Antibiotic use prior to transurethral resection of the prostate: Are we doing what we think we are doing?

In this issue of CUAJ, Lawson and colleagues present a retrospective chart review on the rate of antibiotic use during transurethral resections of the prostate (TURP) in a high volume Canadian institution.¹ Overall, 488 patients are grouped into two distinct sets: A set with an indwelling catheter and the other with no preoperative catheter. It is shown that the compliance rate with the AUA best practice statement (BPS) (which recommended antibiotic prophylaxis in all TURP patients) is 81% in the first set of patients and 37% in the second. The authors conclude that antibiotic prescribing patterns vary significantly prior to TURP, and that compliance to AUA BPS is lower than anticipated.

This is an observational study assessing the rate of compliance with AUA BPS and it does not seek to examine outcomes, such as post-procdural sepsis. As such, it is not clear whether the population under study may have been one at “low risk” for procedural sepsis or not, and the authors do not report the rate of sepsis in patients who did not receive any antibiotics prior to surgery. Additionally, the authors admit that they may have been somewhat stringent in defining compliance in the indwelling catheter group by requiring the use of two different class antibiotics. If they hadn’t done so, the compliance rate in this group is 93%.

Regardless, it is quite surprising that up to 15% percent of patients undergoing TURP overall, and more specifically 7% of the ones with indwelling catheter, did not receive any antibiotic regimen at all. This is despite the level 1 evidence in favour of using antimicrobials in this setting. One may wonder whether such a practice reflects simple medical error or whether the underlying reason is the conviction by the treating physician that antibiotic use was not indicated. As such, it would have been very informative to survey treating physicians from the high-volume centre on their practice to confront it with the facts from the chart review. The authors mention a published study reporting such a survey.² Despite the fact that it is a European study with questionable applicability to the Canadian setting, 98% of urologists report using antibiotics in TURP cases with indwelling catheters, albeit the authors did not report the rate of combination antibiotics use. This figure may suggest a gap between what is done and what is intended, which may be bridged by standardizing procedures, such as including a mention of antibiotics in the timeout before beginning the procedure.

The generalization of the findings from this study to other high volume centres in Canada remains to be established. But the results reported are definitely an eye opener, and a call for vigilance in terms of quality control!