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Prophylactic antibiotics to reduce the risk of urinary tract infections after urodynamic studies

  1. Richard Foon1,*,
  2. Philip Toozs-Hobson2,
  3. Pallavi Latthe3

Editorial Group: Cochrane Incontinence Group

Published Online: 17 OCT 2012

Assessed as up-to-date: 10 DEC 2009

DOI: 10.1002/14651858.CD008224.pub2


How to Cite

Foon R, Toozs-Hobson P, Latthe P. Prophylactic antibiotics to reduce the risk of urinary tract infections after urodynamic studies. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD008224. DOI: 10.1002/14651858.CD008224.pub2.

Author Information

  1. 1

    Royal Shrewsbury hospital, Obstetrics and Gynaecology, Shrewsbury, Shropshire, UK

  2. 2

    Birmingham Women's Hospital, Urogynaecology, Birminhgam, UK

  3. 3

    Birmingham Women's Hospital, Department of Obstetrics & Gynaecology, Birmingham, UK

*Richard Foon, Obstetrics and Gynaecology, Royal Shrewsbury hospital, Mytton Oak Road, Shrewsbury, Shropshire, SY3 8XQ, UK. rpfoon@doctors.org.uk.

Publication History

  1. Publication Status: New
  2. Published Online: 17 OCT 2012

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Characteristics of included studies [ordered by study ID]
Baker 1991

Methods124 female patients attending urodynamics clinic were randomized in two groups.

Randomization: according to hospital number

Blinding: double blinding

Intention to treat analysis: not done

Power calculation: yes

Follow up < 85%


Participants124 patients randomized of which 22 did not complete the study

37 patients in the treatment group

33 in the placebo group


InterventionsNitrofurantoin 50 mg four times daily and phenazopyridine hydrochloride 200mg three times daily for one day - treatment group

Phenazopyridine hydrochloride 200mg three times daily for one day - control group


OutcomesUrinary tract infections (defined as > 105 taken 2-3 days after urodynamics) was found in 4 (8.2%) in the treatment group and 10 (18.9%) in the control group.


NotesNo significant difference in the 2 groups.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskBlinding done according to hospital number

Allocation concealment (selection bias)Unclear riskNo mention of allocation concealment

Blinding of participants and personnel (performance bias)
All outcomes
High riskPatients were not blinded but physician and laboratory technicians were blinded to the treatment patients received.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskLaboratory technicians were blinded to the treatment patients received.

Incomplete outcome data (attrition bias)
All outcomes
High riskOut of the 124 patients; 22 did not complete the study, 12 women did not provide specimens, 8 had urinary tract infections at the start of the study and did not provide specimens and had urinary tract infections. This represented a drop-out rate of 14/124.

Selective reporting (reporting bias)Low riskNo evidence of selective reporting

Other biasLow riskNone

Bergman 1983

MethodsNinety-six patients undergoing urodynamic investigations for different complaints of the lower urinary tract complaints.

Randomization details: quasi-randomized by hospital number

Blinding: not mentioned

Intention-to-treat analysis: no

Power calculation: no

Follow up < 85%


ParticipantsNinety-six patients undergoing urodynamic investigations for different complaints of the lower urinary tract complaints.


InterventionsPatients were allocated to those receiving nitrofurantoin and phenazopyridine hydrochloride and phenazopyridine only for 3 days.


OutcomesThe number of patients with positive cultures (ie > 105 organisms/ml) for urinary tract infections


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskAllocated by hospital number. Even numbers received antibiotics and odd numbers received no antibiotics.

Allocation concealment (selection bias)High riskAt risk for allocation concealment as patients selected to antibiotic group or no antibiotics based on hospital number.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNo blinding mentioned

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo blinding mentioned

Incomplete outcome data (attrition bias)
All outcomes
Low riskAll patients recruited went on to complete the study.

Selective reporting (reporting bias)Low riskNo evidence of selective reporting

Other biasLow riskNone

Coptcoat 1988

Methods43 females and 57 males undergoing urodynamics randomized into 2 groups. All patients had a pre-urodynamics mid-stream urine specimen and a 48 hours post-procedure mid-stream urine sample taken. A questionnaire recording symptoms of frequency, dysuria and haematuria was done.

Randomization details: not mentioned

Blinding: not mentioned

Intention-to-treat analysis: no

Power calculation: no

Follow up < 85%


Participants43 females ( mean age 46 years), 57 males ( mean age 55 years)


InterventionsGroup 1 - control , Group 2 - 200mg of trimethoprim 2 hours before catheterization.


OutcomesPositive cultures were found in 3 post-procedure in Group 1 and one in group 2.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskUnable to comment due to the lack of information on the randomization process.

