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Three Part Question

In [patients requiring urinary catheterisation for urinary retention] are [prophylactic antibiotics better than no antibiotics] at [reducing the incidence of urinary tract infection]?

Clinical Scenario

A 70 year old gentleman presents to the emergency department in acute urinary retention. You decide to catheterise him. Your SHO tells you that when he was doing Urology it was standard practice to give systemic antibiotics to any patient catheterised post operatively. You wonder whether the patient in front of you needs them?

Search Strategy

OVID Medline 1966 to May Week 1 2006 and Embase 1980 to 2006 Week 19 using multifile searching.
The Cochrane Library Issue 2 2006
{urinary catheter.mp OR urinary catheterization.exp OR exp.catheterization} AND {Infection.exp} AND {prophylaxis.mp OR antibiotic, Prophylaxis.exp} AND {urin$} LIMIT Human, English, abstracts
Cochrane:Urinary catheterization [MeSH] AND (Antibiotic prophylaxis [MeSH] OR prophyla* [Title, abstract, keywords])

Search Outcome

104 papers identified in Medline, 81 in Embase and 2 in Cochrane. 1 paper was a systematic review that was relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Niel-Weise, B S, van den Broek, P J, Netherlands, 2005	Three trials of hospitalised adults undergoing non-urological surgery who had postoperative bladder drainage	Systematic review	Antibiotic prophylaxis compared with giving antibiotics when clinically indicated	Only 1 relevant paper: significantly lower symptomatic UTI rate in the group receiving prophylactic antibiotics (RR 0.20, 95% CI 0.06 to 0.66)	Observation based on only 16 cases of infection in women in one small trial Data too heterogeneous to allow meta-analysis
			Antibiotic prophylaxis compared with giving antibiotics when microbiologically indicated	Five to eight-fold fewer cases of bacteriuria amongst those allocated prophylactic antibiotics

Comment(s)

Many papers were found in the search that examined the use of antibiotics for the prophylaxis of urinary instrumentation during surgery, or in the management of patients with long term problems requiring intermittent catheterisation. Such patients are very different to those found in the emergency department. Similarly, epidemiological papers looking at incidence of infection in hospitalised patients show lower levels of infection in those taking antibiotics for other reasons. No papers directly addressed the issue of the patient presenting to the emergency department. The paper presented suggests a role for antibiotics but only in patients requiring medium term catheterisation. Another consideration is the potential for the development of bacterial resistance in the patient and in the general population. The evidence for catheterisation in the emergency patient described is far from conclusive and cannot be routinely recommended. However, there will be high risk patients in whom it may be appropriate.

Clinical Bottom Line

There is insufficient evidence to recommend the routine use of prophylactic antibiotics in the management of acute urinary retention presenting to the emergency department.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Niel-Weise, B S, van den Broek, P J. Antibiotic policies for short-term catheter bladder drainage in adults. Cochrane Database of Systematic Reviews (3):CD005428, 2005