Abstract
Ureteroscopy has become the most performed urologic surgery in the world 1 and present a low rate of infectious complications. The largest study ever conducted in the world showed that infectious complications occur in <3% of patients 2 considering fever and urinary tract infection (UTI) as infection parameters.
However, despite the low frequency, the infectious complication is potentially serious (sepsis), with a significant burden to the health system, since it may involve readmissions, administration of intravenous antibiotics, and also a social/labor burden because of absence and other issues.
According to the American Urological Association (AUA) Best Practice Policy Statement, prophylaxis with a single dose of antibiotic one hour before surgery is recommended and there is no evidence to extend the use of antibiotics for >24 hours. According to the same guideline, the antibiotics of choice are fluoroquinolones and trimethoprim (TMP) + sulfamethoxazole (SMX). In addition, other alternatives are first- or second-generation cephalosporin, aminoglycosides with or without ampicillin, or amoxicillin + clavulanate. However, in a survey conducted by Endourological Society, only 40% of respondent urologists followed the recommendations of the AUA Best Practice Statement, 3 demonstrating that we still need to standardize the rational use of the antibiotic prophylaxis.
Several studies have tried to demonstrate the risk factors for postoperative UTI, which would justify the use of postoperative therapy, but this question remains unanswered. In this issue of the Journal of Endourology, Southern et al. 4 carried out an extensive retrospective review of electronic file records analyzing 3298 ureteroscopies and the risk factors for postoperative fever and SIRS. The study demonstrates a 6.9% rate of fever and postoperative SIRS, in line with other studies. 3
In the study, significant risk factors were female sex, higher Charlson comorbidity index (≥2), longer surgical time, and positive preoperative urine culture. It is important to highlight that history of previous urologic surgeries, more complex stones, and pre-stented patients also presented a higher risk of complication, but after logistic regression these factors corroborated for longer surgical times, which was statistically significant. In contrast, the use of ureteral sheath, which can lower intrapelvic pressure, cannot be considered a protective factor in their study.
The Food and Drug Administration has recently recommended restrictions on the use of fluoroquinolones 5 because of possible side effects. Rates of fluoroquinolones and TMP + SMX resistance may reach 25%, indicating the excessive use of these antibiotics. Therefore, the prophylaxis and postoperative use of antibiotic therapy must be rational and follow defined parameters.
In the author's opinion we must know the community and hospital's bacterial profile. According to the risk factors mentioned, separate the cases between low and high risk. Always have a urine test collected and positive results should be promptly treated before surgery. Prophylaxis should be done with an appropriate antibiotic following the AUA Best Practice Statement, but following the community's bacterial profile. High-risk patients should be closely monitored and postoperative antibiotic therapy can be recommended after a detailed evaluation and tailored for each patient. New randomized studies separating low- and high-risk cases, comparing different postoperative treatment regimens (which drug, how long?) would be necessary to answer if postoperative antibiotic is necessary and which patient should be treated to avoid infection complications.