Pyeloplasty with Ureteral Stent Placement in Children: Do Prophylactic Antibiotics Serve a Purpose?
Dana W. Giel, MD1, Sara Vidovic, MD1, Tristan Hayes, MSc2, Jay Fowke, PhD2, Joseph K. Cline, MD1, Glenn M. Cannon, MD3, Marc A. Colaco, MD3, Kelly A. Swords, MD, MPH4, Laura B. Cornwell, MD4, Carlos Villanueva, MD5, Sean T. Corbett, MD6, Kimberly Maciolek, MD6, Sarah M. Lambert, MD7, Gemma Beltran, BS8, Vijaya M. Vemulakonda, JD, MD8.
1University of Tennessee Health Science Center/Le Bonheur Children's Hospital, Memphis, TN, USA, 2University of Tennessee Health Science Center, Memphis, TN, USA, 3UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA, 4University of California San Diego/Rady Children's Hospital, San Diego, CA, USA, 5University of Nebraska Medical Center, Omaha, NE, USA, 6University of Virginia Children's Hospital, Charlottesville, VA, USA, 7Yale School of Medicine/Yale New Haven Health System, New Haven, CT, USA, 8Pediatric Urology Research Enterprise, Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA.
BACKGROUND:Ureteral stents are commonly used during pyeloplasty to ensure adequate drainage and anastomotic healing. Antibiotic prophylaxis is also often used due to concerns for postoperative urinary tract infection (UTI) related to stent colonization and reflux. Although many pediatric urologists prescribe prophylactic antibiotics following pyeloplasty, these practices vary widely due to the lack of clear evidence-based guidelines to inform antibiotic use. We hypothesize that the rate of stent UTI does not significantly vary between children who receive antibiotics and those who do not.
METHODS:We retrospectively reviewed the medical records of 741 patients who underwent pyeloplasty between January 2010 and July 2018 across seven different institutions. Exclusion criteria were: subjects older than 22 years, no ureteral stent placed, externalized stents used, and incomplete records. Surgical approach, age, antibiotic use, stent duration, Foley catheter duration, and urine culture results were recorded. Patients were further categorized into two groups, those who were younger than 4 years of age and those who were four years and older as a proxy for likely diaper use. Univariate logistic regression was conducted to identify variables associated with UTI (at a level of P < .20). Multivariable backward stepwise logistic regression was used to identify the best model with Akaike information criterion as the model selection criteria. The selected model was used to calculate odds ratios and 95% confidence intervals summarizing the association between prophylactic antibiotics and stent UTI while controlling for age, gender, and intra-operative urine cultures.
RESULTS:672 patients were included of whom 338 received antibiotic prophylaxis and 334 did not. These groups differed in mean age (3.91 vs. 6.91 years, P < .001), mean stent duration (38.5 vs. 35.32 days, P < .001), and surgical approach (53.25% vs. 32.04% open vs. laparoscopic, P < .001). The incidence of stent UTI was low overall (7.59%) and was similarly low in both groups: 31/338 (9.17%) in the prophylaxis group and 20/334 (5.99%) in the non-prophylaxis group (P = .119). Although female gender, likely diaper use, and positive intra-operative urine culture were each associated with significantly higher odds of stent UTI, prophylactic antibiotic use was not associated with significant reduction in stent UTI in any of these groups (Table 1). Notably, surgical approach, ureteral stent duration, and Foley catheter duration were not associated with stent UTI.
CONCLUSIONS:Incidence of stent UTI is low overall following pyeloplasty. Prophylactic antibiotics are not associated with lower rates of stent UTI following pyeloplasty even after controlling for risk factors of female gender, age associated with likely diaper use, and positive intra-operative urine culture. Routine administration of prophylactic antibiotics after pyeloplasty does not appear to be beneficial, and may be best reserved for those with multiple risk factors for UTI.
Table 1: Odds ratio estimates for predicting incidence of Stent UTI
|Effect||Odds Ratio||95% Confidence Interval||P-value|
|Age (<4 years)(N=357)||3.11||1.18||8.17||0.021|
|Intra-operative Culture (+)(N=20)||6.23||2.20||17.63||0.001|
|Prophylactic antibiotics (yes)(N=338)||0.96||0.41||2.27||0.934|
Multivariable logistic regression following backward elimination protocol. Final model: UTI + age + gender + intra-operative culture + antibiotics.
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