Allocation concealment (selection bias)Unclear riskUnable to comment due to the lack of information.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskUnable to comment due to the lack of information.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnable to comment due to the lack of information.

Incomplete outcome data (attrition bias)
All outcomes
Low riskAll patients accounted for in the study.

Selective reporting (reporting bias)Unclear riskUnable to comment due to the lack of information.

Other biasLow riskNone

Darouiche 1994

MethodsPatients were prospectively randomized double blindly into a treatment group and a placebo. The treatment and placebo were given 2 days prior to undergoing urodynamics testing. Pre and post-procedure urine samples were taken and screened for infection and patients screened for symptoms.


Participants46 patients undergoing urodynamics over an 18 month period. Six patients were not available for re-evaluation and were excluded.


Interventions18 patients received prophylactic antibiotics (3 day course of ciprofloxacin).

22 patients received a placebo.


OutcomesNone of the 18 patients who received ciprofloxacin developed symptomatic UTI after urodynamic studies and 3 out of 22 patients in the placebo group.


NotesThis study showed a 14% incidence of symptomatic UTI in the group who received a placebo prior to the urodynamics.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of method used for randomization

Allocation concealment (selection bias)Unclear riskNo information given

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBoth participants and personnel were blinded

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo information given

Incomplete outcome data (attrition bias)
All outcomes
High riskSix patients were not available for re-evaluation and were excluded. In the remaining 40 patients all 40 were followed up.

Selective reporting (reporting bias)Low riskUnable to detect reporting bias

Other biasUnclear riskSmall numbers used therefore an unclear risk of bias

Kartal 2006

Methods192 patients for urodynamics had a mid-stream urine sample taken 24 hours and 48 to 72 hours after the procedure.

Randomization details: not mentioned

Blinding: not mentioned

Intention-to-treat analysis: yes

Power calculation: no

Follow up > 85%


Participants192 patients for urodynamics were randomly assigned to 2 groups


Interventions98 patients were given a single dose of 500mg of ciprofloxacin 1 hour before urodynamics and 94 were given no antibiotics.


OutcomesThe rate of significant bacteriuria in urine culture following urodynamics was 1% in the prophylactic group and 14% in the controls.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskRandomized according to hospital registration numbers

Allocation concealment (selection bias)High riskRandomized according to hospital registration numbers

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNo mentioned method of blinding

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo data given

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo data given

Selective reporting (reporting bias)Low riskAll the patients were accounted for in the study

Other biasLow riskNo other bias detected

Peschers 2001

MethodsThe patients included in the study had a clean catch specimen prior to urodynamics. If the urine tested positive for leukocytes and nitrites, these patients were excluded. The treatment group was given antibiotics while the control group received a placebo and the number of newly acquired urinary tract infections was obtained.

Randomization details: envelope

Blinding: single blinding

Intention-to-treat analysis: not done

Power calculation: done

Follow up < 85%


ParticipantsA single blinded randomized controlled study in which 94 women undergoing urodynamic testing were included: treatment group (n=37), control group (n= 33)


InterventionsThe treatment group received two tablets of cotrimoxazole and the control group receive two tablets of a placebo.


OutcomesNewly acquired infection in treatment group = 2/37

Newly acquired infection in the control group = 2/33


NotesThe power of the sample size was unfortunately too small to draw a conclusions to the efficacy of prophylactic antibiotics.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskOpaque envelopes used to randomise patients however randomization took place at the end the urodynamics examination.

Allocation concealment (selection bias)Low riskSealed opaque envelopes used to randomise patients

Blinding of participants and personnel (performance bias)
All outcomes
High riskOnly single blinding was performed, as the placebo tablets were not identical in shape and colour to the antibiotics.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo information given.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskTen patients failed to provide specimens of urine and hence were excluded, and 8 provided samples with evidence of contamination.

Selective reporting (reporting bias)Low riskNo evidence of reporting bias

Other biasUnclear riskTwo relatively small groups of patients

Siracusano 2008

Methods262 postmenopausal women underwent urodynamics. Prior to having urodynamics they were double blindly randomised into group 1 who received prophylactic antibiotics and group 2 received a control.

Randomization details: yes

Blinding: double

Intention-to-treat analysis: no

Power calculation: no

Follow up > 85%


Participants262 postmenopausal women undergoing urodynamics


InterventionsTreatment group (n=130) received a single dose of 400mg norfloxacin and group 2, the control, received a placebo.


OutcomesUrinary tract infection occurred in 24/130 patients receiving prophylactic antibiotics and 30/132 patients reviving the placebo.


