Year : 2013 | Volume
: 29 | Issue : 3 | Page : 265--266
Antibiotic prophylaxis before extracorporeal shock wave lithotripsy in patients with sterile urine: Routine or targeted
|How to cite this article:|
Abrol N. Antibiotic prophylaxis before extracorporeal shock wave lithotripsy in patients with sterile urine: Routine or targeted.Indian J Urol 2013;29:265-266
|How to cite this URL:|
Abrol N. Antibiotic prophylaxis before extracorporeal shock wave lithotripsy in patients with sterile urine: Routine or targeted. Indian J Urol [serial online] 2013 [cited 2020 Apr 6 ];29:265-266
Available from: http://www.indianjurol.com/text.asp?2013/29/3/265/117275
Antibiotic prophylaxis before shock wave lithotripsy (SWL) is a debatable issue. D'A Honey et al. reported a prospective single cohort study for evaluating the role of targeted prophylaxis before SWL.  All patients 18 years or older treated with SWL for renal or ureteric calculi over 6 months were enrolled. They obtained pre-treatment urine culture within 2 weeks before SWL. Only patients with sterile pre-treatment culture were subjected to SWL. Urine dipstick, urine microscopy and repeat culture were performed on the day of treatment. Antibiotic prophylaxis was given at the discretion of urologist without following any uniform protocol. Following SWL, all patient had post-treatment urine culture and urine analysis after 3 days and a survey documenting fever and urinary symptoms after 1 week. Rate of urinary tract infection (UTI), urosepsis and asymptomatic bacteriuria (ABU) were studied as the primary outcome. For assessing primary outcome, patients who had a positive day of treatment culture (n = 31) and who failed to give post-treatment samples (n = 106) were excluded. However, outcome of these patients were reported.
Out of 529 patients enrolled in this study, 389 (529 - (31 + 106)) were included for primary analysis. 8 (2.1%) patients received antibiotic prophylaxis. 1 of these eight patients developed positive post-treatment culture without having any symptoms. Another 9 (3.1%) patient received post-treatment antibiotics by family physicians for their symptoms developing after SWL, but none had positive urine culture. Only, 1 (0.3%) patient had a symptomatic, culture documented UTI while 11 (2.8%) patients developed ABU. UTI was treated with oral antibiotics and no patient developed urosepsis. None of the 106 patients who were excluded because they did not provide a post-treatment culture developed any post-SWL symptoms. Of 31 patients with positive culture on the day of SWL (result of culture available after SWL), three could not give a post-treatment sample, 10 had positive and 18 had negative post-treatment cultures. None of them developed urosepsis.
Currently, evidence for antibiotic prophylaxis before SWL in patients with sterile urine is conflicting. , A meta-analysis by Pearle et al. including eight randomized clinical trials (RCTs) and six clinical trials concluded that prophylaxis is efficacious in reducing post-SWL UTIs; with median probability of post-SWL UTI of 2.1% and 5.7% with and without prophylaxis respectively.  A recent meta-analysis pooled nine RCTs and did not find any significant difference in prophylaxis versus no prophylaxis.  While previous studies evaluated routine prophylaxis, D'A Honey et al. report the largest non-randomized clinical series examining the role of targeted prophylaxis before SWL.  Rate of UTI (0.3%) and ASB (2.8%) after targeted prophylaxis is similar to median probability of developing UTI after routine prophylaxis in the meta-analysis by Pearle et al.  Thus, this study questions the need of routine pre SWL prophylaxis. However, due to its small sample size and non-uniform policy for antibiotic regimen as well as indication for prophylaxis, the objective of this study to examine the efficacy of targeted prophylaxis cannot be evaluated.
A total of 106 (20.15%) patients failing to give post-SWL urine sample in a prospective study is a major drawback. Though none had developed symptoms, no comment can be made on ABU. Cultures were taken 3 days post-SWL and 0.3% rate of UTI and 2.8% ABU may not be representative at longer follow-up. In a RCT reported by Bierkens et al., rate of bacteriuria was 20% after 2 weeks and 23% after 6 weeks and UTI developed in 2-3%.  Risk of bacteriuria is significantly high for struvite stones (17.3% v 2.1%).  The average stone size in the present study is small (67.2 mm 2 ) and 90.4% were CaOx monohydrate type while only one struvite stone was treated.
Guidelines for antibiotic prophylaxis before SWL are conflicting. Routine pre SWL antibiotic prophylaxis in patients with sterile urine may not be necessary. Further studies are needed to define indications for targeted prophylaxis.
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