Presented by: Jeffrey Johnson MD
Weill Cornell Medicine

Introduction

Updated in 2019, the American Urological Association’s (AUA) Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis outlines prophylaxis recommendations for percutaneous nephrolithotomy (PCNL). Recent studies have challenged these Best Practice Statements. We hypothesized endourologists do not routinely follow the AUA’s statement on antibiotic use during PCNL and assessed their prescribing patterns.

Materials

A 25-question survey was distributed to members of the Endourological Society. The primary outcome was adherence to the AUA’s recommendations. Multivariable logistic regression analysis was performed to assess predictors of Best Practice Statement adherence.

Results

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51.4% of endourologists follow the AUA Best Practice Statement for antimicrobial prophylaxis of uncomplicated PCNL. No demographic data was predictive of following the AUA. 90.9% and 83.6% reported they have “never” used the first-line recommendation options of metronidazole and aztreonam, respectively. Preferred antibiotics were cephalosporins (uncomplicated 60%, complicated 52.6%), fluoroquinolones (13.3%, 7.2%), aminoglycosides (12.7%, 17.8%), penicillins (7.9%, 11.2%), carbapenems (0.6%, 0.7%), trimethoprim-sulfamethoxazole (2.4%, 5.9%), fosfomycin (0.6%, 0.7%), nitrofurantoin (2.4%, 2.6%), aztreonam (0%, 0.7%), and clindamycin (0%, 0.7%). For uncomplicated PCNL, 37.9% prescribe > 24 hours of perioperative antibiotics. For complicated PCNL, 16.2% prescribe ≤ 24 hours of perioperative antibiotics while 20.4% begin antibiotics 7 or more days prior.

Conclusion

Nearly half of respondents do not follow the AUA’s recommendations for antibiotic choice for PCNL. Few endourologists prescribe 7 days of preoperative antibiotics for complicated PCNL despite supporting data. Metronidazole and aztreonam are rarely used as a first line antibiotic choice for PCNL and their roles needs to be further evaluated as first line prophylaxis recommendations.  Updates on antibiotic recommendations for PCNL are needed based on current literature, antimicrobial stewardship, and contemporary practice patterns.

Funding

None

Lead Authors

Ojas Shah, MD
Columbia University Irving Medical Campus

Co-Authors

Prakash Gorroochurn, PHD
Columbia University Department of Biostatistics

Miyad Movassaghi, MD
Columbia University Irving Medical Campus

David Han, MD, MS
Columbia University Irving Medical Campus

Juliana Villanueva, MD, MPH
Columbia University Mailman School of Public Health

Michael Schulster, MD
Columbia University Irving Medical Campus