Antimicrobial prophylaxis in TURB and TURP: time for a paradigm shift?

Abstract

Antimicrobial resistance is an increasing problem in healthcare and could threaten public safety. The over- and misuse of antibiotics is an enormous problem and created the concept of antimicrobial stewardship, which is a global initiative for a rational antibiotic use. Antimicrobial prophylaxis (AMP) is widely used to prevent surgical infections and although the use of AMP is generally recognized as efficient in preventing infectious complications, some remarks can be made in certain procedures. Antibiotics have adverse drug reactions, allergic reactions and unnecessary antibiotics needlessly increase hospital costs. Overuse of antibiotics is also a reason for an increase in microbial resistance and even single-use antibiotic use has an impact on resistance in uropathogens. TURP or transurethral resection of the prostate is a very common urologic procedure, which nearly every urologist performs on a regular base, in which a hot iron loop is used to resect the inner part of an enlarged prostate. The (inter-)national guidelines recommend AMP for every TURP procedure but these recommendations are mostly based on obsolete or underpowered data. Our first study was a large, prospective cohort study in which a very low infection rate in patients undergoing TURP without AMP was observed and was published in World Journal of Urology. Avoiding unnecessary antibiotic use is a keystone of antimicrobial stewardship and we wanted to confirm these findings and set up a randomized trial to confirm the safety of omitting AMP in a group of patients undergoing TURP, in support of antimicrobial stewardship. Our study, which is the largest RCT to date investigating the impact of AMP in post-TURP fever, showed that omitting AMP is non-inferior in patients undergoing TURP without a pre-operative, indwelling catheter and pyuria. This study was published in Journal of Urology. TURB or transurethral resection of bladder tumor is a very similar procedure to TURP and many guidelines don’t differentiate their recommendations for this urethrocystoscopy with manipulation-procedure. The contrast between the frequency of the procedure and the absence of scientific evidence for AMP in TURP is striking and was the reason for investigating this topic. The multivariable analysis of our RCT demonstrated the safety of omitting AMP in patients undergoing TURB without a pre-operative indwelling catheter and pre-operative, positive urinary culture. This study was published in World Journal of Urology. These studies demonstrate the safety of omitting AMP in the majority of patients and we hope that these findings will be implemented in the international guidelines so a more rational approach towards AMP in TURB/P can be performed in the daily, urologic practice.