NotesThere was not significant difference in the incidence of urinary tract infection between those receiving the prophylactic antibiotics and the placebo.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomization done by a computer, generated in a double blinding fashion.

Allocation concealment (selection bias)Low riskLow risk due to the method of randomization

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBoth participants and personnel were blinded

Blinding of outcome assessment (detection bias)
All outcomes
Low riskBlinding of personnel performing the analysis of the urine was also performed

Incomplete outcome data (attrition bias)
All outcomes
Low riskAll participants were accounted for in the study

Selective reporting (reporting bias)Low riskNo evidence given

Other biasLow riskNo other bias detected

Tosto 1989

Methods37 male patients undergoing urodynamics were randomized into a treatment group and placebo group. A catheter specimen was taken before urodynamics and 3-7 days after.

Randomization: unclear

Blinding: unclear

Intention-to-treat analysis: no

Power calculation: done

Follow up > 85%


Participants37 male patients undergoing urodynamics


InterventionsTreatment group received prophylactic cinoxacin 500mg twice a day for 5 days. The control group received no treatment.


OutcomesIrritative symptoms occurred in 12/15 in the treatment group while it occurred in 14/16 in the no treatment group.


NotesUrinary tract infection was defined as > 105 bacteriuria on MSU taken 1 week post-urodynamics.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo details of the method of randomization given

Allocation concealment (selection bias)Unclear riskNo details given

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskUnclear from the manuscript whether blinding was performed

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo details given

Incomplete outcome data (attrition bias)
All outcomes
High riskNot all participants were accounted for in the study

Selective reporting (reporting bias)Unclear riskNo details given

Other biasUnclear riskTwo small groups of patients used

Yip 2006

Methods130 consecutive women attending were randomized into two groups, one receiving prophylactic antibiotics and the other group receiving a placebo.

Randomization method: not mentioned

Intention to treat analysis: yes

Power calculation: not mentioned

Follow up > 85%


Participants130 female patients undergoing urodynamics


Interventions65 in each group. One group receiving Augmentin 375 mg stat, 30 minutes before urodynamics and the other group receiving a placebo.


OutcomesPatients developing newly acquired infection: 1/65 in the treatment group and 8/65 in the control group.


NotesSingle dose of 375 mg Augmentin offers effective prophylaxis against bacteriuria following urodynamics.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of the method of randomization

Allocation concealment (selection bias)Unclear riskNo mention in the manuscript

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNo details given on blinding

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo data given

Incomplete outcome data (attrition bias)
All outcomes
Low riskAll patients were accounted for in the study

Selective reporting (reporting bias)Unclear riskNo data given

Other biasLow riskNo other bias detected

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Bhatia 1985The population studied included patients undergoing urethrocystoscopy, cytometry and simultaneous urethrocystometry. Unable to contact authors to clarify.

Cundiff 1999aThe population studied included were those undergoing both urodynamics and cystourethroscopy hence this study was excluded after discussion between the three review authors.

 
Comparison 1. Antibiotics versus placebo (adult patients)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Clinical urinary tract infection following urodynamics4415Risk Ratio (M-H, Fixed, 95% CI)0.73 [0.52, 1.03]

    1.1 Antibiotics versus placebo in male patients
275Risk Ratio (M-H, Fixed, 95% CI)0.69 [0.38, 1.26]

    1.2 Antibiotics versus placebo in female patients
2300Risk Ratio (M-H, Fixed, 95% CI)0.80 [0.53, 1.21]

    1.3 Antibiotics versus placebo in patients with spinal injury
140Risk Ratio (M-H, Fixed, 95% CI)0.17 [0.01, 3.14]

 2 Bacteriuria following urodynamics9970Risk Ratio (M-H, Fixed, 95% CI)0.35 [0.22, 0.56]

    2.1 Antibiotics versus placebo in male patients
3176Risk Ratio (M-H, Fixed, 95% CI)0.21 [0.06, 0.78]

    2.2 Antibiotics versus placebo in female patients
7757Risk Ratio (M-H, Fixed, 95% CI)0.40 [0.24, 0.67]

    2.3 Antibiotics versus placebo in patients with spinal injury
137Risk Ratio (M-H, Fixed, 95% CI)0.15 [0.01, 2.72]

 3 Haematuria following urodynamics2344Risk Ratio (M-H, Fixed, 95% CI)0.46 [0.23, 0.91]

 4 Fever following urodynamics2299Risk Ratio (M-H, Fixed, 95% CI)5.16 [0.94, 28.16]

 5 Dysuria following antibiotics1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Adverse effects from prophylactic antibiotics2262Risk Ratio (M-H, Fixed, 95% CI)4.47 [0.22, 89.94]