Infection Risk and Preoperative Antimicrobial Therapy

As stated previously, documented preoperative urinary tract infection must be eradicated with appropriate antimicrobial therapy. This is very important given the observation that bacteremia occurs postoperatively in 10-32% of patients without recognized preoperative bacteri-uria and occurs much more frequently in patients with infected urine (9,10). Prophylactic antibiotic administration to reduce immediate and long-term infection-related risks in patients without preoperatively documented infection has a limited effect on perioperative infections or fever, although a reduced incidence of postoperative bacteremia has been noted (9). Gorelick and associates documented demonstrable bacteria in as many as 20% of prostatectomy tissue specimens (11). As a result, antibiotics used for prophylaxis should eradicate bactericidal tissue as well as reduce levels in urine. In low-risk patients with negative preoperative urine cultures, we commonly initiate coverage about 1 h before surgery using intravenous levofloxacin or cefazolin. Patients with increased risk factors for infection such as azotemia, upper tract calculi, a history of an elevated PVR, debility, diabetes mellitus, and those who are immunocompromised are given a longer course of pre-operative oral antimicrobial prophylaxis. All patients currently receive empiric intravenous antimicrobial therapy for 24-48 h after surgery. Before catheter removal, urine is again submitted for culture and sensitivity testing. If infection is documented, appropriate targeted antimi crobial therapy is provided. If the cultures are negative, patients are given a 3-d course of nitrofurantin or a fluoroquinolone to begin on the day of catheter removal.

The American Heart Association recommends endocarditis prophylaxis at the time of prostatic surgery for those with the following conditions: (1) a prosthetic cardiac valve; (2) congenital cardiac malformation; (3) surgically constructed systemic-pulmonary shunts; (4) rheumatic and other acquired valvular dysfunction; (5) idiopathic hypertrophic cardiomyopathy; (6) history of baterial endorcarditis;

(7) mitral valve prolapse with regurgitation or thickened leaflets; or

(8) cardiac surgery within the preceding 6 mo. Enterococci bacteria are the most common cause of endocarditis after gastrointestinal and genitourinary procedures. For genitourinary surgery and instrumentation, a standard parenteral antibiotic regimen would include 2.0 g ampicillin (50 mg/kg) intramuscularly or intravenously plus 1.5 mg/kg gentamicin (maximum 120 mg) administered within 30 min of beginning surgery. Oral ampicillin (1 g intramuscularly or intravenously) or 1 g of oral amoxicillin should be administered 6 hr later for high-risk patients. Moderate-risk patients can be treated with 2 g of amoxicillin orally 1 hr before or 2 g of ampicillin intramuscularly or intravenously within 30 min of the planned procedure. Vancomycin (1 g intravenously infused slowly over 1 h, beginning 1 h before surgery) is used in penicillin-allergic patients. High-risk patients include those individuals with prosthetic heart valves, a history of endocarditis, and those patients taking continuous oral penicillin for rheumatic fever prophylaxis (1).

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Diabetes 2

Diabetes 2

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