%
10%
52%
0%
23%
13%
pr e-op Rat e
Post -op Rat e
60%
N=42
55
O t her s :
%
50%
Antibiotic dose
40%
33 %
30%
23
25 %
%
20%
6%
10%
12 %
9%
7%
3% 3%
6%
3%
0%
0%
0%0 %
0%
pre-op Rat e
Post -op Rat e
10 %
6%
1 dose
1 day
2 days
3 days
5 days
7 days
1 4 days
mi ssi ng
answ er
no
request
55%
23%
3%
7%
0%
0%
0%
6%
6%
6%
33%
3%
25%
3%
9%
0%
12%
10%
Discussion: Practice of Prophylactic Antibiotics
in USL in patients with pyuria, without fever
• Almost all (94%) use pre-op antibiotics.
• 23% did not use post op antibiotics.
Follow our results.
• 33% use two kinds of antibiotics.
(Adequate?)
• 40% use postop. antibiotics ≧ 3 days.
(Break the rule!)
• Afraid of infection without evidence?
Discussion: Practice of Prophylactic
Antibiotics in USL in Patients Without fever
• USL is frequently associated with pyuria
(around 50%), febrile UTI (3.1%) and possible
ureteral stricture.
• Recommend prophylaxis for all patients.
• Optimal dose: 1 dose for cases with single
ureteral stone without postoperative fever.
• Preoperatvie pyuria did not need additional
antibiotics.
Prophylaxis for PCNL
Regulations : short course, 1-3 days?
• EAU guideline:2nd or 3rd cepha or TMP
+/- SMX or Aminopenicillin/BLI or
fluoroquinolones. Short course (<72
hrs.)
• Campbell 2007: Ampicillin + GM or
Fluoroquinolones. Single dose to 1 day.
Antibiotic prophylaxis in PCNL:
prospective study
• 81 patients with preop sterile urine.
• 43 cases with single dose (ofloxacin 200mg iv) vs. 38
cases with standard tx (ofloxacin 400mg iv per day)
till catheter removal.
• 19 (23%)patients had positive stone culture.
• Post fever: 9/43 (21%) and 8/38 (21%).
• The febrile patients had longer operations with the
use of more irrigation fluid and longer postoperative
hospital stays.
• Short-term prophylaxis has no advantage over singledose prophylaxis.
• Dogan HS, et al. J Enodourol 2002;16:649-53.
PCNL (A) No pyuria、APN or UTI
49
%
48 %
N＝69
41 %
50%
pr e-op Rat e
Post -op Rat e
45%
40%
32
35%
Antibiotic use
%
30%
25%
13
20%
%
7%
15%
1%
10%
5%
0%
1%
1%
N o ant i bi ot i c
use
1 t h l i ne
cephal 1 . 0
gm
1 t h l i ne
am i no
Com bi ne w i t h
cephal +
am i no
O t her s :
13%
49%
1%
32%
1%
7%
48%
1%
41%
3%
pr e-op Rat e
Post -op Rat e
70%
62
%
3%
antibiotic dose
60%
50%
36%
40%
30%
30%
19
20%
%
13%
13
6%
10%
0%
0%
3%
0%
1%
6%
0%
0%
0%
0%
pr e-op Rat e
Post -op Rat e
1 dose
1 day
62%
19%
0%
30%
%
7%
3%
3 days
5 days
7 days
1 4 days
m i ssi ng
answ er
no
r equest
0%
3%
0%
0%
0%
3%
13%
13%
36%
1%
6%
0%
6%
7%
2 days
Discussion on Prophylactic Antibiotics in
PCNL without signs of preoperative infection
• 81% use pre-op antibiotics, and of them 41%
use combination therapy.
• 79% use short course (1-3 days) post op
antibiotics.
• Few cases of staghorn stone had sterile
urine.
• Renal function impairment is common in
these cases.
