Antibiotic Guidelines – Antibiotic Prophylaxis
in Urology
Classification: Clinical Guideline
Lead Author: Antibiotic Steering Committee
Additional author(s):
Authors Division: DCSS & Tertiary Medicine
Unique ID: 144TD(C)25(F5)
Issue number: 4
Expiry Date: October 2018
Contents
Section
Who should read this document
2
Key practice points
2
Background/ Scope/ Definitions
2
What is new in this version
2
Policy/Procedure/Guideline
4
Surgical Prophylaxis Principles
4
Antibiotic Prophylaxis in Urology – table of recommendations
6
Standards
9
References and Supporting Documents
9
Roles and Responsibilities
9
Document control information (Published as separate document)
Document Control
Policy Implementation Plan
Monitoring and Review
Endorsement
Equality analysis
Issue 4
Oct 2016
10
Antibiotic Guidelines – Antibiotic Prophylaxis in Urology
Current Version is held on the Intranet
Check with Intranet that this printed copy is the latest issue
Page 1 of 8
Who should read this document?
This policy applies to all clinical staff involved the prescribing of antimicrobials.
Key Practice Points
This policy recommends surgical prophylaxis options for adult patients undergoing
specified urological procedures.
Background/ Scope/ Definitions
Antimicrobial agents are among the most commonly prescribed drugs and
account for 20% of the hospital pharmacy budget. Unfortunately, the benefits
of antibiotics to individual patients are compromised by the development of
bacterial drug resistance. Resistance is a natural and inevitable result of
exposing bacteria to antimicrobials.
Good antimicrobial prescribing will help to reduce the rate at which antibiotic
resistance emerges and spreads. It will also minimise the many side effects
associated with antibiotic prescribing, such as Clostridium difficile infection. It
should be borne in mind that antibiotics are not needed for simple coughs and
colds. In some clinical situations, where infection is one of several possibilities
and the patient is not showing signs of systemic sepsis, a wait and see
approach to antibiotic prescribing is often justified while relevant cultures are
performed.
This document provides treatment guidelines for the most common situations
in which antibiotic treatment is required. The products and regimens listed
here have been selected by the Trust's Medicines Management Group on the
basis of published evidence. Doses assume a weight of 60-80kg with normal
renal and hepatic function. Adjustments may be needed for the treatment of
some patients.
This document provides treatment guidelines for the appropriate use of
antibiotics. The recommendations that follow are for empirical therapy and do
not cover all clinical circumstances. Alternative antimicrobial therapy may be
needed in up to 20% of cases. Alternative recommendations will be made by
the microbiologist in consultation with the clinical team.
This document refers to the treatment of adult patients (unless otherwise
stated).
Please refer to up to date BNF/SPC for a full list of cautions, contra-indications,
interactions and adverse effects of individual drugs.
Issue 4
Oct 2016
Antibiotic Guidelines – Antibiotic Prophylaxis in Urology
Current Version is held on the Intranet
Check with Intranet that this printed copy is the latest issue
Page 2 of 8
What is new in this version?
The definition of ‘high risk for MRSA infection’ has been changed to make it clear
that a history of ever having been colonised/infected with MRSA, even if
subsequently screen-negative, is still an indication for MRSA cover (as this has not
been routinely happening).
Policy/ Guideline/ Protocol
Surgical Prophylaxis Principles
Antimicrobial prophylaxis is indicated during selected clean surgical procedures and
during procedures which involve incision of non-sterile mucosal surfaces (oral
mucosa, respiratory tract, gastrointestinal tract and female genito-urinary tract).
Local departmental protocols should be followed where available. Prophylactic
antibiotics should be prescribed on the EPMAR (using the relevant prescribing order
set where available).
Where a patient is at high risk of post-operative MRSA infection, teicoplanin
should be included in the prophylaxis regimen.
Patients at high risk of MRSA infection include:
Patients with a history of any MRSA colonisation or infection (EVEN IF
SUBSEQUENT NEGATIVE SCREENS)

