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Customer Support. Jill George Read More! UBP Instructor. Prostate biopsy has evidence for the use of fluoroquinolone prophylaxis; however, it is recommended that you not prescribe more than 24 hours of the medication to reduce exposure.

Additionally, recommendations are for empiric therapy only. If the choice of antimicrobial is based upon results of a documented rectal swab culture, then culture-directed antimicrobials can be administered. The risk of peripheral neuropathy associated with fluoroquinolones taken by mouth or injection should be relayed to patients. This potential serious side effect may be permanent.

Please see page 20 for revisions to the recommendation. In July , the FDA issued a notice that a boxed warning and a Medication Guide for patients are to be added to the prescribing information to strengthen the existing warnings about the increased risk of developing tendinitis and tendon rupture in patients taking fluoroquinolone antimicrobial drugs for systemic use.

Fluoroquinolones are associated with an increased risk of tendinitis and tendon rupture. This risk is further increased in those over age 60, in kidney, heart, and lung transplant recipients and with use of concomitant steroid therapy.

Physicians should advise patients, at the first sign of tendon pain, swelling, or inflammation, to stop taking the fluoroquinolone, to avoid exercise and use of the affected area and to promptly contact their doctor about changing to a nonfluoroquinolone antimicrobial drug.

Selection of a fluoroquinolone for the treatment or prevention of an infection should be limited to those conditions that are proven or strongly suspected to be caused by bacteria. Purpose: Antimicrobial prophylaxis is the periprocedural systemic administration of an antimicrobial agent intended to reduce the risk of postprocedural local and systemic infections.

Methods: Recommendations are based on a review of the literature and the Panel members' expert opinions. Results: The potential benefit of antimicrobial prophylaxis is determined by patient factors, procedure factors, and the potential morbidity of infection. Antimicrobial prophylaxis is recommended only when the potential benefit outweighs the risks and anticipated costs including expense of agent and administration, risk of allergic reactions or other adverse effects, and induction of bacterial resistance.

The prophylactic agent should be effective against organisms characteristic of the operative site. Cost, convenience, and safety of the agent also should be considered.

Prophylaxis should begin within 60 minutes of the surgical incision minutes for intravenous fluoroquinolines and vancomycin and generally should be discontinued within 24 hours. The American Heart Association no longer recommends antimicrobial prophylaxis for genitourinary surgery solely to prevent infectious endocarditis. Justifications and recommendations for specific antimicrobial prophylactic regimens for specific categories of urologic procedures are provided.

Conclusions: The recommendations provided in this document, including specific indications and agents enumerated in the Tables, can assist urologists in the appropriate use of periprocedural antimicrobial prophylaxis. Surgical site infections SSIs and postoperative urinary tract infections UTIs are a common cause of patient morbidity.

Surgical site infections almost double the direct costs of hospitalization, and patients with SSI are more likely to be readmitted, require stay in the intensive care unit, and suffer mortality. Although the effectiveness of perisurgical antimicrobial prophylaxis in reducing SSIs and postoperative UTIs is well established, surveys have demonstrated wide variation in utilization of periprocedural antimicrobial prophylaxis, including inappropriate selection of agents, improper timing of administration, and excessive duration of prophylaxis.

To this end, the American Urological Association AUA convened the Urologic Surgery Antimicrobial Prophylaxis Best Practice Policy Panel, comprised of six urologists Appendix 1 , to formulate recommendations for the use of antimicrobial prophylaxis during urologic surgery.

Assessment of the literature by the AUA Practice Guidelines Committee suggested that insufficient information was available to derive a guideline statement on antimicrobial prophylaxis during urologic surgery based solely on literature meta-analyses. As such, the Panel was charged with developing a Best Practice Policy Statement, which uses published data in concert with expert opinion, but does not employ formal meta-analysis of the literature.

A Medline search was performed using the MeSH index headings "antimicrobial prophylaxis," "postoperative complications," "surgical wound infection," "anti-bacterial agents," and the names of specific urologic procedures, from through This initial search was supplemented by scrutiny of bibliographies and additional focused searches, and publications were selected for analysis by the Panel members. These included guidelines and policies from other groups, some of which were identified by Panel members outside of the Medline search; the guidelines from other groups were considered in the Panel's deliberations.

The Panel formulated recommendations based on review of all material and the Panel members' expert opinions. Levels of evidence were assigned Appendix 2. This document was submitted for peer review, and comments from all 20 responding physicians and researchers were considered by the Panel in making revisions. Funding of the Panel was provided by the AUA. Members received no remuneration for their work. Each Panel member provided a conflict of interest disclosure to the AUA.

Surgical antimicrobial prophylaxis is the periprocedural systemic administration of an antimicrobial agent intended to reduce the risk of postprocedural local and systemic infections. Antimicrobial prophylaxis is only one of several measures thought to reduce SSI.

Others include bowel preparation, preoperative hair removal, antiseptic bathing, hand-washing protocol, double gloving, and sterile preparation of the operative field.

Commonly practiced, the use of mechanical bowel preparation MBP prior to colorectal surgery has recently been called into question. Similarly, the traditional preoperative removal of hair in preparation for surgery may not be necessary. An analysis of RCTs comparing hair removal with no hair removal, different methods of hair removal, hair removal conducted at different times prior to surgery, and hair removal carried out in different settings concluded that there was no difference in SSIs among patients who had their hair removed prior to surgery and those who did not.

