Procedure | Likely organisms | Prophylaxis indicated | Antimicrobial(s) of choice | Alternative antimicrobial(s), if required | Duration of therapy* |
Lower tract instrumentation | |||||
Cystourethroscopy with minor manipulation, break in mucosal barriers, biopsy, fulguration, etc; clean-contaminated | GNR, rarely enterococci¶ | UncertainΔ; consider host-related risk factors. Increasing invasiveness increases risk of SSI. | TMP-SMX, amoxicillin/clavulanate | First/second-generation cephalosporin + aminoglycoside (aztreonam◊) ± ampicillin | Single dose |
Transurethral cases (eg, TURP, TURBT, laser enucleative and ablative procedures, etc); clean-contaminated§ | GNR, rarely enterococci | All cases | Cefazolin, TMP-SMX | Amoxicillin/clavulanate, aminoglycoside (aztreonam◊) ± ampicillin | Single dose |
Prostate brachytherapy or cryotherapy; clean-contaminated | Staphylococcus aureus, skin; GNR | All cases | Cefazolin | Clindamycin¥ | Single dose |
Transrectal prostate biopsy; contaminated | GNR, anaerobes‡; consider MDR coverage, if risks of systemic antibiotics within six months, international travel, health care worker | All cases | Fluoroquinolone, first/second/third-generation cephalosporin (ceftriaxone commonly used) + aminoglycoside | Aztreonam May need to consider ID consultation | Single dose |
Upper tract instrumentation | |||||
Percutaneous renal surgery (eg, PCNL); clean-contaminated | GNR, rarely enterococci, and skin†, S. aureus | All cases | First/second-generation cephalosporin, aminoglycoside (aztreonam◊) + metronidazole, or clindamycin | Ampicillin/sulbactam | ≤24 hours |
Ureteroscopy, all indications; clean-contaminated | GNR, rarely enterococci | All cases; of undetermined benefit for uncomplicated, diagnostic-only procedures | TMP-SMX, first/second-generation cephalosporin | Aminoglycoside (aztreonam◊) ± ampicillin, first/second-generation cephalosporin, amoxicillin/clavulanate | Single dose |
Open, laparoscopic, or robotic surgery | |||||
Without entering urinary tract (eg, adrenalectomy, lymphadenectomy, retroperitoneal or pelvic); clean | S. aureus, skin | Consider in all cases; may not be required | Cefazolin | Clindamycin | Single dose |
Penile surgery (eg, circumcision, penile biopsy, etc); clean-contaminated | S. aureus | Likely not required | |||
Urethroplasty; reconstruction of the anterior urethra; stricture repair, including urethrectomy; clean; contaminated; controlled entry into the urinary tract | GNR, rarely enterococci, S. aureus | Likely required | Cefazolin | Cefoxitin, cefotetan, ampicillin/sulbactam | Single dose |
Involving controlled entry into urinary tract (eg, renal surgery; nephrectomy, partial or otherwise; ureterectomy; pyeloplasty; radical prostatectomy); partial cystectomy, etc; clean-contaminated | GNR (Escherichia coli), rarely enterococci | All cases | Cefazolin, TMP-SMX | Ampicillin/sulbactam, aminoglycoside (aztreonam◊) + metronidazole, or clindamycin | Single dose |
Involving small bowel (ie, urinary diversions, cystectomy with small bowel conduit, other GU procedures); ureteropelvic junction repair, partial cystectomy, etc; clean-contaminated | Skin, S. aureus, GNR, rarely enterococci | All cases | Cefazolin | Clindamycin and aminoglycoside, cefuroxime (second-generation cephalosporin), aminopenicillin combined with a beta-lactamase inhibitor + metronidazole | Single dose |
Involving large bowel**; colon conduits; clean-contaminated | GNR, anaerobes | All cases | Cefazolin + metronidazole, cefoxitin, cefotetan, or ceftriaxone + metronidazole, ertapenem NB: These IV agents are used along with mechanical bowel preparation and oral antimicrobial (neomycin sulfate + erythromycin base or neomycin sulfate + metronidazole) | Ampicillin/sulbactam, ticarcillin/clavulanate, piperacillin/tazobactam | Single parenteral dose |
Implanted prosthetic devices: AUS, IPP, sacral neuromodulators; clean | GNR, S. aureus, with increasing reports of anaerobic and fungal organisms | All cases | Aminoglycoside (aztreonam◊) + first/second-generation cephalosporin or vancomycin¶¶ | Aminopenicillin beta-lactamase inhibitor, including ampicillin/sulbactam, ticarcillin, or tazobactam | ≤24 hours |
Inguinal and scrotal cases (eg, radical orchiectomy, vasectomy, reversals, varicocelectomy, hydrocelectomy, etc); clean | GNR, S. aureus | Of increased risk; all cases | Cefazolin | Ampicillin/sulbactam | Single dose |
Vaginal surgery, female incontinence (eg, urethral sling procedures, fistulae repair, urethral diverticulectomy, etc); clean-contaminated | S. aureus, streptococci, enterococci, vaginal anaerobes; skin | All | Second-generation cephalosporin (cefoxitin, cefotetan) provides better anaerobic coverage than first-generation cephalosporins; however, cefazolin is equivalent coverage for the vaginal anaerobes in sling procedures | Ampicillin/sulbactam + aminoglycoside (aztreonam◊) + metronidazole, or clindamycin | Single dose |
Other | |||||
Shock-wave lithotripsy; clean | GNR, rarely enterococci; GU pathogens | Only if risk factors | If risks, consider TMP-SMX, first-generation cephalosporin (cefazolin), second-generation cephalosporin (cefuroxime), aminopenicillin combined with a beta-lactamase inhibitor + metronidazole | First/second-generation cephalosporin, amoxicillin/clavulanate, ampicillin + aminoglycoside (aztreonam◊), clindamycin | Single dose |