One week pre-operative oral antibiotics for percutaneous nephrolithotomy reduce risk of infection: a systematic review and meta-analysis

Danilovic, Alexandre; Talizin, Thalita Bento; Torricelli, Fabio Cesar Miranda; Marchini, Giovanni S.; Batagello, Carlos; Vicentini, Fabio C.; Nahas, Willaim C.; Mazzucchi, Eduardo

doi:10.1590/S1677-5538.IBJU.2022.0544

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Sumário

REVIEW ARTICLE • Int. braz j urol 49 (2) • Mar-Apr 2023 • https://doi.org/10.1590/S1677-5538.IBJU.2022.0544 copy

One week pre-operative oral antibiotics for percutaneous nephrolithotomy reduce risk of infection: a systematic review and meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose

The aim of this meta-analysis is to assess the efficacy of extended dose of preoperative antibiotics to reduce infectious risk in patients undergoing percutaneous nephrolithotomy (PCNL).

Materials and Methods

A literature search for prospective case-control studies or randomized controlled trials was done. PICO framework was used. Population: adult patients that underwent to PCNL; Intervention: extended dose preoperative antibiotic prophylaxis before PCNL; Control: short dose preoperative antibiotic prophylaxis before PCNL; and Outcome: systemic inflammatory response syndrome (SIRS) or sepsis, fever after PCNL and positive intraoperative urine and stone culture. This meta-analysis was registered in PROSPERO database under the number: CRD42022359589.

Results

Three RCT and two prospective studies (475 patients) were included. SIRS/sepsis outcome was retrieved from all studies included. Seven days preoperative oral antibiotics for PCNL was a protective factor for developing SIRS/sepsis (OR 0.366, 95% CI 0.234 - 0.527, p < 0.001). There was no statistical association between seven-day use of antibiotics and fever (OR 0.592, 95% CI 0.147 – 2.388, p = 0.462). Patients who received seven days preoperative antibiotics had lower positive intraoperative urine culture (OR 0.284, 95% CI 0.120 – 0.674, p = 0.004) and stone culture (OR 0.351, 95% CI 0.185 – 0.663, p = 0.001) than the control group.

Conclusion

one week of prophylactic oral antibiotics based on local bacterial sensitivity pattern plus a dose of intravenous antibiotics at the time of surgery in patients undergoing PCNL reduces the risk of infection.

Anti-Bacterial Agents; Drug Therapy; Kidney Calculi; Nephrolithotomy, Percutaneous

Study	Country	Design	Inclusion criteria	Definition of SIRS or Sepsis	Procedure	Patients, n	Mean age, years	Stone size, mm
Mariappan, et al. 2006 ( ¹⁵15. Mariappan P, Smith G, Moussa SA, Tolley DA. One week of ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study. BJU Int. 2006;98:1075-9. )	UK	Prospective	Stones ≥ 20 mm and/or dilated pelvicalyceal system	SIRS was defined as the systemic response to infection, manifested by two or more of the following conditions as a result of infection: - Temperature ≥ 38^o C or ≤ 36^o C - Heart rate > 100 beats/min - Respiratory rate > 20/min - White blood cell count > 12,000 white blood cells/mL or < 4,000 white blood cells/mL	7 days of antibiotic (250 mg of ciprofloxacin twice daily) before PCNL vs. No antibiotic before PCNL	52 vs. 46	55.5 vs. 53.1	30.8 vs. 32.8
Bag et al. 2011 ( ¹⁶16. Bag S, Kumar S, Taneja N, Sharma V, Mandal AK, Singh SK. One week of nitrofurantoin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study. Urology. 2011;77:45-9. )	India	RCT	Patients with stones ≥ 2,5 cm and/or hydronephrosis and sterile urine	Hard criteria for SIRS were fever > 38^o C and/or leukocyte counts > 12,000	7 days of antibiotic (100 mg of nitrofurantoin twice daily) before PCNL vs. No antibiotic before PCNL	48 vs. 53	39.2 vs. 40.4	34.1 vs. 36.7
Chew et al. 2018 ( ²³23. Chew BH, Miller NL, Abbott JE, Lange D, Humphreys MR, Pais VM Jr, et al. A Randomized Controlled Trial of Preoperative Prophylactic Antibiotics Prior to Percutaneous Nephrolithotomy in a Low Infectious Risk Population: A Report from the EDGE Consortium. J Urol. 2018;200:801-8. )	USA/ Canada	RCT	Patients with sterile urine and no urinary drain	Sepsis was defined as having an infection source in addition to 2 or more of the following criteria at least 12 hours after the procedure: temperature > 38,3^oC or < 36^oC, heart rate > 90/minute, respiratory rate > 20/minute, altered mental status, systolic blood pressure < 90mmHg, mean arterial pressure decrease of more than 40 mmHg and white blood cell count > 12,000 or < 4,000.	7 days of antibiotic (100 mg of nitrofurantoin twice daily) before PCNL vs. No antibiotic before PCNL	43 vs. 43	56 vs. 62	19 vs. 17
Sur et al. 2021 ( ¹⁷17. Sur RL, Krambeck AE, Large T, Bechis SK, Friedlander DF, Monga M, et al. A Randomized Controlled Trial of Preoperative Prophylactic Antibiotics for Percutaneous Nephrolithotomy in Moderate to High Infectious Risk Population: A Report from the EDGE Consortium. J Urol. 2021;205:1379-86. )	USA/ Canada	RCT	Patients ≥ 18 years old who had stone burden of any size for which PCNL was recommended. Subjects had to have had either a positive preoperative urine culture within 3 months of the planned procedure or an internalized ureteral stent, nephrostomy tube or nephroureteral stent at time of PCNL.	Sepsis was defined as having an infection source in addition to 2 or more of the following criteria at least 12 hours after the procedure: temperature > 38,3^oC or < 36^oC, heart rate > 90/minute, respiratory rate > 20/minute, altered mental status, systolic blood pressure < 90mmHg, mean arterial pressure decrease of more than 40 mmHg and white blood cell count > 12,000 or < 4,000.	7 days of antibiotic (100 mg of nitrofurantoin twice daily) before PCNL vs. 2 days of antibiotic (100 mg of nitrofurantoin twice daily) before PCNL	68 vs. 55	61 vs. 54	20 vs. 23
Xu et al. 2022 ( ²⁴24. Xu P, Zhang S, Zhang Y, Zeng T, Chen D, Wu W, et al. Preoperative antibiotic therapy exceeding 7 days can minimize infectious complications after percutaneous nephrolithotomy in patients with positive urine culture. World J Urol. 2022;40:193-9. )	China	Prospective	Patients with positive urine culture undergoing primary PCNL	SIRS was defined as the co-existence of at least two of the following items during the whole hospitalization: temperature > 38^oC or < 36^oC, heart rate > 90/min, respiratory rate > 20/min or PaCO2 < 32 mmHg, and white blood cell count > 12,000 or < 4,000.	7 days of empiric antibiotic before PCNL vs. No antibiotic before PCNL	30 vs. 28	NA	NA

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[1] Correspondence address: Alexandre Danilovic, MD Departamento de Urologia, Univ. de São Paulo Hospital das Clínicas - HCUSP Rua Dr Enéas de Carvalho Aguiar 255 São Paulo, SP, 05403-000, Brasil Telephone: +55 11 2661-8080 E-mail: alexandre.Danilovic@gmail.com