Cua Guidelines On Antibiotic Prophylaxis For Urologic-PDF Free Download

CUA Guidelines on antibiotic prophylaxis for urologic
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Mrkobrada et al, in patients who did not have a known pre procedural infec outcome assessors We also assessed whether the trial was. tion terminated prematurely due to benefit and whether the anal. ysis was conducted according to the intention to treat princi. Information sources ple We also used the GRADE Grading of Recommendations. Assessment Development and Evaluation approach to, A librarian experienced in conducting systematic reviews assess the quality of evidence 4. in the healthcare field assisted us in conducting our search. We electronically searched the following bibliographic data Statistical analyses. bases EMBASE January 1980 to October 2012 Medline, January 1950 to October 2012 and All evidence based For each trial outcome we calculated the relative risk RR to. medicine EBM reviews ACP Journal Club Database of summarize the outcomes for patients treated with antibiotics. Abstracts of Reviews of Effects Cochrane Central Register of versus placebo or no treatment For all relative risks we deter. Controlled Trials Health Technology Assessment Cochrane mined 95 confidence intervals We pooled results using a. Database of Systematic Reviews National Health Service random effects model We quantified statistical heterogeneity. Economic Evaluation and Cochrane Methodology Register using the I2 statistic We interpreted an I2 value of 0 to 25. from inception of database to October 2012 There was no as low heterogeneity 25 to 50 as moderate heterogene. language restriction We identified relevant papers from the ity and greater than 50 as high heterogeneity The risk of. grey literature by consulting with experts in the field Our publication bias across trials was assessed using funnel plots. searches were supplemented by reviewing the reference lists. of all citations that met our final inclusion criteria Development of evidence based guideline recommendations. Study selection The panel convened to make a draft of the guideline recom. mendations This draft was presented to the CUA Guidelines. We entered the retrieved citations into RefMan v12 and Committee. duplicate records were removed Two investigators inde. pendently screened the title and abstract of the citations If Guideline findings and recommendations. either investigator felt that a citation might be relevant it. was marked for full text retrieval Two investigators indepen. dently evaluated the retrieved full text articles for eligibil Antibiotic prophylaxis for transrectal prostate biopsy. ity Cohen s kappa statistic was used to quantify agreement. between the investigators Disagreements were resolved Results of literature search. through a consensus process of having the two reviewers. discuss their decisions and a third investigator was con Our literature search identified recently published system. sulted in case of an impasse to provide a final decision atic review of high methodological quality based upon the. PRISMA Statement 5 We based our recommendations on the. Data collection findings of this systematic review. Two reviewers independently abstracted the data from Results of the systematic review. included trials Any disagreement in the abstracted data. between the two reviewers was resolved through the same The systematic review identified a total of 9 RCTs 3599. consensus process used in study selection patients comparing antibiotics with control treatment 5. The following data items were abstracted from the articles Fluoroquinolones were studied most frequently 5 RCTs. included in the systematic review Demographic data study 1188 patients. interventions and the study outcomes of mortality bacteri There was a high incidence of adverse infection related. uria bacteremia urinary tract infection fever septicemia events in patients undergoing TRPB without antibiotic pro. pyuria and adverse events We used the study s definition phylaxis Compared with untreated controls antibiotics sig. of the outcome nificantly reduced the rates of bacteriuria 14 8 vs 3 9. bacteremia 8 6 vs 2 1 fever 10 8 vs 4 0 urinary, Risk of bias tract infection UTI 9 0 vs 3 3 and hospitalization. 3 3 vs 0 3 No adverse events related to antibiotic. We assessed for the risk of bias in the included trials by prophylaxis were recorded. determining the adequacy of allocation concealment along. with blinding of the trial participants care providers and. 14 CUAJ January February 2015 Volume 9 Issues 1 2, cua guidelines on antibiotic prophylaxis.