Patients without a negative MRSA screen from this admission or pre-op clinic
who
o Are admitted from a residential or nursing home
o Are healthcare workers
o Have had an inpatient admission in the past 12 months (UK or
overseas)
o Have had a prolonged pre-operative hospital inpatient stay
General Principles
1. The final decision regarding the benefits and risks of antibiotic prophylaxis for
an individual patient will depend on:
 the patient’s risk of surgical site infection
 the potential severity of the consequences of surgical site infection
 the effectiveness of prophylaxis in that operation
 the consequences of prophylaxis for that patient (e.g. increased risk of C.
difficile colitis)
2. Prophylaxis should be administered ≤ 60 minutes prior to surgical incision
(administration must be complete before the surgical incision, and before
inflation of the tourniquet when used).
Issue 4
Oct 2016
Antibiotic Guidelines – Antibiotic Prophylaxis in Urology
Current Version is held on the Intranet
Check with Intranet that this printed copy is the latest issue
Page 3 of 8
During induction of anaesthesia great care must be taken to prevent
drug substitution errors between anaesthetic drugs and antibiotics
(which has the potential to lead to unintentional awareness).
3. Penicillin Allergy:
Patients with a history of angiodema, anaphylaxis, or severe skin reaction to any beta
lactam antibiotics, are likely to have a true penicillin allergy and are therefore at an
increased risk of immediate hypersensitivity to penicillins.They should not receive
prophylaxis with a beta–lactam antibiotic (these include penicillins, cephalosporins,
monobactams and carbapenems).
Patients with a minor or delayed rash, may not have a true penicillin allergy and can
therefore receive prophylaxis with a cephalosporin, monobactam or carbapenem but
not a penicillin.
4. Teicoplanin, gentamicin and ciprofloxacin have long half lives and additional
doses during surgery are not required. Where other antibiotics are used, an
additional dose of prophylactic antibiotic during the operation is indicated if:
 there is major intra-operative blood loss blood loss of > 1500 ml during
surgery. In this case, additional dose of the prophylactic antibiotic
should be given after fluid replacement.
 haemodilution up to 15ml/kg
 surgery has lasted for more than 4 hours
Issue 4
Oct 2016
Antibiotic Guidelines – Antibiotic Prophylaxis in Urology
Current Version is held on the Intranet
Check with Intranet that this printed copy is the latest issue
Page 4 of 8
Antibiotic Prophylaxis in Urology
General points:
1. Where there is evidence of ongoing infection or particular clinical concern then a
longer course of antibiotics may be necessary. Discuss problematic cases with
microbiology.
2. In the case of PCNL / complex stone surgery / ureteroscopy procedures a larger
dose of gentamicin (3-5 mg /kg adjusted body weight) may be indicated at the
discretion of the consultant. This dosage needs to be reviewed if there is
evidence of renal impairment.
3. Prophylaxis in joint replacements (in flexible cystoscopy): use antibiotics if within
3 months of prosthetic insertion.
4. Prophylaxis in heart valve disease (in flexible cystoscopy): Antibiotics are not
usually indicated. See Trust policy on Endocarditis Prophylaxis.
Operation
Prophylaxis
Prophylaxis if
known to be
penicillin allergic or
ever colonised or
infected with MRSA
at any site
Cystoscopy
Not recommended routinely unless a below factor present
Cystoscopy with any
of:
Bacteriuria
Manipulation e.g.
cystodiathermy
Immunocompromise
Gentamicin IV 120mg + IV
amoxicillin 1g at induction
IV teicoplanin 400
mg + IV gentamicin
120 mg at induction
TRUS of prostate and
biopsy
Oral Ciprofloxacin 1000 mg 30
minutes prior to biopsy
IV teicoplanin 400
mg + oral
ciprofloxacin 1000
mg 30 minutes prior
to biopsy
Issue 4
Oct 2016
Antibiotic Guidelines – Antibiotic Prophylaxis in Urology
Current Version is held on the Intranet
Check with Intranet that this printed copy is the latest issue
Page 5 of 8
Endourological surgery
ESWL
(extracorporeal shock
wave lithotripsy)
TURP
Not routinely required unless risk factors present i.e.
- Bacteriuria or
- Immunocompromise
If so then give:
Gentamicin IV 120mg + IV
amoxicillin 1g at induction
IV teicoplanin 400
mg + IV gentamicin
120 mg at induction
Gentamicin IV 120mg + IV
amoxicillin 1g at induction
IV teicoplanin 400
mg + IV gentamicin
120 mg at induction
IV Co-amoxiclav 1.2g + IV
Gentamicin 120mg at induction
IV teicoplanin 400
mg + IV gentamicin
120 mg at induction
TURBT
Urethrotomy
Change of stent/s
Ureteroscopy for
stone treatment
Nephrostomy
Percutaneous
nephrolithotomy
(PCNL)
Given the possibility of preexisting infection, alternative
agents may be appropriate if
based on culture results
e.g.IV piperacillin-tazobactam 4.5g
tds commenced before the
procedure (+/- gentamicin)
Open Urinary Tract Surgery and Laparoscopic procedures
Clean procedures (surgery without entry into the urinary tract)
Scrotal surgery
Groin surgery
Circumcision
Issue 4
Oct 2016
Antibiotic prophylaxis not routinely
recommended, however if
adequate skin preparation is
difficult then give IV Co-amoxiclav
1.2g at induction
IV teicoplanin 400
mg + IV gentamicin
120mg + IV
metronidazole 500
mg at induction
Antibiotic Guidelines – Antibiotic Prophylaxis in Urology
Current Version is held on the Intranet
Check with Intranet that this printed copy is the latest issue
Page 6 of 8
Clean contaminated procedures (opening of the urinary tract)
Nephrectomy
IV Co-amoxiclav 1.2g + IV
gentamicin* (dosed as per table
below) at induction followed by a
second dose 4 hours later of Coamoxiclav 1.2g only if operation >
4 hours or > 1500 ml blood loss
Prostatatectomy
Cystectomy
IV teicoplanin 400
mg + IV gentamicin*
(dosed as per table
below) at induction
NB: for cystectomy, further doses
may be given depending on the
clinical situation although there is
insufficient evidence for routine
prolonged prophylaxis.
Contaminated procedures
Procedures involving
bowel
IV Co-amoxiclav 1.2g + IV
gentamicin* (dosed as per table
below) at induction followed by a
second dose 4 hours later of Coamoxiclav 1.2g only if operation >
4 hours or > 1500 ml blood loss
.
IV teicoplanin 400
mg + IV gentamicin*
(dosed as per table
below) + IV
metronidazole 500
mg at induction
followed by second
dose 4 hours later of
IV metronidazole 500
mg if operation >4
hours or >1500ml
blood loss
Implantation procedures
Prosthesis:
Penile/Sphincter/Testis
IV teicoplanin 400 mg + IV
gentamicin 120 mg at induction,
and a second dose of IV
teicoplanin 400 mg 12 hours later
Sacral
Neuromodulation
IV teicoplanin 400
mg + IV gentamicin
120 mg at induction,
and a second dose of
IV teicoplanin 400
mg 12 hours later
*Gentamicin dose in clean/contaminated & contaminated procedures:
Estimated
Body
Weight
(kg)
<60
60-90
>90
Normal renal
function (eGFR
>30ml/min,
creatinine
<200umol/L)
160
240
360
Issue 4
Oct 2016
Ready made
bags/vials to
be used
2 x 80mg vials
1 x 240mg bag
1 x 360mg bag
CKD stage 4-5
(eGFR
<30mls/min,
creatinine
>200umol/L)
120mg
160mg
240mg
Ready made
bags/vials to be
used
1.5 x 80mg vials
2 x 80mg vials
1 x 240mg bag
Antibiotic Guidelines – Antibiotic Prophylaxis in Urology
Current Version is held on the Intranet
Check with Intranet that this printed copy is the latest issue
Page 7 of 8
Standards

