Version May 2024
| Procedure | Likely organisms | Prophylaxis indicated | Antimicrobial(s) of choice | Alternative antimicrobial(s), if required | Duration of therapy* |
| Lower tract instrumentation | |||||
| Cystourethroscopy with minor manipulation, break in mucosal barriers, biopsy, fulguration, etc; clean-contaminated | GNR, rarely enterococci¶ | UncertainΔ; consider host-related risk factors. Increasing invasiveness increases risk of SSI. | TMP-SMX, amoxicillin/clavulanate | First/second-generation cephalosporin + aminoglycoside (aztreonam◊) ± ampicillin | Single dose |
| Transurethral cases (eg, TURP, TURBT, laser enucleative and ablative procedures, etc); clean-contaminated§ | GNR, rarely enterococci | All cases | Cefazolin, TMP-SMX | Amoxicillin/clavulanate, aminoglycoside (aztreonam◊) ± ampicillin | Single dose |
| Prostate brachytherapy or cryotherapy; clean-contaminated | Staphylococcus aureus, skin; GNR | All cases | Cefazolin | Clindamycin¥ | Single dose |
| Transrectal prostate biopsy; contaminated | GNR, anaerobes‡; consider MDR coverage, if risks of systemic antibiotics within six months, international travel, health care worker | All cases | Fluoroquinolone, first/second/third-generation cephalosporin (ceftriaxone commonly used) + aminoglycoside | Aztreonam May need to consider ID consultation | Single dose |
| Upper tract instrumentation | |||||
| Percutaneous kidney surgery (eg, PCNL); clean-contaminated | GNR, rarely enterococci, and skin†, S. aureus | All cases | First/second-generation cephalosporin, aminoglycoside (aztreonam◊) + metronidazole, or clindamycin | Ampicillin/sulbactam | ≤24 hours |
| Ureteroscopy, all indications; clean-contaminated | GNR, rarely enterococci | All cases; of undetermined benefit for uncomplicated, diagnostic-only procedures | TMP-SMX, first/second-generation cephalosporin | Aminoglycoside (aztreonam◊) ± ampicillin, first/second-generation cephalosporin, amoxicillin/clavulanate | Single dose |
| Open, laparoscopic, or robotic surgery | |||||
| Without entering urinary tract (eg, adrenalectomy, lymphadenectomy, retroperitoneal or pelvic); clean | S. aureus, skin | Consider in all cases; may not be required | Cefazolin | Clindamycin | Single dose |
| Penile surgery (eg, circumcision, penile biopsy, etc); clean-contaminated | S. aureus | Likely not required | |||
| Urethroplasty; reconstruction of the anterior urethra; stricture repair, including urethrectomy; clean; contaminated; controlled entry into the urinary tract | GNR, rarely enterococci, S. aureus | Likely required | Cefazolin | Cefoxitin, cefotetan, ampicillin/sulbactam | Single dose |
| Involving controlled entry into urinary tract (eg, kidney surgery; nephrectomy, partial or otherwise; ureterectomy; pyeloplasty; radical prostatectomy); partial cystectomy, etc; clean-contaminated | GNR (Escherichia coli), rarely enterococci | All cases | Cefazolin, TMP-SMX | Ampicillin/sulbactam, aminoglycoside (aztreonam◊) + metronidazole, or clindamycin | Single dose |
| Involving small bowel (ie, urinary diversions, cystectomy with small bowel conduit, other GU procedures); ureteropelvic junction repair, partial cystectomy, etc; clean-contaminated | Skin, S. aureus, GNR, rarely enterococci | All cases | Cefazolin | Clindamycin and aminoglycoside, cefuroxime (second-generation cephalosporin), aminopenicillin combined with a beta-lactamase inhibitor + metronidazole | Single dose |
| Involving large bowel**; colon conduits; clean-contaminated | GNR, anaerobes | All cases | Cefazolin + metronidazole, cefoxitin, cefotetan, or ceftriaxone + metronidazole, ertapenem NB: These IV agents are used along with mechanical bowel preparation and oral antimicrobial (neomycin sulfate + erythromycin base or neomycin sulfate + metronidazole) | Ampicillin/sulbactam, ticarcillin/clavulanate, piperacillin/tazobactam | Single parenteral dose |