• More studies are needed to confirm the
adequacy of single dose prophylaxis.
Prophylaxis for TURP
Regulations : short course, 1-3 days?.
• EAU guideline: all patients.
• Campbell: all patients till catheter
removal.
• Taiwan guideline for TUR BT: cefazoline
1.0 gm IV at induction.
Antimicrobial Prophylaxis for TURP
• A meta analysis of 32 RCT showed that
a risk reduction in bacteriuria from 26%
to 9%. Septicemia from 4.4% to 0.9%.
• FluoroQ, aminoglycosides, TMP/SMX ,
Cephalosporines. Used for a short
course (2-5 days), or while catheter
remained in place.
• Failure to eradicate bacteriuria resulted
in bactereuria in 50% of patients (Morris
1976).
TURP
N＝69
Antibiotic use
59%
60%
pr e-op Rat e
Post -op Rat e
49%
50%
40%
26%
30%
16%
17%
20%
10%
9%
10%
4%
0% 0%
0%
N o ant i b i o t i c
use
1 t h l i ne
cephal 1 . 0
gm
1 t h l i ne
am i no
Co m b i ne w i t h
cephal +
am i no
O t her s :
pr e-o p Rat e
16%
59%
0%
17%
4%
Po st -o p Rat e
10%
49%
0%
26%
9%
70%
68 %
Antibiotic dose
60%
50%
40%
29 %
25 %
30%
20%
14 %
9%
10%
3%
6%
0%
1%
0%
1% 0%
Post -op Rat e
14 %
9%
6%
4%
0%
0%
pre-op Rat e
10 %
1 dose
1 day
2 days
3 days
5 days
7 days
1 4 days
mi ssi ng
answ er
no
request
68%
6%
0%
1%
0%
0%
0%
10%
14%
3%
29%
14%
25%
1%
4%
9%
6%
9%
Discussion on Prophylactic
Antibiotics in TURP
• 16% did not use AMP: no complying to
guidelines.
• 17%-26% use combination therapy:
abuse?
• 14% use antibiotics longer than 3 days:
break the rule?
Infection:
War Between Host and Bacteria
Host
Defense
Proper
AMP
Proper
Disinfection
decrease
Impaired
Immune
system, or
anatomaica
factors
Urological
Intervention
Dirty instrument
Bacterial
Virulence
increase
Abuse of
Antibiotics
The Host:
SSI in the Elderly Population
• Kaye KS, et al: CID 2004;39:1835-41. A review.
• THE RISK OF SSI DOES NOT SEEM TO INCREASE
AFTER THE AGE OF 65 YEARS.
• More co-morbidity in the elder patients.
• Independent risk factors of SSI: obesity, COPD,
contaminated or dirty wound.
• Protective factor: private insurance. (MONEY
MATTERS)
• Sharing the same clinical presentation of infection
and the pathogens that cause infection.
• However, the mortality rate, the duration of
hospitalization, and the costs associated with hospital
care are greater for elderly patients with SSI than for
younger patients with SSI.
Obese Patients Run Higher Risk of
Postoperative Complications
• Bamgbade OA, et al: World J Surg 2007 (3)
• Analyze 6773 patients. 2217 were obese,
including 993 morbid obesity.
• Heart attack rate 0.5% vs. 0.1%.
• Wound infection 6% vs. 3.5%.
• Peripheral nerve injury 0.4% vs. 0.15.
• UTI 3.9% vs. 2.6%.
• Death rate: 2.2% vs. 1.2%.
• Suggestions: Morbid obesity patient have
outpatient surgery should undergo a 23-hour
hospital stay for post-op monitoring.
‘Complicated' UTIs: They are not
standard patients!
