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Antibiotic Prophylaxis
Antibiotic Prophylaxis
Antibiotic Prophylaxis
RESULTS
PATIENTS AND METHODS
The patient demographics were similar in
Patients undergoing PCNL, and who fulfilled both arms. There was three times less risk of
strict selection criteria, were recruited upper tract infection (relative risk 3.4, 95%
prospectively into a study which was confidence interval 1.0–11.8, P = 0.04) and
conducted in two phases. The study methods SIRS (2.9, 1.3–6.3, P = 0.004) in the patients
were similar to those previously described; receiving ciprofloxacin (treatment arm).
patients with dilated pelvicalyceal systems
and/or stones of ≥20 mm from phase 1 CONCLUSIONS
(previously published) acted as controls. In the
subsequent phase, the same selection criteria The administration of oral ciprofloxacin for
applied and only those with stones of 1 week before PCNL in patients with stones of
≥20 mm and/or dilated pelvicalyceal systems ≥20 mm or dilated pelvicalyceal systems
were given ciprofloxacin 250 mg twice daily significantly reduced the risk of urosepsis.
for 1 week before PCNL and comprised the
treatment arm. Midstream urine samples, KEYWORDS
renal pelvic urine and fragmented stones
were collected to assess culture and percutaneous nephrolithotomy, controlled
sensitivity. Systemic inflammatory response study, urosepsis, urine culture and sensitivity,
syndrome (SIRS) was used to define urosepsis systemic inflammatory response syndrome
after PCNL. The urologists monitoring the
INTRODUCTION FIG. 1. Flow chart of patient recruitment into either arm of the current analysis. Data collection from phase
2 is ongoing and forms part of a separate analysis.
Urosepsis is a potentially catastrophic
complication that can follow percutaneous PHASE 1
nephrolithotomy (PCNL) despite sterile (Commenced: June 2003)
preoperative urine and prophylactic
antibiotics [1,2]. O’Keeffe et al. [1] reviewed
retrospectively a series of 700 patients
EXCLUSION CRITERIA
undergoing upper tract manipulation; nine
(Appendix 1)
developed severe septicaemia and 66% died.
The source of this systemic infection has
often been attributed to infection in the upper
tracts, although preoperative mid-stream N = 54 PHASE 2
(Analysis completed and (Commenced June 2004)
urine (MSU) samples were sterile. We showed
submitted in May 2004)
in a previous report [3] that infection in the
upper tracts (either renal pelvic urine or
stones) had four times the risk of resulting in
urosepsis after PCNL. That study showed EXCLUSION CRITERIA
simultaneously that patients with larger Subgroup with non-dilated (Appendix 1)
stones (≥20 mm) or dilated pelvicalyceal pelvicalyceal systems and/
systems had a significantly greater risk of or stones <20mm
N=8 N = 61
infected upper tracts. Therefore, as a natural
continuation of this study, we further
evaluated if a 1-week course of ciprofloxacin
in patients with a dilated pelvicalyceal system
Subgroup with Dilated
or stones of ≥20 mm could reduce the risk of pelvicalyceal systems and/
upper tract infection or urosepsis, thus Subgroup with Dilated or stones ≥20mm
completing the audit loop. pelvicalyceal systems and/ (TREATMENT ARM –
or stones ≥20mm given Ciprofloxacin prior
(CONTROL ARM) to PCNL)
PATIENTS AND METHODS N = 46 N = 52
28
smaller than the uninfected stones (37.6 mm;
P = 0.04). This relationship was maintained in
60
45 both phases of the study.
40
DISCUSSION
20 18
Most centres worldwide use antibiotic
7 prophylaxis in accordance with the Infectious
0 Diseases Society of America and European
Control Treatment (ciprofloxacin) Society of Clinical Microbiology and
Infectious Diseases guidelines [6], but the
SIRS; No SIRS empirical prescription of preoperative
antibiotics for longer is being used for FIG. 4. Relationship between stone bulk (in mm), stone C&S and SIRS in both phases.
patients with a ‘higher risk’ of urosepsis. To
our knowledge this is the first controlled Study phase
study of its kind to show the benefits of this 1 2
extended period of antibiotic prophylaxis
100.00
before stone surgery. We showed that
infected pelvic urine, infected stones and
urosepsis can significantly be reduced with
1 week of oral ciprofloxacin in patients with 80.00
large stones and dilated pelvicalyceal systems,
who are at greater risk of urosepsis after
PCNL. The inability to reduce the infection 60.00
Stone bulk
within stones in a few patients might be
attributed to the impenetrability of the
stones, presence of endotoxins in the stone
matrix [7] and the possibility that the patients 40.00
did not comply with the preoperative
antibiotic regimen.
20.00
Despite careful preparation before PCNL,
patients still develop systemic and sometimes
catastrophic infection. Urosepsis and shock
0.00
occur in direct proportion to the duration of
the procedure, bacterial load in the urine, negative positive negative positive
severity of obstruction by the stone and
presence of infection in the stone [8]. MSU Stone C&S
samples have been shown not to represent SIRS absent present
the infection present in the upper tracts
[3,4,9–11]. Conversely, stone and pelvic urine
C&S were better predictors of urosepsis after However, using stone bulk and pelvicalyceal CONFLICT OF INTEREST
surgery and large stones appeared more likely dilatation as suitable surrogate markers [3] for
to be infected. Shigeta et al. [12] found upper UTI, ciprofloxacin for 7 days before None declared.
infected stones in 10% of their 57 patients PCNL reduced the risk of sepsis afterward, and
with renal stones, and found that bacteriuria the potentially longer course of antibiotics REFERENCES
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We used SIRS to define urosepsis, as it is a urosepsis following percutaneous
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