Finally, there was no difference in SSIs among patients shaved or clipped on the day before surgery versus the day of surgery. A review of six RCTs involving a total of 10, patients undergoing surgery compared the effects of preoperative bathing with antiseptic preparation to showering with nonantiseptic preparations.

The antiseptic preparation provided no benefit in terms of reducing the risk of SSI. Surgical hand scrubbing has long been considered an important aspect of surgical technique. Recently, surgical hand rubbing with an aqueous alcohol solution has been proposed as an alternative to the traditional surgical hand scrubbing.

While double gloving protects the surgical team from contamination by reducing perforations to the innermost glove, there is no direct evidence that additional glove protection worn by the surgical team reduces surgical infection in the patient. Sterile preparation of the operative site is the cornerstone of sterile surgical technique.

Many substances are effective, including ethyl alcohol, isopropyl alcohol, aqueous iodine topical solution, iodine tincture, povidone-iodine, and chlorhexidine gluconate. Recent studies call into question the skin scrub that traditionally has been performed prior to paint with a sterile substance. In a RCT of skin preparation for abdominal surgery, Ellenhorn and colleagues 11 found that scrub with povidine-iodine soap followed by paint with providine-iodine was associated with no fewer SSIs than painting with povidine-iodine alone.

The combination formulation of povidone-iodine and alcohol is similar or superior to a povidone-iodine aqueous solution in terms of reducing the occurrence of SSIs 12,13 , and delivers effective antimicrobial activity with only a second application. Transrectal ultrasound guided prostate biopsy, performed through a grossly contaminated field, presents additional infectious considerations. There is wide variation in the topical preparation of the rectum. Otrock et al 15 found no benefit of preprocedure povidine-iodine enemas.

Carey and Korman 16 concluded that sodium biphosphate enemas added no additional protection from infectious complications. Jeon and associates 17 however, found that bisacodyl suppository rectal preparation the night before or morning of the procedure did decrease infectious complications.

No standard for topical preparation of the rectum prior to transrectal ultrasound guided prostate biopsy has been established. In addition to proper sterile technique, experience suggests that other aspects of surgical technique play an important role in preventing SSIs.

Gentle tissue handling, maintaining vascularity, avoiding hematomas or other unperfused spaces, and minimizing operative time are all thought to reduce the incidence of SSIs. Thus, antimicrobial prophylaxis is only one of many factors associated with a reduction in SSI, albeit a very important one. The potential benefit of surgical antimicrobial prophylaxis is determined by three considerations: patient-related factors ability of the host to respond to bacterial invasion , procedural factors likelihood of bacterial invasion at the operative site , and the potential morbidity of infection.

The ability of the host to respond to bacteriuria or bacteremia is affected by the specific patient-related factors described in Table 1. Infections are more likely to occur because of increased inocula or are more difficult to treat because of increased bacterial resistance, respectively.

These factors frequently act in an additive manner, compounding their impact. Moreover, the effect of some conditions is difficult to specify. For example, a patient with well-controlled diabetes mellitus has little impairment of bacterial immunity, whereas the poorly controlled diabetic may be clinically immunodeficient.

The clinician should use judgment as to the influence of these various factors as no absolute values can be used to determine their precise effect on the patient's immunological response. The likelihood of bacterial invasion is also affected by the amount of bacteria at the site of the surgical procedure as classified in Table 2. The third type of factor in determining the potential benefit of prophylaxis is the potential morbidity of infection.

For example, an episode of cystitis which has little risk in a healthy person can cause serious complications in a recently immunosuppressed patient after organ transplantation. Similarly, potential seeding of a prosthetic joint enhances the sequelae of systemic infections.

A thorough understanding of the impact of these factors and careful assessment of the situation of each patient is required to direct antimicrobial prophylaxis for a urologic procedure. Surgical antimicrobial prophylaxis is recommended only when the potential benefit exceeds the risks and anticipated costs. Data regarding the costs associated with prophylactic antimicrobial use specifically for urologic surgery are not readily obtainable, but data from other surgical disciplines are enlightening.

Clearly, SSIs are associated with poorer patient outcome and increased costs. Herwaldt and associates 21 reviewed the outcomes of 3, surgical patients general, cardiothoracic, and neurosurgical with an overall nosocomial infection rate of Even after accounting for covariates, nosocomial infection was associated with increased postoperative length of stay, hospital readmission rate, and outpatient use of antimicrobial agents - all of which significantly increased costs and utilization of medical resources.

A recent large review of data from European centers confirmed the great cost of SSIs. Prophylactic antimicrobial use is associated with financial, personal-health, and public- health costs. Included in the consideration of the financial impact are the expense of the agent, route of administration, associated administration supplies, and labor.

Costs vary widely with the antimicrobial agent selected and also according to the setting in which the administration occurs. Another important factor is variation in the duration of antimicrobial prophylaxis.

A single preoperative administration has less total associated cost than a cycle of three administrations during the hour perioperative period. Finally, the ultimate financial cost of antimicrobial prophylaxis incorporates both the costs associated with the agent and the costs associated with patient outcomes SSIs, adverse reactions, etc. Comprehensive cost differences between different regimens can be demonstrated.

The personal-health risks of prophylactic antimicrobial administration include allergic reactions, which vary from minor rashes to anaphylaxis, and suppression of normal bacterial flora, which can lead to Clostridium difficile colitis, colonization and infection with resistant organisms, and other adverse effects.

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