• Foreign bodies in the urinary tract, such as indwelling
urinary catheters and stents;
• Increased postvoiding residual urine >=100 mL
• urinary tract stones
• congenital developmental or anatomic anomalies;
• obstructive uropathy (eg, as a result of stones, fibrosis, or
bladder outlet obstruction);
• vesicoureteric reflux, or structural urologic abnormalities,
including surgically created structural changes, such as
ileal loops;
• neurogenic bladder disorder (with residual urine and/or
overactive detrusor)
• uremia from renal causes; and
• renal transplantation.
Proper Disinfection
General measures recommended for
prevention of surgical infections
• Bathing patients preoperatively with an
antimicrobial soap has been suggested as a
preventive strategy. Proper vaginal
disinfection.
• Preoperative removal of hair from the
operative site by clipping rather than by
shaving, reduces the overall incidence of SSI
and should minimize the risk of S. aureus
infection.
• Adequate Scrubbing of surgeons’ and all
assistants’ hands before the procedure.
Inappropriate Disinfection of Endoscope
• Painful experiences in TCH, Taipei,
Taiwan.
• Cluster infection in patients after
prostate biopsy in 2005.
• Cluster infections in patients after USL
in 2006.
• All were pseudomonas infection.
• Reluctant to report! A war between
Urologists and OR nurses? A
punishment form superior?
Local Bacterial Resistance!!!
Susceptibility of Isolates in TCH, Taipei
Ampic Amox Cefaz
illin
+clavu oline
Genta
micin
Ciprox Levofl Ceftria Vanco
in
oxacin xone
mycin
E- Coli 25
44
75
73
70
75
87
-
Paerugi
nosa
-
-
83
76
73
-
-
Kpneu
monia
e
0
78
82
81
86
86
88
-
S
aureu
s
-
-
-
55
59
66
-
100
-
-
-
-
-
-
100
E
96
faecali
s
Proper AMP
Timing of Antibiotics
• Parental agents: 30-60 minutes IV at
induction of anesthesia.
• Oral agents: 2 hours before operation.
• Additional dose in prolonged operation.
E.g. >3-4 hours.
Monotherapy Versus
Combination Therapy
• Most UTIs can be treated with monotherapy.
• Some complicated infections, especially CAUTI,
may have a polymicrobial etiology, in which case
multiple antibiotics may be needed. Combination
therapy is often used (eg, ampicillin is often
combined with gentamicin), but there is little
evidence that such combination therapy is more
effective than monotherapy in most cases.
• Note: Taiwanese doctors tend to combine
cefalosporines with aminoglycosides.
Oral Versus Intravenous
Administration
• Most uncomplicated UTIs, and many
complicated infections can be treated
adequately with oral therapy. (Equally
effective?!!)
• Generally, intravenous therapy would be
indicated in seriously ill patients with
complicated UTIs; and patients with
pyelonephritis at risk.
Surgery and Cephalosporines:
A Marriage Made In Heaven Or Time For Divorce
• Morgan M. Internet J Surg. 2006; 8(1)
• Cephalosporines are ineffective against the
common pathogens causing SSI and are
associated with superinfection.
• In UK, 47% of microorganism identified as
causing SSIs were staphylococci, of which
82% were Staph aureus. 62% Staph aureus
were MRSA.
• Enterococcal infections (predominantly UTI
and enodcarditis) are on the increase, and
this may well be due to overuse of the
cephalosporines.
Proactive Monitoring to Decrease SSI
• Dellinger EP, et al. Am J Surg 2005;190:9-15.
• 56 hosptials and 42 quality-improvement
organizations form 50 states or territories in the USA
agreed to participate.
• Administration of the prophylactic antibiotic prior to
incision increased from 72% to 92%.
• Antibiotic prophylaxis was discontinued within 24 h
increased from 67% to 85%.
• The overall SSI decreased from 2.28% in the first 3
months of the study to 1.65% in the last 3 months.
• Examine our results and Change our
practice.
• May we all have reduced SSI in
enodurological surgeries!
Gaps Between Practice and
Regulations/Guidelines (I)
• Controversy exists between different
guidelines.