| Implanted prosthetic devices: AUS, IPP, sacral neuromodulators; clean | GNR, S. aureus, with increasing reports of anaerobic and fungal organisms | All cases | Aminoglycoside (aztreonam◊) + first/second-generation cephalosporin or vancomycin¶¶ | Aminopenicillin beta-lactamase inhibitor, including ampicillin/sulbactam, ticarcillin, or tazobactam | ≤24 hours |
| Inguinal and scrotal cases (eg, radical orchiectomy, vasectomy, reversals, varicocelectomy, hydrocelectomy, etc); clean | GNR, S. aureus | Of increased risk; all cases | Cefazolin | Ampicillin/sulbactam | Single dose |
| Vaginal surgery, female incontinence (eg, urethral sling procedures, fistulae repair, urethral diverticulectomy, etc); clean-contaminated | S. aureus, streptococci, enterococci, vaginal anaerobes; skin | All | Second-generation cephalosporin (cefoxitin, cefotetan) provides better anaerobic coverage than first-generation cephalosporins; however, cefazolin is equivalent coverage for the vaginal anaerobes in sling procedures | Ampicillin/sulbactam + aminoglycoside (aztreonam◊) + metronidazole, or clindamycin | Single dose |
| Other | |||||
| Shock-wave lithotripsy; clean | GNR, rarely enterococci; GU pathogens | Only if risk factors | If risks, consider TMP-SMX, first-generation cephalosporin (cefazolin), second-generation cephalosporin (cefuroxime), aminopenicillin combined with a beta-lactamase inhibitor + metronidazole | First/second-generation cephalosporin, amoxicillin/clavulanate, ampicillin + aminoglycoside (aztreonam◊), clindamycin | Single dose |
GNR: gram-negative rod; SSI: surgical site infection; TMP-SMX: sulfamethoxazole and trimethoprim; TURP: transurethral resection of the prostate; TURBT: transurethral resection of bladder tumor; MDR: multidrug resistant; ID: infectious diseases; PCNL: percutaneous nephrolithotomy; GU: genitourinary; IV: intravenous; AUS: artificial genitourinary sphincter; IPP: implantable penile prosthesis; GPC: gram-positive cocci; AP: antimicrobial prophylaxis.
* Or full course of culture-directed antimicrobials for documented infection (which is treatment, not prophylaxis).
¶ GU GNR: Common urinary tract organisms are E. coli, Proteus spp, Klebsiella spp, and GPC Enterococcus.
Δ If urine culture shows no growth prior to the procedure, antimicrobial prophylaxis is not necessary.
◊ Aztreonam can be substituted for aminoglycosides in patients with kidney function impairment.
§ Includes transurethral resection of bladder tumor and prostate and any biopsy, resection, fulguration, foreign body removal, urethral dilation or urethrotomy, or ureteral instrumentation including catheterization or stent placement/removal.
¥ Clindamycin, or aminoglycoside + metronidazole or clindamycin, are general alternatives to penicillins and cephalosporins in patients with penicillin allergy, even when not specifically listed.
‡ Intestine: Common intestinal organisms include aerobes and anaerobes: E. coli, Klebsiella spp, Enterobacter, Serratia spp, Proteus spp, Enterococcus, and Anaerobes.
† Skin: Common skin organisms are S. aureus, coagulase-negative Staphylococcus spp, Group A Streptococcus spp.
** For surgery involving the colorectum, bowel preparation with oral neomycin plus either erythromycin base or metronidazole is added to systemic agents.
¶¶ Routine administration of vancomycin for AP is not recommended. The antimicrobial spectrum of vancomycin is less effective against methicillin-sensitive strains of S. aureus.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
