Vol 13 No 05 September-October 2016 2744
The Effect of Antibiotic Prophylaxis on Post-Operative Infection in Patients Undergone Flexible
Cystos-copy
Miguel Ángel Arrabal-Polo1,2*, María del Carmen Cano-García1,2, Miguel Arrabal-Martín2, Sergio Merino-Salas3
Purpose: The aim of this study is to determine whether antibiotic prophylaxis is required in this outpatient proce-
dure.
Materials and Methods: A non-randomised, prospective observational study that included 184 patients subjected
to flexible cystoscopy divided into three groups: - Group 1:60 patients with prophylaxis of 500 mg of ciproflox-
acin; - Group 2:62 patients with prophylaxis of 3 g of phosphomycin; and Group 3:62 without antibiotic prophy-
laxis. Prior to inclusion in the study, absence of infection was checked by means of a urine culture obtained 7 days
before the procedure. An analysis was made of urinary infection after 7 days, the cystoscopy indications and its
diagnosis, the presence of comorbidities, and the urinary symptoms during the following 7 days.
Results: The mean age of the patients in Group 1 was 65.3 (SD: 12.5) years, 66.7 (10.8) years in Group 2, and 66.9
(10.8) years in Group 3 (P = .7). Bacteriuria was present in 15% of the patients in Group 1, compared to 22.6% in
Group 2, and 12.9% in Group 3, with the differences not statistically significant. In multivariate analysis, it was
observed that there was no association with the appearance of bacteriuria between the groups for age (P = .8), dia-
betes (P = .2), smoking (P = .4), lower urinary tract symptoms (P = .7), or immunosuppression (P = .6).
Conclusion: The use of ciprofloxacin or phosphomycin as prophylaxis does not appear to be indicated in flexible
cystoscopy in our health area.
Keywords: ciprofloxacin; flexible cystoscopy; prophylaxis; phosphomycin; urinary infection.
INTRODUCTION
Antibiotic prophylaxis in urological surgery contin-ues to be a subject of debate years after the first
publications that recommended the use of beta-lactams
only, or in combination with aminoglycosides, and
placing special emphasis on patients of advanced age
and with certain comorbidities(1,2). Subsequent studies
continue to indicate that more studies are required in
order to optimize and establish the correct prophylaxis
in urological procedures performed on outpatients, as
well as in those that require hospital admission(3,4). The
increase in the performing of transurethral procedures
has led to the need to find a more suitable plan of action
as regards antibiotic prophylaxis, since although some
authors recommend its use in high risk procedures, they
do not believe it is indicated in low risk procedures,
such as flexible cystoscopy(5). As regards the use of an-
tibiotic prophylaxis, two recent reviews recognized that
there is low-moderate scientific evidence that lead us
to the option of not giving prophylactic antibiotic treat-
ment, although they mention that more well-designed
studies are required to compare the use of antibiotic
prophylaxis against not using it(6,7). Different types of
antibiotics have been used in the prophylaxis of out-
1 Urology department. La Inmaculada Hospital. Huercal Overa. Spain..
2 IBS Granada. Spain.
3 Urology department. Poniente Hospital. Almería. Spain.
*Correspondence: Urology department. La Inmaculada Hospital. Huercal Overa. Spain.
Adress: Plaza Ciudad de los Carmenes, 6, PZ 18013. Granada.
Received August 2016 & Accepted January 2017
patient procedures such as cystoscopy. These include
quinolones that, although some authors defend their use
in decreasing bacteriuria and urinary infection(8,9), this
point must be clarified, as we have previously seen in
recent reviews(6,7). As can be seen from the current sci-
entific evidence and from usual clinical practice, there
are no protocols on the use or not of antibiotic prophy-
laxis in flexible cystoscopy, nor is there a consensus on
whether or not it is appropriate. The justification for this
study is based mainly on this, in the interest that it con-
tributes to increasing the scientific evidence on whether
there is a need or not to give antibiotic prophylaxis. The
interest of this study is that is a clinical study without
intervention, but with a well designed method in clinical
habitual practice comparing two antibiotic prophylax-
is with no prophylaxis. As different studies(1-3,8,9) have
used quinolones and phosphomycin as prophylaxis in
flexible cystoscopy, asserting its usefulness in the re-
duction of bacteriuria and infection, we established that
the main objective of this study is to analyse the role
of ciprofloxacin and phosphomycin versus not carrying
out any prophylactic treatment in patients subjected to
flexible cystoscopy, evaluating the presence of urinary
tract infections, bacteriuria, as well as other variables
that will be mentioned in the following section.
ENDOUROLOGY AND STONE DISEASE
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MATERIALS AND METHODS
The prospective non-randomised study included 184
patient candidates for flexible cystoscopy. These were
performed by 3 different urologists according to their
usual individual clinical practice, with one of them
using 500 mg ciprofloxacin as antibiotic prophylaxis,
another with 3 g of phosphomycin as prophylaxis, and
another without using any prophylaxis. All patients had
a urine culture performed to check for the absence of
urinary infection before inclusion in the study. The pa-
tients were divided into 3 groups:
- Group 1: 60 patients, who took 500 mg ciprofloxacin
1 hour before being subjected to flexible cystoscopy.