• The guidelines were conducted by experts and
based on published results that may be the
best clinical results, and that may be not true
for average doctors.
• Regulations were made for financial causes
rather than scientific evidence.
• Regulations/Guidelines may be out of date.
• Urologists were not involved in
making up the Guidelines.
Gaps Between Practice and
Regulations/Guidelines (II)
• Details or variations of each procedure
were not discussed yet!
• Invasiveness of the procedure was less
discussed in the guidelines.
• Serious infection did occur! (Strong and
permanent memory to use more
antibiotics).
Gaps Between Practice and
Regulations/Guidelines (III)
• High Drug resistance in local community.
• Surgeons Do not trust the disinfection
procedures. Too many points to miss!
• Surgeons’ heavy duty to kill any pathogens
entering the patients. Safety for the patients?
• Afraid of law suing? Safety for the doctors:
overuse of antibiotics to prevent minor
infections.
Fill the Gap
and
Become A
HUMANE
DOCTOR
志為人醫
Welcome to Taipei, Taiwan
11th WPCCID and 5th AAUS!
November 29 ~ December 03, 2008
歡
迎
蒞
臨
台
北
E-mail:
wpccid2008@
elitepco.com.
tw
Deadline for
Abstract
Submission:
June 30, 2008
Sat. Nov.29
Sun. Nov.30
07:00-08:30
Mon. Dec.1
Tue. Dec.2
Meet the Experts
Meet the Experts
Wed. Dec.3
08:30-09:15
Keynote 2
Keynote 3
Keynote 4
Keynote 5
09:15-10:00
Plenary 1-4
Plenary 9-12
Plenary 17-20
Plenary 25-28
10:00-10:30
Break
Break
Break
Break
Symposium 1-4
Symposium 9-12
Symposium 17-20
Symposium 2528
Satellite Symposium
& Lunch
1-2
Satellite Symposium
& Lunch
5-6
Satellite
Symposium &
Lunch
9-10
12:00-12:30
Closing
Ceremony
13:30-14:30
Poster Session
Poster Session
Poster Session
14:30-15:00
Plenary 5-8
Plenary 13-16
Plenary 21-24
15:00-15:30
Break
Break
Break
Symposium 5-8
Symposium 13-16
Symposium 21-24
10:30-12:00
12:00-13:30
4th Annual
Meeting of
GCAMID
15:30-17:00
City Tour
17:30-18:00
18:00-19:00
19:00-19:30
Registration
(08:30-18:00)
Satellite
Satellite Symposium Symposiu GCAMID
3-4
m & Dinner
Forum
7-8
Opening
Ceremony &
Keynote 1
Congress Banquet
19:30-21:00
Satellite
Symposium
11-12
Welcome
Reception
GCAMID
Gala
Dinner
Farewell Party
(WPSC)
Asian Association of UTI and STD (AAUS)
in conjunction with 5th Asian UTI/STD
Forum (AAUS 2008)
Ms. Emily Shih
Address: 10F-2, No. 51, Sungjiung Road,
104 Taipei, Taiwan
Tel: +886-2-2504-4338 ext.18 Fax: +886-22504-4362
E-mail: [email protected]
Important Dates
Deadline for Abstract Submission: June 30,
2008
Deadline for Early Bird Registration:
August 31, 2008
Deadline for Pre-Registration: September
15, 2008
Congress Dates: November 29 ~
December 03, 2008
Congress Secretariat
Antimicrobial Prophylaxis for Clean
Wound Surgery: Kaoshiung VGH
• In 1999~2000, 3110 surgical cases.
• 156 (2%) cases did not use antibiotics at all.
• Mean antibiotic days: 6.39 days (parental 2.41days
and oral 4.02 days).
• SSI rate in clean surgery: one dose of AMP: 0.9%,
one dose after surgery: 3.2%, no use : 1.9%.
