Studies of urinary tract infection presented at the 2007 AUA annual meeting had important lessons for practicing urologists.
Patients who performed an at-home scrub of the abdomen and perineal region for 5 days prior to surgery showed a four-fold reduction in preoperative perineal colonization and reduction in postoperative bacterial count. However, there is a good deal of bacteria within the skin that no amount of scrubbing can reduce.
"This study clearly shows that you can significantly decrease the colony count on the skin, although you can't eliminate it, and that lessens the chance of morbid complications," Dr. Childs said.
"Based on these data, I'm going to suggest to all my patients who are going to have these devices inserted that they adhere to 5 days of washing and use something like chlorhexidine antibiotic wash or povidone-iodine," he said. "I don't think that I'm going to recommend it for transurethral surgery. And I'm not sure that I'm going to recommend it for open prostatectomy or for any type of surgery that doesn't involve an implantable device."
Infectious Diseases Society of America guidelines for treating asymptomatic bacteriuria advise not to screen and treat premenopausal nonpregnant women, diabetic women, older members of the community, elderly institutionalized patients, people with spinal cord injuries, or patients with in-situ catheters.
"When you chronically treat people highly prone to repeated infection who are asymptomatic, all you're doing is trading a susceptible bacterial infection for a resistant bacterial infection. The bacteria are always going to become resistant eventually if they are treated multiple times," said Dr. Childs, who agrees with the guidelines on avoiding treatment. "If treatment is not getting rid of patients' pain and, certainly, in spinal cord injuries, they're not having pain, if they don't have fever or hematuria and they're not septic, why treat them?"
If patients have symptoms, especially fever and hematuria, which increase the risk of sepsis or bacteremia, he recommends treating the infection. Dr. Childs emphasized that women with diabetes need to be watched very carefully because "their immune systems are compromised, and if they develop fever, they must be treated immediately."
When it comes to screening, Dr. Childs thinks it's prudent to think carefully about each of these types of patients. In fact, he thinks patients in all these categories need to be screened periodically.
"When somebody calls me from the nursing home or from the rehabilitation center and says a patient with an in dwelling catheter or a spinal cord injury has a fever of 103, I want to know what the presumptive antibiotic is that I should prescribe. If I haven't done a culture and I don't have a current sensitivity, I won't know. If there has been a culture and sensitivity and the patient hasn't received any antibiotics since then, the chances are very good that that culture and sensitivity are valid. It's my policy-and I think this should be everyone's policy, especially urologists'-to periodically get a culture and sensitivity," he explained.
How often that needs to be done is a question that should be answered with a prospective study, Dr. Childs said. For now, he thinks it's reasonable to do a culture and sensitivity about as frequently as the patient gets a symptomatic infection.