Hypothesis / aims of study
Urinary tract disorders are a common reason for urology consultations, and urodynamics serves as the gold standard for their study. This invasive procedure aims to replicate the symptoms reported by the patient and measure variables influencing the physiology of bladder storage and emptying functions (1). Urinary tract infection following urodynamic testing may occur in up to 10% of patients, with some series reporting rates as high as 20%.
Currently, there is no global consensus regarding the use of antibiotic prophylaxis. This study aims to identify the main recommendations regarding prophylactic antibiotic therapy associated with urodynamic procedures.
Study design, materials and methods
A systematic literature review was conducted on clinical practice guidelines and systematic reviews addressing antibiotic prophylaxis in urodynamics in adults with any antibiotic, in any regimen, and dosage. Guidelines were considered as documents reporting recommendations for urodynamic testing for any reason, with a focus on documents published in english and spanish in the last 12 years (2012-2024). The quality of the selected guidelines was evaluated using the AGREE-II instrument in its spanish version. Only guidelines with a score higher than 60% in the domains of methodological rigor and editorial independence were considered for inclusion.
For recommendations regarding the use of antibiotic prophylaxis in urodynamics, the recommendation statement along with its level of evidence and grade of recommendation was extracted from each guideline. Systematic reviews comparing MESH terms were also included, evaluating their methodological quality using AMSTAR 2.
Out of a total of 320 references, four clinical practice guidelines, one meta-analysis, and one systematic review were chosen. Three clinical practice guidelines with an overall acceptable quality and one "Best Practice Statement" were included.
Results
Three clinical practice guidelines with an overall acceptable quality and a "Best Practice Statement" that did not meet all the GPC criteria, but was the only one specific to urodynamics, were identified. Only one of the clinical guidelines is specific to urodynamic testing (Cameron et al., 2017). The other selected management guidelines are antibiotic prophylaxis guidelines for multiple surgical procedures with a specific section for Urology (Bratzler et al., 2013), and for urological (Mrkobrada et al., 2015) and gynecological (Van Eyk et al., 2012) procedures, mentioning antibiotic prophylaxis in urodynamic testing.
Interpretation of results
All guidelines agree that antibiotic prophylaxis is not recommended in low-risk patients, only in those at high risk of post-procedure infection. None of the guidelines mention specific infection risk conditions.
Antibiotic prophylaxis is recommended for urodynamic studies in patients over 70 years of age (Level of evidence: II), significant lower urinary tract dysfunction (Level of evidence: IV), clinically significant post-void residual volume, regardless of the cause (Level of evidence: IV), patients with asymptomatic bacteriuria (Level of evidence: IV), patients with congenital or acquired immunosuppression, or receiving chronic steroid or other immunosuppressive therapy, particularly those who have undergone renal transplantation (Level of evidence: IV), patients with permanent urinary catheters, urethral or suprapubic catheterization, or intermittent catheterization (Level of evidence: IV), patients with total joint replacements at risk of joint infection due to bacteremia or at risk of bacteremia (Level of Evidence III).Van Eyk's study, after a decision analysis incorporating published benefit and adverse event estimates, the authors concluded that antibiotic prophylaxis for urodynamic testing in low-risk women should only be administered when the urinary infection rate at the study site exceeds 10%.
Regarding the choice of antimicrobial agent in patients with risk factors for urinary tract infection, trimethoprim-sulfamethoxazole or fluoroquinolones are recommended, taking into account the resistance profile of the institution where the procedure is performed. Antibiotic prophylaxis should be administered one to two hours before the procedure.
Wu et al.'s meta-analysis demonstrates that prophylactic antibiotics can significantly reduce the risk of bacteriuria after urodynamics (RR = 0.42, 95% CI: 0.30-0.60); with no increased incidence of adverse events (RR = 4.93, 95% CI: 0.61-40.05). They determine independent risk factors, or high-risk patients, for developing urinary tract infection due to urodynamic examination, including advanced age, recurrent UTI, previous urological surgery, hypothyroidism, advanced pelvic organ prolapse, body mass index > 30, and PVR > 50 ml, for whom prophylactic antibiotic use is recommended, with ciprofloxacin, levofloxacin, and amoxicillin-clavulanic acid being the recommended antibiotics. (2)
The systematic review conducted by Benseler et al. of three randomized controlled trials in women indicated that prophylactic antibiotics can reduce the risk of bacteriuria after urodynamics in women; however, a narrative synthesis of the findings, with insufficient evidence to suggest that this same intervention reduces the risk of UTI after urodynamic test (3).
Concluding message
This review of secondary studies aims to synthesize guidelines on antibiotic prophylaxis in urodynamics to influence clinical decisions and infectious outcomes in patients undergoing such procedures. In this regard, and based on the available evidence and the quality supporting the recommendations, the appropriate use of antimicrobial prophylaxis in an individual patient requires consideration of the guidelines mentioned in these guidelines, a comprehensive assessment of the patient's particular conditions, and the treating physician's clinical judgment.
Among the limitations of our review, it is worth noting the selective bias with studies in English and Spanish. Systematic reviews regarding antibiotic prophylaxis in urodynamics are based on an insufficient number of clinical trials of questionable quality. Considering publication bias, given the higher likelihood of publication of trials with statistically significant results, it will be considered that the findings are inconclusive until additional studies with rigorous methodology demonstrate the clinical importance of the findings.