Length of antibiotic prophylaxis Utility of pre procedural enema. With respect to short 1 day versus long 3 days course With regards to antibiotics versus enema or antibiotic versus. regimens the only significant difference was a decreased antibiotic and enema only 4 trials were analyzed with lim. incidence of bacteriuria in the 3 day group However the ited number of patients in each trial There was no evidence. differences between the groups were not significant with that pre procedural enemas affected infection rates. regards to bacteremia fever UTI and hospitalization In. the analysis between single dose and multiple doses mul Guideline recommendations. tiple doses were associated with significantly reduced rates. of bacteriuria without any effect on other outcomes Also There is a high risk of adverse infection related events in. there was no difference between oral versus systemic admin patients undergoing TRPB and prophylactic antibiotics. istration of the antibiotics are recommended for these patients Grade A Level of. Evidence IA Most studies investigated the use of fluoroqui. Antibiotic class nolones single dose or short courses of antibiotics appear. to be as effective as the longer course regimens There was. In studies comparing different classes of antibiotics i e insufficient evidence for efficacy of pre procedural enemas. fluoroquinolones sulfonamides or piperacillin tazobactam to recommend their routine use The choice of specific. versus other antibiotics there were no differences in out agent for prophylaxis should be based in part on the local. comes The best evidence exists for quinolones as they were epidemiology of drug resistance in potential uropathogens. the most commonly utilized and analyzed and had the larg Grade D Level of Evidence IV In patients at increased. est number of patients included in the various trials With risk of harboring resistant organisms perirectal culture. emerging quinolone resistances novel approaches using swabs prior to TRPB should be considered. multi agent and perirectal cultures to determine appropri. ate antibiotic selection have been used 6 7 Although further Antibiotic prophylaxis for ESWL. RCTs are required before recommending this approach uni. versally we recommend that patients with increased risk of Methods of literature search. harboring resistant organisms previous history of urosepsis. or multiple treatments with antibiotics should have perirec We included all RCTs comparing the use of antibiotic pro. tal culture swabs performed prior to biopsy phylaxis versus control Study participant inclusion crite. ria involved adults with preoperative sterile, urine who underwent ESWL We excluded. Identification, Records identified through Additional records identified. database searching through other sources participants with positive preoperative urine. n 1308 n 142 cultures The primary outcomes of interest. were postoperative infectious complications, Records after duplicates removed. of UTI fever or any other serious infectious, n 1450 complication We excluded trials that did not. report on these outcomes of interest, Records screened Records excluded.
n 1450 n 1396, Results of the systematic review, Full text articles excluded The literature search identified 1450 cita. Full text articles assessed n 42, for eligibility, tions and we selected 54 articles for full. Eligibility, Not RCT 24, n 54 Participant age 5 text retrieval Fig 1 Eight met the eligibility. Nonsterile preoperative criteria for final inclusion in the systematic. Studies included in No suitable comparison review 8 15. qualitative synthesis arm 1 Eight controlled trials randomized a total. n 12 No suitable outcomes, reported 8 of 940 study participants Table 1 The inci. dence of UTI and fever were 4 2 and 3 4, Studies included in meta analysis Studies included in meta analysis respectively Antibiotic prophylaxis in patients.
of ESWL procedures of other stone manipulation, n 8 procedures. undergoing ESWL Fig 2 Fig 3 was not asso, n 4 ciated with a statistically significant difference. in the risk of post procedural UTI RR 0 76, Fig 1 Study selection flowsheet for extracorporeal shock wave lithotripsy and other stone. manipulation procedures RCT randomized controlled trial. 95 CI 0 39 to 1 48 p 0 42 or an inci, CUAJ January February 2015 Volume 9 Issues 1 2 15. Mrkobrada et al, Table 1 Study characteristics of trials investigating antibiotic prophylaxis for ESWL.
Total dose, Author Year Procedure Ntot Control Antibiotic Route Dosing regimen. Ciprofloxacin IV 200 1 dose 30 min before surgery, IV 200 1 dose 30 min before surgery. PO 3000 2 doses day for 6 days after surgery, Bierkens 1997 ESWL 177 Placebo. Cefuroxime IV 750 1 dose 30 min before surgery, IV 750 1 dose 30 min before surgery. PO 3000 2 doses day for 6 days after surgery, No Amoxicillin.
