Should Antibiotics Be Given Prior to Outpatient Cystoscopy? A Plea to Urologists to Practice Antibiotic Stewardship

BackgroundAntimicrobial resistance is a major health problem, caused primarily by overuse of antibiotics in clinical situations in which they are not necessary. Practice guidelines recommend that antibiotics be given before outpatient cystoscopy to prevent symptomatic urinary tract infection (UTI).ObjectiveTo determine the frequency of febrile UTI after outpatient flexible cystoscopy in antibiotic-naive bladder tumor patients.Design, setting, and participantsA total of 2010 consecutive outpatients with bladder tumors were entered into a prospective registry study. All patients underwent cystoscopy after they submitted a voided urine sample for culture. Significant bacteriuria was defined as >104 colony-forming units per milliliter with a single organism. Patients were stratified for known risk factors for UTI.InterventionPatients underwent flexible cystoscopy and received no antibiotics immediately before or after cystoscopy. They were followed for 30 d for onset of febrile UTI.Outcome measurements and statistical analysisThe end point was incidence of febrile UTI within 30 d of cystoscopy. Febrile UTI was defined as temperature >38 °C and dysuria, or having received antibiotics from an outside physician for urinary symptoms.Results and limitationsOf the 2010 patient cystoscopies, 489 (24%) had asymptomatic bacteriuria, and 1521 (76%) had sterile urine. Thirty-nine patients (1.9%) developed febrile UTI ≤30 d after cystoscopy—4.5% in colonized patients and 1.1% in uninfected patients (p = 0.02). All UTIs resolved in ≤12–24 h with oral antibiotics. None of the patients was admitted for bacterial sepsis. Limitations of the study are that it is a single-surgeon experience in one institution, and results may not apply to other patient populations.ConclusionsAntibacterial therapy before outpatient flexible cystoscopy does not appear necessary in bladder tumor patients who have no clinical signs or symptoms of acute UTI, including asymptomatic bacteriuria. Antibiotic stewardship is the responsibility of all urologists.