Document the Indication/rationale for antimicrobial therapy.

Review and document the patient’s allergy status.

Ensure the choice of antibiotic complies with the antibiotic guidelines.

Prescribe single dose antibiotics for surgical prohylaxis, unless policy states
otherwise.

Administer antibiotic prophylaxis within 60 minutes prior to surgical incision
(administration must be complete before the incision, and before inflation of
the tourniquet when used)
Explanation of terms & Definitions
NA
References and Supporting Documents
1. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guidelines Network.
Guideline No.104; ISBN 978 90581334 6; July 2008
2. Burden H, Ranasinghe W, Persad R. Antibiotics for Transrectal
Ultrasonography-Guided prestate biopsy: Are we practising evidence-based
medicine? BJU International 2008;101(10):1202-1204
3. Grabe M. Antibiotic prophylaxis in urological surgery, a European viewpoint.
Int J Antimicrob Agents 2011;38s:58-63
4. Bootsma AM, Laguna Pes MP, Geerlings SE, Goossens A. Antibiotic
prophylaxis in urologic procedures: a systematic review. Eur Urol
2008;54(6):1270-86
5. Zani EL, Clark OAC, Rodrigues Netto Jr N. Antibiotic prophylaxis for
transrectal prostate biopsy. Cochrane Database Syst Rev 2011, Issue 5. Art.
No.: CD006576. DOI: 10.1002/14651858.CD006576.pub2
Roles and responsibilities
All clinical staff involved in the prescribing of antimicrobials to adhere to this policy
including full documentation on EPMAR as detailed.
Issue 4
Oct 2016
Antibiotic Guidelines – Antibiotic Prophylaxis in Urology
Current Version is held on the Intranet
Check with Intranet that this printed copy is the latest issue
Page 8 of 8