Claes 1989 ESWL 181 IV 2000 200 1 dose 30 min before surgery. treatment clavulanate, 1 dose every 12 hours beginning 48. Dejter 1989 ESWL 49 Placebo Norfloxacin PO 2000, hours before surgery. No Co trimoxazole PO 400 80 Unclear, Ghazimoghaddam 2011 ESWL 150. treatment Nitrofurantoin PO 100 Unclear, 1 dose 30 min before surgery. Herrlinger 1987 ESWL 64 Azlocillin IV 5000 continued until 6 to 8 hours after. Knipper 1989 ESWL 50 Enoxacin PO 400 1 dose 1 hour before surgery. Trimethoprim 1 dose 24 hours before surgery 2, No PO 1280 6400.
sulfamethoxazole doses day for 7 days from surgery. Pettersson 1989 ESWL 149 treatment, Methenamine 1 dose 24 hours before surgery 3. hippurate doses day for 7 days from surgery, No 3 doses beginning 8 hours before. Rigatti 1989 ESWL 120 Aztreonam IM 3000, treatment surgery. dence of fever RR 0 26 95 CI 0 06 to 1 10 p 0 07 No Guideline recommendations. adverse events related to antibiotic prophylaxis were recorded. in these studies The overall quality of evidence was moderate Pre procedural antibiotics do not significantly reduce the. as judged by the GRADE criteria risk of UTI and fever in patients undergoing ESWL but. should be considered in patients at high risk of infectious. Antibiotic class complications Grade B Level of Evidence IB Patients with. large stone burden associated pyuria history of pyelone. Fluoroquinolones were the most commonly studied anti phritis and adjunctive operative procedure including stent. biotics 3 trials Third generation second generation and nephrostomy insertion PCNL or ureteroscopy are at a high. first generation cephalosporins penicillin aminoglycosides er risk of developing pyelonephritis post ESWL 2 The choice. and sulfa based antibiotics were each studied once Studies of specific agent for prophylaxis should be based in part. varied in terms of dose route and timing of administration on the local epidemiology of drug resistance in potential. in the treatment arms uropathogens Grade D Level of Evidence IV. Fig 2 Forest plot of relative risk of urinary tract infection with antibiotic prophylaxis for extracorporeal shock wave lithotripsy. 16 CUAJ January February 2015 Volume 9 Issues 1 2, cua guidelines on antibiotic prophylaxis. Fig 3 Forest plot of relative risk of fever with antibiotic prophylaxis for extracorporeal shock wave lithotripsy. Antibiotic prophylaxis for stone manipulation procedures RR 0 30 95 CI 0 15 to 0 58 p 0 001 but was not. associated with a significant reduction in the incidence of. Methods of literature search fever RR 0 38 95 CI 0 12 to 1 21 p 0 10 No adverse. events related to antibiotic prophylaxis were recorded in. We included all RCTs comparing the use of antibiotic pro these studies The overall quality of evidence was moderate. phylaxis versus control Study participant inclusion criteria as judged by GRADE criteria. involved adults with preoperative sterile urine who under. went PCNL percutaneous stone removal or ureteroscopic Antibiotic class. stone removal We excluded participants with positive pre. operative urine cultures The primary outcomes of interest Fluoroquinolones were studied in 2 trials third generation. were postoperative infectious complications of UTI fever cephalosporins first generation cephalosporins and ami. or any other serious infectious complication We excluded noglycosides were each examined in single trials Study. trials that did not report on these outcomes of interest interventions varied in terms of dose route and timing of. administration in the treatment arms, Results of systematic review.
Guideline recommendations, The literature search identified 1450 citations and we. selected 47 articles for full text retrieval Fig 1 Of the 54 Antibiotics reduce the risk of UTI following non ESWL stone. articles 4 met the eligibility criteria for final inclusion in manipulation procedures and there is a trend towards a. the systematic review 2 trials studied ureteroscopy 16 17 1 reduction in the incidence of fever We recommend that. trial studied PCNL18 and 1 studied both ureteroscopy and peri procedural antibiotics should be considered in patients. cua guidelines on antibiotic prophylaxis Length of antibiotic prophylaxis With respect to short 1 day versus long 3 days course regimens the only significant difference was a decreased incidence of bacteriuria in the 3 day group However the differences between the groups were not significant with

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