Urinary tract infections (UTIs) are amongst the most common reasons for ER visits, hospitalization and urology consultations. Studies suggest that up to 60% of women and 30% of men will experience at least one UTI during their lifetime. This entails a substantial economic burden, that has been continuously exacerbated by increasing antimicrobial resistance, with costs reaching approximately $2 billion annually. Amongst the most understudied risk factors of UTIs is the manipulation of the low urinary tract, especially in diagnostic tests such as urodynamic investigation.  Currently there is no universal protocol that dictated this usage of antibiotics in this patient, with some institutions forgoing their application entirely.  This situation underscores the need for prompt diagnosis and tailored treatment strategies.  For this reason, our institution has developed a protocol to guide antimicrobial prophylaxis and usage in urodynamic and video urodynamic studies. However, little is known about the true impact of this guideline. Therefore, the aim of this study is to determine and evaluate the impact of using an antimicrobial guideline in patients undergoing urodynamic studies.

We conducted retrospective observational study in a cohort of patients who underwent urodynamic and video urodynamic testing from January 2022 to December 2023 in our institution. During the first year of the study the patients that received a standardized dosage of norfloxacin were determine by the urologist preferences, this primarily where older men with high postvoid residuals. Conversely, during the second year of the study the protocol had become approved and was stabilized, this ensured that a bigger portion of patients received prophylaxis, and this was not limited to older men, neurological diagnosis and comorbidities where one of the many additions. Through this organic transition we were able to observe the impact of the guideline while also identifying the patients who developed complications and the possible explanations behind them.

A total of 2,740 patients were included and follow for this study, 1,300 were enrolled during 2022 and 1,440 in 2023. The mean age of the population was 62 years with 72,4% of them being men and 27,6% being women. We recorded a total of 9 UTIs post urodynamic studies. Most of these complications occurred during the first year of the study with 7 urinary tract infections representing 0.005% of the cases. In contrast, only 2 patients in the 2023 cohort developed UTIs corresponding to 0.0013% of patients.  Of the patients identified as complications we were able to determine that the majority consisted of febrile episodes that resolved withing 24 hours of starting cephalosporin management. The primary causative pathogen was either Escherichia coli or Klebsiella and all patients shared significant comorbidities such as arterial hypertension, hypothyroidism and coronary artery disease.

The comparative analysis of these two groups suggests a significant reduction in UTI complications when implementing the adjusted prophylactic strategy. This is primarily attributed to the fact that the guidelines take into consideration already described risk factors such as ad asymptomatic bacteriuria, use of previous catheters, evidence of intravesical obstruction or elevated postvoid residue, aligning with the current consensus of all major urological associations. On the other hand, it is important to acknowledge the possibility of moving towards a policy of no antimicrobial prophylaxis, especially when considering our results where the total number of complications was minimum, and the clinical implication considered insignificant. Most of the episodes consisted of non-complicated cases where patients did not require hospital stay or further interventions.

In conclusion, the management and prophylaxis of UTIs after urological procedures demands a nuanced approach that considers differential diagnoses of asymptomatic bacteriuria, the evolution of comorbid conditions, the judicious use of antibiotic prophylaxis, and preventative measures such as patient education on voiding habits. This tailored approach should be continuously evaluated and adapted based on clinical outcomes to minimize risks and optimize patient care in healthcare settings. More studies need to be conducted to propose worldwide approved guidelines to prevent post-urodynamic UTIS while also minimizing unnecessary antimicrobial use.

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