• 90% use 1st Cepha as AMP, and 50%
aminoglycosides.
• Conclusion: one dose of AMP is enough and
better than no use of AMP.
• Ho M: My route to education and medicine. 2002.
Back to ER rate
N
Prophylactic
Group
Therapeutic
Group
No Preop
data
ER
UTI
Pain
62
2 (3.2%)
4 (6.4%)
57
1 (1.8%)
1 (1.8%)
8
1 (12.5%)
2 (25%)
Correctable Urologic Abnormalities That Cause
Bacterial Persistence Infection stones
•
•
•
•
•
•
•
•
•
•
•
•
Infection stones
Chronic bacterial prostatitis
Unilateral infected atrophic kidneys
Ureteral duplication and ectopic ureters
Foreign bodies
Urethral diverticula and infected periurethral glands
Unilateral medullary sponge kidneys
Nonrefluxing, normal-appearing, infected ureteral stumps
after nephrectomy
Infected urachal cysts
Infected communicating cysts of the renal calyces
Papillary necrosis
Perivesical abscess with fistula to bladder
Guidelines for the use of prophylatctic antibiotics in
surgery in Taiwan
Site/procedu Likely
re
pathogens
Recommended
antibiotics
Alternative
Herniorraphy S. aureus
+ mesh, open CoNS
or LPS
Cephazolin 1gm,
IV at IA
Clindamycin
1 dose
600mg IV at IA
Herniorraphy
No mesh,
open or LPS
Nil or Cephazolin
1gm, IV at IA
Clindamycin
1 dose
600mg IV at IA
Oral Neomcin
1gm QID+
metronidazole
1gm qid the day
before op or
cefa+/- GM +/metron IV at IA
Clindamycin
+GM IV at IA.
Or … or …
S. aureus
CoNS
Colorectal
Enteric
( clean
GNB
contaminated) Anaerobes
Duration
<1 day
J Microbiol Immunol Infect 2004;37:71-4
Guidelines for Antimicrobial
Therapy of UTIs in Taiwan
Alternative Choice
Diagnosis
Drug of Choice
Asymptomatic
bacteriuria or
Acute bacterial
cystitis
Nitrofurantoin,
Ampicillin or amoxicillin
1st or 2nd cepha,
Ampicillin/sulbactam
TMP+SMX
Amoxicillin/calvulanate
Quinolones (pimpemic acid,
etc)
NO FLUOROQUINOLONES
Acute
uncomplicated
Pyelonephritis
TMP+SMX
1st or 2nd cephalo
Aminoglycosides
NO FLUOROQUINOLONES
Ampicillin or amoxicillin
Ampicillin/sulbactam
Amoxicillin/calvulanate
Aminoglycosides (single) +
1st or 2nd cepha,
• J Microbiol Immunol Infect
2000;33:271-2.
Discussion: Prophylactic Antibiotics in
TURP
• 16% did not use AMP (Did not comply
to guidelines)
• 14% use postop ABx longer than 3 days.
(Break the rule!)
• More use of combination antibiotics
(preop. 17%, and postop.26%).
(Cefazoline plus Gentamycin).
Prophylaxis for Nephrectomy
Regulations for : 0-1 dose 1st line antibotics?
• EAU guideline:
• Campbell-Walsh 2007:
• Taiwan: single dose or short course, 13 days?. Clean wound after op for RCC.
Clean contaminated wound after op for
TCC.
Open or Laparoscopic
Nephrectomy/Nephrourerectomy
• In general, LPS procedures lowers the risk of
surgical site infections. (Kluytmans, 1997)
• Regarded as clean wound.
• Entry into urinary tract  clean
contaminated wound. prophylaxis with 1st
gen. Cephalosporines. For 1-3 days.
• Using bowel  neomycin + erythromycin or
neomycin +metronidazole 18-24 hrs before
op. and parental cefotetan or cefoxitin 30-60
min before incision.
