One week of ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study

Abstract

Urosepsis after percutaneous nephrolithotomy (PCNL) is a severe complication, and its avoidance can sometimes be difficult despite antibiotic prophylaxis. Authors from the UK with a considerable experience in this procedure describe a prospective controlled study using ciprofloxacin for 1 week before PCNL, and found that it significantly reduces the risk of urosepsis. OBJECTIVE To evaluate whether 1 week of ciprofloxacin before percutaneous nephrolithotomy (PCNL) in patients with stones of ≥ 20 mm or pelvicalyceal dilatation, reduces urosepsis, as we previously reported that such patients have four times the risk of urosepsis after PCNL. PATIENTS AND METHODS Patients undergoing PCNL, and who fulfilled strict selection criteria, were recruited prospectively into a study which was conducted in two phases. The study methods were similar to those previously described; patients with dilated pelvicalyceal systems and/or stones of ≥ 20 mm from phase 1 (previously published) acted as controls. In the subsequent phase, the same selection criteria applied and only those with stones of ≥ 20 mm and/or dilated pelvicalyceal systems were given ciprofloxacin 250 mg twice daily for 1 week before PCNL and comprised the treatment arm. Midstream urine samples, renal pelvic urine and fragmented stones were collected to assess culture and sensitivity. Systemic inflammatory response syndrome (SIRS) was used to define urosepsis after PCNL. The urologists monitoring the patients after PCNL and conducting the analysis were all unaware of the characteristics of the stones or intravenous urography findings before PCNL. In all, 115 patients (54 in phase 1 and 61 in phase 2) were recruited, of whom 46 in phase 1 and 52 in phase 2 had stones of ≥ 20 mm and/or a dilated pelvicalyceal system, and became the control and treatment arms, respectively. RESULTS The patient demographics were similar in both arms. There was three times less risk of upper tract infection (relative risk 3.4, 95% confidence interval 1.0–11.8, P = 0.04) and SIRS (2.9, 1.3–6.3, P = 0.004) in the patients receiving ciprofloxacin (treatment arm). CONCLUSIONS The administration of oral ciprofloxacin for 1 week before PCNL in patients with stones of ≥ 20 mm or dilated pelvicalyceal systems significantly reduced the risk of urosepsis.

Fever and Systemic Inflammatory Response Syndrome Seen After Percutaneous Nephrolithotomy: Review of 1290 Adult Patients

“…Number of tracts, blood transfusion, stone size and presence of pyelocaliectasis were identified as risk factors for the development of SIRS. Another study by Mariappan et al investigated 52 patients with stones ≥ 2cm and dilated pelvicalyceal systems to whom 1 week per os ciprofloxacin treatment was given as an extended antibiotic prophylaxis [12]. They found a 7% SIRS rate in these patients compared to 18% SIRS in the control group.…”

Initial Experience of Percutaneous Nephrolithotomy at Lumbini Medical College

“…15 However, other investigators described supine position approach with different techniques including the use of flexible ureterorenoscope, with comparable About prophylactic antibiotics, all our patients received a full course antibiotics in case of proved growth in urine culture, and during induction of anesthesia as most of the protocols, however, Mariappan et al in their study showed that one week oral ciprofloxacin in case of large renal stone more that 20mm or in case of hydronephrosis significantly reduced the risk of urosepsis after PCNL procedures. 17 Fluoroscopy was done to monitor the access to the collecting system in all our steps of dilatation . Nephrostomy catheter was inserted by size 20F chest tube drainage catheter at the end of our procedure, the aim is to tamponade venous bleeding, to prevent urine extravasations or allow healing of minimal pelvicalyceal system injury and allow an access for a second look PCNL through the same tract in case of significant residual stones.…”

Percutaneous Nephrostomy

“…A prospective controlled study of patients undergoing percutaneous nephrolithotomy (Mariappan, Smith et al 2006) reported significant reduction in the risk of upper tract infection and urosepsis following 1 week of prophylactic ciprofloxacin. However this may not be extrapolated in cases of percutaneous nephrostomy not related to underlying calculus or nephrolithotomy, as the presence of calculus is known to be associated with increased risk of infection.…”

“…Several factors have been found to contribute towards increased risk of sepsis, and this includes the duration of the procedure itself, urine bacterial load, severity of urinary tract obstruction as well as presence of bacteria within the calculus (Mariappan, Smith et al 2006). Mariappan also reported higher risk of upper urinary tract infections in patients with calculi larger than 20mm or a dilated pelvicalyceal system.…”

“…The use of prophylactic antibiotics is therefore recommended in high-risk patients, and this has been shown to be of some benefit as reported in a prospective controlled study by Mariappan, who prescribed one week of ciprofloxacin to patients prior to percutaneous nephrolithotomy (Mariappan, Smith et al 2006). Patients who received prophylactic ciprofloxacin were reported to have significantly reduced incidence of upper urinary tract infection as compared to the control group, with three times less risk of developing systemic inflammatory response syndrome.…”