Author(s): Suraj Godara1, Shameer Deen2, T. C. Sadasukhi3, Manish Gupta4, H. L. Gupta5, Govind Sharma6
OBJECTIVE Ureteral stents are the basic and the most frequently used agents in the area of urology. The specialty has bloomed after its invention. A ureteric stent is a specially designed hollow tube, made of a flexible plastic material that is placed in the ureter. Its length varies from 24 to 30 cm. Additionally, they come in different diameters to fit different size ureters. Over the last two decades, different types of stents have been used, all of them serve the same purpose i.e., urinary diversion, ureteral obstruction relief, and postoperative drainage, thus issues related to their use have also increased. Peri-interventional antibiotic prophylaxis is recommended by the European Association of Urology for prevention of urinary tract infections, but there is no adequate evidence supporting the role of low-dose empiric antibiotics with respect to the time of indwelling. Drugs and doses are catered to each patient with the conception that it will have a positive effect on controlling SRS; this is yet to be proved.
OBJECTIVES In this study, we analyse UTI and SRS rates in patients and study the advantages and disadvantages of a peri-interventional antibiotic prophylaxis only vs. a continuous low-dose antibiotic treatment for the entire stent-indwelling time.
PLACE AND DURATION This randomised prospective study included 500 patients admitted to the Department of Urology, Mahatma Gandhi Hospital from January 2015 to December 2015 undergoing ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) for urolithiasis.
METHODS This randomised prospective study included 500 patients admitted to the Department of Urology, Mahatma Gandhi Hospital from January 2015 to December 2015 undergoing ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) for urolithiasis. Patients were randomly allocated into two groups on lottery basis at the time of admission: Group A with 250 patients were given peri-operative antibiotic and Group B with 250 patients were given a continuous low-dose antibiotic treatment for the entire stent-indwelling time. All patients received peri-interventional antibiotic prophylaxis with 1g ceftriaxone given IV 30 minutes prior to anaesthesia induction to obtain a peak concentration at the time of highest risk during the procedure. According to the local pathogens profile and susceptibility in our region, the antimicrobial agent of choice for continuous low-dose treatment was levofloxacin (250 mg) once daily.
RESULTS In Group A, 47 patients developed UTI who were managed with a full course of antibiotics and 20 patients developed SRS with symptoms of haematuria, nocturia and pain abdomen. In Group B, 73 patients developed UTI and were managed with a full course of antibiotics and 24 patients developed SRS with symptoms of haematuria, nocturia and pain abdomen. 17 patients were further excluded from the study due to positive urinary cultures/staghorn calculi and/or septicaemia requiring full-dose antibiotic treatment. None of the patients experienced any side effects from the drugs prescribed. Compared with reports using no antibiotic prophylaxis, in the present study there was a lower rate of UTI and SRS in patients receiving peri-interventional antibiotics (19.42% and 8.26%) in comparison to low-dose continuous antibiotics (30.29% and 9.95%).
CONCLUSION It is imperative to perform a urine culture and analysis in all patients undergoing interventional urological procedures to avoid the risk of development of SRS. Peri-operative antibiotic therapy is better than low-dose continuous antibiotics. In our experience, we suggest that peri-operative antibiotics with due follow-up of urine analysis, culture and sensitivity is mainstay to avoid both URS and SRS. Many different pharmaceutical and technical approaches have been investigated to reduce the symptoms. Thus, only culture confirmed infections may be prescribed antibiotics, more or less to avoid creating drug-resistant bacteria.