Bacteria of preoperative urinary tract infections
contaminate the surgical field and develop surgical
site infections in urological operations.
•
•
•
•
•
•
Hamsuna R, et al: Int J Urol 2004;11:941-7
134 major open urological operations.
Surgical wound swab cuture at the end of op:
AMP after op and lasting for 3 days.
34 (25%) infectious complications.(SSI and UTI, etc)
Of 20 SSI (+), 15 (75%) had swab culture (+) and the
bacteria was sensitive to AMP in 20%.
• Of 114 SSI (-), 14 (12%) had swab culture (+) and the
bacteria was sensitive to AMP in 86%.
• Preop UTI was observed in 11 (55%) patients with
SSI.Of them 4 had same species in urine and wound.
• Conclusions: preop UTI was the most important risk
factor for SSI following urological op.
Open nephrectomy-
N＝69
Antibiotic use
67 %
pr e-op Rat e
Post -op Rat e
70%
52 %
60%
50%
40%
29 %
30%
13 %
20%
13 %
10 %
0%
10%
0%
3%
1%
0%
N o ant i bi ot i c
use
1 t h l i ne cephal
1 . 0 gm
1 t h l i ne am i no
Com bi ne w i t h
cephal + am i no
O t her s :
pr e-op Rat e
13%
67%
0%
13%
1%
Post -op Rat e
10%
52%
0%
29%
3%
80 %
80%
Antibiotic dose
70%
60%
53 %
50%
40%
30%
20%
12 %
10%
%
0% 3
9%
0%
0%
1 dose
pr e-op Rat e
Post -op Rat e
6%
0%
3%
%
0% 3
4% %
4
13 %
10 %
0%
0%
3 days
5 days
7 days
1 4 days
m i ssi ng
answ er
no
r equest
1 day
2 days
80%
3%
0%
0%
0%
0%
0%
4%
13%
0%
12%
9%
53%
6%
3%
3%
4%
10%
Hand -assisted Laparoscopic nephrectomy
54 %
60%
52
pr e-op Rat e
Post -op Rat e
%
N＝69
50%
Antibiotic use
40%
30%
22
12 %
20%
13 %
6%
10%
0%
pr e-op Rat e
%
0%
0%
0%
N o ant i bi ot i c
use
1 t h l i ne
cephal 1 . 0
gm
1 t h l i ne
am i no
Com bi ne w i t h
cephal +
am i no
O t her s :
12%
54%
0%
13%
0%
6%
52%
0%
22%
0%
Post -op Rat e
0%
70%
61
%
60%
50%
Antibiotic dose
39 %
40%
30%
%
22 23 %
20%
13 %
12 %
12
6%
10%
0%
0%
3%
pr e-op Rat e
Post -op Rat e
1 day
6%
3%
0%
0%
2 days
3 days
5 days
7 days
1 4 days
m i ssi ng
answ er
no
r equest
0%
1 dose
0%
%
0% 1%
61%
6%
0%
0%
0%
0%
0%
22%
12%
0%
13%
12%
39%
3%
1%
3%
23%
6%
Discussion: Prophylactic Antibiotics in
Open Nephrectomy
• 12% did not use preop. ABx. (Not complying to
guidline)
• 58%-74% use postop ABx longer than 1 day.
(Break the rule!)
• More use of Two kinds of antibiotics (preop. 13%,
and postop.22%-29%) (Break the rule!)
• The rate of using antibiotics was less in LPS
nephrectomy.
• But this is a clean op!! What are urologists afraid
of? Invasiveness of the procedure and possible
major adverse events after op.