- Group 2: 62 patients, who took 3 g phosphomycin 1
hour before being subjected to flexible cystoscopy.
- Group 3: 62 patients, with no prophylaxis before being
subjected to flexible cystoscopy.
· Inclusion criteria: Males and females aged over 18
years in whom a flexible cystoscopy according to rou-
tine clinical practice was indicated (presence of hema-
turia, voiding symptoms, bladder tumour revision).
· Exclusion criteria: Patients with a bladder catheter or
Antibiotic prophylaxis in flexible cystoscopy-Arrabal-Polo et al.
Endourology and Stone Diseases 3051
Table 1. Characteristics of patients performed flexible urethrocystoscopy with antibiotic prophylaxis with ciprofloxacin 500 mg (group
1), phosphomycin 3 gr (group 2) and without (group 3).
Group 1 Group 2 Group 3 p
Sex 0.62
Men 73.3% 77.4% 80.6%
Women 26.7% 22.6% 19.4%
Smoking 0.03
Yes 35% 14.5% 19.4%
No 30% 25.8% 25.8%
Ex-smoking 35% 59.7% 54.8%
Bladder instillations 0.16
Yes 35% 41.9% 25.8%
No 65% 58.1% 74.2%
Diabetes mellitus 0.99
Yes 28.3% 27.4% 27.4%
No 71.7% 72.6% 72.6%
Immunosuppression 0.21
Yes 10% 16.1% 6.5%
No 90% 83.9% 93.5%
LUTS* 0.31
Yes 38.3% 41.9% 51.6%
No 61.7% 58.1% 48.4%
Indication 0.59
Tumor Follow-up 63.3% 62.9% 51.6%
Haematuria 16.7% 19.4% 16.1%
Mictional symptoms 8.3% 6.5% 14.5%
Others 11.7% 11.2% 17.8%
Diagnosis 0.001
Normal 56.7% 58.1% 38.7%
Bladder tumor 25% 35.5% 27.4%
Urothelial edema 10% 1.6% 0%
Strength bladder 6.7% 0% 6.5%
Others 1.6% 4.8% 27.4%
*LUTS: Lower urinary tract symptoms
suprapubic drainage line, patients who had a urinary in-
fection in the previous month, patients with a ureteral
catheter or nephrostomy line, and patients with urethral
stenosis.
· Primary variables analyzed: Urinary infection symp-
toms during the 7 days after the cystoscopy, attending
an emergency department or Primary Care clinic due to
infection symptoms, bacteriuria (by urine culture at 7
days), and the type of microorganism present in cases
of infection.
· Secondary variables: Age, gender, concomitant dis-
eases, presence of prior lower urinary tract symptoms,
reason for cystoscopy, result of the cystoscopy, and
bladder instillations.
· Statistical analysis: The proportions and means of the
variables recorded in the study was analyzed first, fol-
lowed by a statistical analysis of the results, by applying
an ANOVA test for the analysis of the qualitative-quan-
titative variables, and the chi-squared test for the anal-
ysis of the qualitative variables. The normality of the
variables was checked using the Kolmogorov-Smirnov
test, and the analysis of variance with the Levene test. A
multivariate analysis was performed using binary logis-
tic regression. P≤.05 was considered significant. The
analysis was performed using the program SPSS 17.0
for Windows.
· Calculation of sample size: At least 180 patients need-
ed to be included in the study, considering a beta error
of 80% and alpha error of 5%, in order to obtain a sta-
tistically significant difference between the groups, and
taking into account an estimated percentage loss of 5%
and a precision of 3%. The patients were included in
each following routine clinical practice of each urolo-
gist that perform cystoscopy.
· Ethics: All patients were informed about the study
and gave their informed consent to participate in it.
The Ethics Committee of our Health Area approved
the conducting of the study. In this study urologists for
3 different Hospitals have participated. Each urologist
has assessed and checked the patients in our health area
for urinary tract infection after flexible cystoscopy. If
urinary tract infection was present after the procedure
a correct antibiotic treatment and follow up has been
practiced.
