9.2 Introduction

Almost 50 years after its introduction, peri-operative prophylaxis is still controversial. Whereas a clear benefit has been established for certain surgical operations (e.g. elective colonic surgery), there is no general consensus on the use of antibacterial prophylaxis in urology. The traditional classification of surgical procedures according to Cruse and Foord (1) into clean, clean-contaminated, contaminated and dirty does not adequately describe the risk of infection in endo-urology. The overall risk is influenced by the patient's condition, the surgical procedure and environmental factors. However, the significance of each factor has not yet been quantified (2).

At present, most studies are poorly designed or lack statistical power. The differentiation between therapy and prophylaxis is not clear. Evaluation of risk factors is unsatisfactory and the terms bacteriuria and infection are used uncritically. In addition, many of these studies lack knowledge of pharmacokinetics and pharmacodynamics, bacterial pathogenicity and the role of nosocomial infections (3,4). Thus, it is not surprising that the literature is inconclusive with regard to prophylaxis, showing negative as well as positive results for every kind of urological intervention.

A recent survey of 320 German urologists revealed controversial opinions about peri-operative antibiotic prophylaxis (5). It was administered in only 51 % of procedures involving the urinary tract and 9% of the responding urologists did not even use prophylaxis when opening the intestine. There was little agreement on the choice of antibiotics (35.3% used co-trimoxazole, 26.6% cephalosporins and 8.7% fluoroquinolones) and the duration of prophylaxis (only 10% used a single pre-operative dosing regimen). There are also variations between countries (6-8). Consequently, guidelines for the indication of peri-operative prophylaxis in urology are certainly necessary to improve the quality of patient care.

Presented are practical recommendations covering patients with normal and increased susceptibility, as well as different types of surgical procedures. These recommendations are based on clinical studies, expert opinion and professional consensus. They also consider the recommendations of societies, such as the Paul Ehrlich Society for Chemotherapy (9), the Working Group "Infectiology" of the German Society for Urology (10), Association Frangais d'Urologie (11) and the Swedish-Norwegian Consensus Group (12).

9.3 Goals of peri-operative antibacterial prophylaxis

The aim of peri-operative prophylaxis is to limit infection related to intervention. However, it can nevercompensate for poor operative technique. Antibiotic prophylaxis is only one component of infection prevention

management and should be integrated into the local antibiotic policy. Other important factors should not be neglected (e.g. short hospital stay, catheter care, use of closed drainage systems) and the education of the health care team is of paramount importance (13-15).

The endpoints of peri-operative prophylaxis in urology are debatable. It is generally agreed that its main aim is to prevent symptomatic/febrile genito-urinary infections, such as acute pyelonephritis, prostatitis, epididymitis and urosepsis, as well as serious wound infections. This might be extended to include post­operative asymptomatic bacteriuria or even a small wound infection, which could easily be treated on an outpatient basis. In some circumstances, these might assume greater significance, e.g. in implant surgery where either can cause the patient to risk loss of the implant. On the contrary, asymptomatic bacteriuria after TURP may disappear spontaneously and is usually of no significance. Another question is: should peri-operative prophylaxis also be concerned with the prevention of non-urological infections, e.g. endocarditis and post-operative pneumonia? It is considered that peri-operative antibacterial prophylaxis in urology has to go beyond the traditional aim of prophylaxis, which is the prevention of wound infections (3,16).

With transurethral resection of the prostate (TURP), several controlled studies have shown that the rate of post-operative bacteriuria can be reduced by peri-operative prophylaxis. And yet this does not necessarily translate into a reduction of symptomatic UTIs or the prevention of febrile episodes (17-22). Moreover, since the rate of septic complications is generally < 1 %, a prospective study will require large numbers of patients to be recruited to reach statistical power. Until now, most of our knowledge on the prevention of urosepsis has come from retrospective studies and is therefore deficient (23).

It is generally agreed that the incidence of post-operative septic complications has fallen over the past 10-15 years, and this may have more to do with improved asepsis and advanced technology than with antibiotic prophylaxis.