Bacterial
Virulence
Reliable Coverage of Antimicrobials
Antimicrobial or Antimicrobial Class
Gram-Positive
Pathogens
Gram-Negative Pathogens
Amoxicillin or ampicillin
Streptococcus
Enterococci
Escherichia coli
Proteus mirabilis
Amoxicillin with clavulanate
Streptococcus
E. coli
Ampicillin with sulbactam
Staphylococcus
(not MRSA)
Enterococci
P. mirabilis
Haemophilus influenzae, Klebsiella
species
First-generation cephalosporins
Streptococcus
Staphylococc
us (not
MRSA)
E. coli
P. mirabilis
Klebsiella species
Second-generation cephalosporins
(cefamandole, cefuroxime, cefaclor)
Streptococcus
Staphylococc
us (not
MRSA)
E. coli, P. mirabilis
H. influenzae, Klebsiella species
Second-generation cephalosporins (cefoxitin,
cefotetan)
Streptococcus
E. coli, Proteus species (including indole +)
H. influenzae, Klebsiella species
Third-generation cephalosporins (ceftazidime,
ceftriaxone)
Streptococcus
Most, including P. aeruginosa
Aminoglycosides
Staphylococcus
(urine)
Most, including P. aeruginosa
Fluoroquinolones
Streptococcus *
Most, including P. aeruginosa
Gap Between Regulations/ Guidelines and
Practice on AMP for Herniorraphy
• Surgeons’ heavy duty? Safety for the patients
or for the doctors? Empiric use of antibiotics
to kill any pathogen that may enter through
the open wound.
• Personal experience is not so good as the
published reports and Severe mesh infection
did occur. Are we afraid of legal problem?
• Selection of standard patients: Good results
of Shouldice repair come from good selection
of patients
Cephalosporin resistant urinary tract
infections in young children
• Mehr SS, et al: J Paediatr Child Health 2004;40:48-52.
(Melbourne, Australia)
•
•
•
•
<6 y/o
100 culture proved UTI.
E coli 90%. Proteus mirabilis 5%.
In vitro resistance to
Ampicillin/amoxicillin: 52%, to TMP 14%,
to cephalothin/cephalexin 24%.
• High resistance to TMP in Taiwan!!
Once Daily vs. Conventional use
of Gentamicin
Emergence of Reduced Sucsceptibility
and Resistance to F-Quinolones in E Coli
• Taiwan had been ‘famous’ as one of the
countries with highest resistant bacteria.
• In 1998, 1203 E coli isolates from 44 hospitals
in Taiwan.
• 136 (11.3%) isolates were resistant to F-Q.
and another 261 (21.7%) had reduced
susceptibility.
• Acute and chronic quinolone use in cancer
patients is a major selective pressure for
resistance.
• McDonald LC, et al: Antimicrobial agents and chemotherapy
2001;45:3084-91.
Taiwan Surveillance On Antimicromial
Resistance: Use of Antibiotics in Hospitals
• 6 medical centers + 8 regional hospitals
• 663 adult inpatients in early 1999.
• A total of 447 (67%) patients received
antibiotics for an overall rate of 813 antibiotic
days per 1000 hospital days.
• Reasons to use antibiotics: 36% by
experience, 29% by culture, and 30% for
prophylaxis for SSI.
• Medical center was an independent predictor
for increased use of antibiotics.
• McDonald LC, et al: Infection Control & Hospital
Epidemiology 2001;22:565-71.
Taiwan Surveillance of Antimicromial
Resistance in Taiwan: Bacteria
• 1st Cephalosporines were the most frequent
(50%) prescribed antibiotics (Data from NHI).
• In 22 hospitals, The most common isolates
were Enterobacteriaceae (E coli, K
pneuomniae), S aureus, P aeruginosa.
Accinobacter spp accounted for 10% isolates.
• MRSA accounts for 82% of hospital acquired
infection, and . 40% of community acquired
infection.
• Ho M, et al: J Microbio Immuno Infect
1999;32:239-49.