RESULTS
The mean age of the patients in Group 1 was 65.3 (12.5)
years, 66.7 (10.8) years in Group 2, and 66.9 (10.8)
years in Group 3, which was not statistically significant
(P=.7). Table 1 summarizes the variables recorded:
gender, smoking, bladder instillations, as well as the
presence of diabetes mellitus, immunosuppression and
lower urinary tract symptoms, the reason for cystos-
copy, and its results. The analysis of the urine culture
performed 7 days after cystoscopy showed the presence
of bacteriuria in 15% of the patients in Group 1, com-
pared to 22.6% in the patients of Group 2, and 12.9%
of Group 3 patients, with no statistically significant dif-
ferences (P = .31). The microorganisms isolated in 13%
of the previously indicated Group 1 patients were: E.
coli (n = 3), K. pneumoniae (n = 1), E. faecalis (n=1),
S. epidermidis (n = 1), and P. mirabilis (n = 3); while in
22.6% of Group 2 they were: E. coli (n = 2), K. pneu-
moniae (n=6), E. faecalis (n = 3) and others (n = 2),
and in 12.9% of Group 3 they were: E. coli (n = 2),
E. faecalis (n = 1), P. mirabilis (n = 1) and others (n
= 4). Only 1 patient in Group 2 went to the emergen-
cy department due to symptoms of a urinary infection
arising from the flexible cystoscopy, and only 1 patient
from Group 1 went to primary care due to urinary infec-
tion symptoms. A multivariate analysis was performed
to determine the relationship between different factors
and the appearance of bacteriuria, which included age
(P = .8), smoking (P = .4), presence of diabetes (P = .2),
immunosuppression (P = .6), and lower urinary tract
symptoms (P = .7), observing a lack of relationship be-
tween these and the appearance of bacteria in the urine.
DISCUSSION
The use of antibiotic prophylaxis in flexible cystoscopy
is controversial. Despite the European Urology Associ-
ation clinical guidelines(10) recommending its use only in
high risk patients, in usual clinical practice it depends to
a great extent on the preferences of the urologist. Man-
son, in a study with 138 patients, stated that the routine
use of an antibiotic did not prevent the appearance of
bacteriuria and thus, was not indicated(11). Rané et al.(12),
on the other hand showed that the use of gentamicin in a
single dose decreased the rate of urinary infection after
flexible cystoscopy, and administering it as a prophy-
lactic would be indicated. Karmouni et al.(13), after con-
ducting a study with 126 patients, stated that the use
of antibiotic prophylaxis did not decrease the incidence
of urinary tract infection and therefore, it would not be
necessary to use it. On the other hand, Trinchieri et al.
stated that the use of levofloxacin reduced the incidence
of urinary infection after endoscopic procedures in the
urinary tract(9). However, Wilson et al.(14) did not ob-
serve a benefit in the administration of norfloxacin in
patients subjected to flexible cystoscopy in terms of
urinary infection incidence. On the contrary to this last
study, Johnson et al.(8) did observe a benefit of another
quinolone, ciprofloxacin, in the prevention and reduc-
tion of bacteriuria after flexible cystoscopy. However,
in our study, after analyzing the different variables and
comorbidities, we observe that the use of prophylaxis
with ciprofloxacin did not reduce the presence of bac-
teriuria or the urinary infection symptoms, suggesting,
according to our results, that its use is not recommend-
ed. For their part, Cam et al.(15) and Jiménez et al.(16), did
not observe any benefit of antibiotic prophylaxis with
phosphomycin in a population with no risk factors and
appropriately selected; although they stated that fur-
ther studies are necessary to establish the real risk in
these types of patients. In a study by García-Perdomo
et al.(17), using 500 mg levofloxacin compared to pla-
cebo, no statistically significant decrease in bacteriuria
or urinary infection was observed between both groups.
Therefore, they did not recommend the use of this an-
Table 2: Results of urinary culture after flexible cystocospy. No
statistically differences were observed between groups (p = 0.31).
Group 1 Group 2 Group 3
Urinary culture positive 15% 22.6% 12.9%
Urinary culture negative 85% 77.4% 87.1%
Antibiotic prophylaxis in flexible cystoscopy-Arrabal-Polo et al.
Vol 14 No 03 May-June 2017 3052
tibiotic as prophylaxis, unlike other studies(8,9) that did
recommend the use of quinolones as prophylactics. We
are in accordance with the study by García-Perdomo,
in that the use of quinolones as a prophylactic does not
reduce the presence of bacteriuria. The recent studies by
Herr(18,19), with a very large cohort of patients, showed
that antibiotic therapy before cystoscopy does not ap-
pear to be necessary in patients who do not have signs
or symptoms of a urinary tract infection, although these
results cannot be extrapolated to another health area,
and the responsibility for whether to use it or not falls
uniquely on the urologist. As can be observed in the
data presented here, and in the literature, as well as that
indicated by Mossanen et al.(20), there is a wide variabil-
ity in antibiotic prophylaxis in urological procedures.
Therefore, it is important to perform further studies in
order to achieve a better understanding of the reasons
for this variability in prophylaxis, with the aim of de-
creasing complications and improving the outcomes of
the procedures routinely performed by urologists.
CONCLUSIONS
As a conclusion, despite the limitations of our study,
due to the number of patients and not being a clinical
trial, it is clear on looking at the results, that we do not
believe that the use of ciprofloxacin or phosphomycin
is routinely indicated as antibiotic prophylaxis in the
performing of flexible cystoscopy regardless of other
concomitant factors.
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