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| A prospective randomized study to define the role of low dose continuous prophylactic antibiotics and anti-adherence agents in altering the microbial colonization related to indwelling double‐J stents |
Kumar Madhavan,Sanchit Rustagi,Rahul Jena,Uday Pratap Singh,M.S. Ansari,Aneesh Srivastava,Rakesh Kapoor,Sanjoy Kumar Sureka( )
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| Department of Urology and Renal Transplantation, SGPGIMS, Lucknow, India |
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Abstract Objective: Despite conflicting evidence, it is common practice to use continuous antibiotic prophylaxis (CAP) in patients with indwelling double-J (DJ) stents. Cranberry extracts and d-mannose have been shown to prevent colonization of the urinary tract. We evaluated their role in this setting.
Methods: We conducted a prospective randomized study to evaluate patients with indwelling DJ stents following urological procedures. They were randomized into three groups. Group A (n=46) received CAP (nitrofurantoin 100 mg once daily [OD]). Group B (n=48) received cranberry extract 300 mg and d-mannose 600 mg twice daily (BD). Group C (n=40) received no prophylaxis. The stents were removed between 15 days and 45 days after surgery. Three groups were compared in terms of colonization of stent and urine, stent related symptoms and febrile urinary tract infections (UTIs) during the period of indwelling stent and until 1 week after removal.
Results: In Group A, 9 (19.5%) patients had significant bacterial growth on the stents. This was 8 (16.7%) in the Group B and 5 (12.5%) in Group C (p-value: 0.743). However, the culture positivity rate of urine specimens showed a significant difference (p-value: 0.023) with Group B showing least colonization of urine compared to groups A and C. There was no statistically significant difference in the frequency of stent related symptoms (p-value: 0.242) or febrile UTIs (p-value: 0.399) among the groups.
Conclusion: Prophylactic agents have no role in altering bacterial growth on temporary indwelling DJ stent, stent related symptoms or febrile UTIs. Cranberry extract may reduce the colonization of urinary tract, but its clinical significance needs further evaluation.
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Received: 09 July 2019
Available online: 24 August 2020
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Corresponding Authors:
Sanjoy Kumar Sureka
E-mail: drsksureka@gmail.com
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The enrolment criteria and experimental process of the patients who underwent unilateral elective double-J stenting following various urological procedures. CKD, chronic kidney disease; CAP, continuous antibiotic prophylaxis; OD, once daily; DJR, double-J stent.
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| Characteristic | Antibiotic group (Group A) | Cranberry group (Group B) | No prophylaxis (Group C) | p-Value | | Patient, n | 46 | 48 | 40 | | | Median age (range), year | 36 (19-64) | 39 (21-59) | 33 (18-55) | 0.811 | | Male/female, n | 35/11 | 40/8 | 31/9 | 0.917 | | Procedure, n | | Percutaneous nephrolithotomy | 19 | 17 | 20 | 0.837 | | Ureteroscopy and lithotripsy | 18 | 20 | 14 | 0.975 | | Laparoscopic pyeloplasty | 9 | 11 | 6 | | Staghorn calculi, n | 7 | 6 | 7 | | Location of calculi, n | | Kidney | 15 | 13 | 15 | 0.705 | | Upper ureter | 10 | 10 | 6 | | Mid ureter | 5 | 10 | 6 | | Lower ureter | 7 | 4 | 5 | | Median indwelling stent time, mean (range), day | 30 (18-41) | 29 (21-45) | 26 (19-36) | 0.842 | | Febrile urinary tract infection (temperature >37.8 °C with positive urine culture), n | 6 | 7 | 3 | 0.399 | | Dysuria, n | 15 | 13 | 16 | 0.425 | | Macroscopic hematuria, n | 3 | 1 | 4 | 0.242 | | Flank pain, n | 25 | 22 | 19 | 0.754 | | Drug related adverse effects, n | | Nausea | 14 | 17 | 11 | 0.684 | | Vomiting | 5 | 3 | 0 | 0.174 | | Upper gastrointestinal discomfort/heartburn | 11 | 13 | 7 | 0.562 | | Skin rashes | 3 | 1 | 0 | 0.385 | | Diarrhea | 7 | 3 | 2 | 0.310 | | Multidrug resistance (resistance to more than 1 drug) | 4 | 1 | 1 | 0.574 |
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Baseline parameters of our patients and categorisation into groups.
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The culture positivity rate of the stent cultures and urine cultures among the three groups. (A) Stent culture positivity rate (p‐value: 0.743); (B) Urine culture positivity rate (p‐value: 0.023).
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| Organism | Urine culture, n | Stent culture, n | | Group A | Group B | Group C | Group A | Group B | Group C | | Escherichia coli | 7 | 2 | 6 | 6 | 5 | 3 | | Enterococcus faecalis | 1 | 1 | 0 | 2 | 1 | 1 | | Klebsiella | 0 | 0 | 0 | 1 | 0 | 1 | | Streptococcus | 0 | 0 | 1 | 0 | 0 | 0 | | Pseudomonas aeruginosa | 1 | 0 | 0 | 0 | 1 | 0 | | Staphylococcus | 1 | 0 | 0 | 0 | 1 | 0 | | Total | 10 | 3 | 7 | 9 | 8 | 5 |
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Various microorganisms isolated from our patients.
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| Duration of indwelling stent (day) | Prophylaxis group | Predictive value of a positive stent culture (%) | | 15-29 | -No prophylaxis | 3.4-25.0 | | -Cranberry prophylaxis | 5.0-29.0 | | -Antibiotic prophylaxis | 7.4-32.1 | | 30-45 | -No prophylaxis | 5.9-32.0 | | -Cranberry prophylaxis | 9.3-34.2 | | -Antibiotic prophylaxis | 11.5-42.1 |
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Prediction of positive cultures depending on duration of stent.
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