Lessons from clean wound surgery
Prophylaxis for Herniorraphy
Regulations: 0-1 dose
Guidelines for the use of prophylatctic
antibiotics in Herniorraphy in Taiwan
Site/proced
ure
Likely
Recommended
pathogens antibiotics
Alternative
Duration
Mesh +,
open or
LPS
No mesh,
open or
LPS
S. aureus
CoNS
Cephazolin 1gm, Clindamycin
IV at IA
600mg IV at
IA
1 dose
S. aureus
CoNS
Nil or
Clindamycin
Cephazolin 1gm, 600mg IV at
IV at IA
IA
1 dose
J Microbiol Immunol Infect 2004;37:71-4
Prophylactic Antibiotics for mesh ingunal
hernioplasty: a meta-analysis
Terzi C, J Hosp Infect. 2006 Jan. meta-analysis:
the value of prophylaxis on heriorraphy is
inconclusive
• Sanabria A, et al: Ann Surg 2007;245:392-6
• 6 RCT, 2507 eligible patients.
• Antibiotic prophylaxis use in patients
submitted to mesh inguinal hernioplasty
decreased the rate of SSI by almost 50%.
(2.89%  1.38%)
•Tzovaras G, et al: Int J ClinPract 2007;61:236-9: No
effectiveness of prophylactic antibiotics for
tension-free mesh hernia repair. (amoxicillin +
clavoulani acid vs. placebo. 4.2% vs. 5.8%.
SSI in Inguinal Herniorraphy,
TCH, Taipei (2005-2006)
*All men had preoperative antibiotics,
including 10 boys less than 18years.
*54 (69.2%) cases used post op antibiotics.
(Breaking regulations)
*56 Mesh (+) cases. one (1.78%) had SSI.
*22 Mesh (-) cases. None had SSI.
*The only one SSI occurred in the mesh (+)
patient who took post op antibiotics.
*Conclusions: post op antibiotics is not
necessary in herniorraphy.
Hernia
N=69
Antibiotic use
65%
70%
pr e-op Rat e
Post -op Rat e
54%
60%
50%
40%
35%
25%
30%
20%
7%
6%
10%
0%
0%
0%
0%
0%
N o ant i b i o t i c
use
1 t h l i ne
cephal 1 . 0
gm
1 t h l i ne
am i no
Co m b i ne w i t h
cephal +
am i no
O t her s :
pr e-o p Rat e
35%
54%
0%
6%
0%
Po st -o p Rat e
65%
25%
0%
0%
7%
70%
60%
65 %
Antibiotic dose
57 %
50%
35 %
40%
30%
20%
16 %
10 %
10%
4%
4%
3%
0%
0%
0%
0% 0%
1%
4%
0% 0%
0%
0%
1 dose
1 day
2 days
3 days
5 days
7 days
1 4 days
mi ssi ng
answ er
no
request
pre-op Rat e
57%
4%
0%
0%
0%
0%
0%
4%
35%
Post -op Rat e
10%
4%
3%
16%
0%
1%
0%
0%
65%
Discussions: AMP for Hernia Repair
• Regulations and Guidelines: No antibiotics for repair
without mesh. One dose for repair with mesh.
• Evidence: published reports on SSI rates after Inguinal
hernia repair were around 2%, mostly skin infection.
• Mesh infection 0.9% in one report. (Jezupovs A, Mihelsons
M: World J Surg 2006;30:2270-8)
• Our SSI rate after Mesh free repair was 0%, while that after
mesh repair was 1.8%.
• Practice: 57% Taiwanese urologists followed the regulation.
While 16% urologists used postoperative antibiotics for 3
days (much lower than 70% in 1990s) and 70% of cases in
our hospital did not follow the regulations. (Better figures
than that in 2000)
Lessons learned: Identifying Patients at
risk of SSI in Herniorraphy
• Old age (>65 yrs or >75 yrs) (Chronological
age vs. Biological Age)
• Obesity
• Urinary catheterization.
• Previous herniorraphy
• Lengthy op time
• DM
• COPD.
• Other factors to decrease host immunity?