Prophylactic antibiotics after RARC lower 90-day UTIs, complications

The use of antibiotic therapy for 30 days following robot-assisted radical cystectomy (RARC) results in reduced 90-day urinary tract infections (UTIs), infectious complications, UTI-related readmissions, and costs without an increase in adverse events (AEs), a study has shown.

“Antibiotic prophylaxis might be incorporated into standard postoperative care for patients after RC,” the researchers said.

Patients who underwent RARC with urinary diversion (median age 69 years, 25 percent female, 36 percent received neoadjuvant chemotherapy) were randomly allocated to standard of care (SOC; n=40) or prophylactic antibiotics (nitrofurantoin 100 mg daily or trimethoprim/sulfamethoxazole 160/800 mg daily; n=37) for 30 days after discharge. Follow-up was ≥90 days.

UTI, defined as positive urine culture with >10⁵ cfu/mL associated with clinical symptoms, such as fever, chills, or flank pain, developed in 10 patients (25 percent) in the SOC but not (0 percent) in the antibiotic arm (p=0.001). [J Urol 2025;214:147-155]

Complications or high-grade complications did not significantly differ between groups. Infectious complications at day 90 were significantly higher in the SOC arm (43 percent vs 14 percent; p=0.006), as was the 90-day infection-related readmissions (30 percent vs 5 percent; p=0.007).

Furthermore, the antibiotic arm had a mean postcystectomy cost that was lower by $9,074 than the SOC arm (p=0.007). The number needed to treat to prevent a single UTI was 4.0 (95 percent confidence interval, 2.5–7.0).

“We found that prophylactic administration of oral antibiotics for 30 days after RARC was associated with a substantial decrease in 90-day UTIs, infectious complications, infection-related readmissions, and cystectomy-related costs without a significant increase in adverse events,” the researchers said.

Fluoroquinolones

An earlier study examined the effect of Enhanced Recovery After Surgery protocol, including oral suppressive antibiotics such as fluoroquinolones, until stent removal on UTIs. Compared with other antibiotics, fluoroquinolones correlated with a lower risk of UTIs. However, 36 percent of patients developed UTIs and 7 percent urosepsis at 90 days. [J Urol 2014;192:50-55]

The authors attributed the high UTI rates to their inclusive definition, which involved patients who received antibiotic therapy for possible UTIs, regardless of the results of the urine culture and their symptoms. [J Urol 2014;192:50-55]

In the current study, the researchers used a definition combining positive urine culture with symptoms because “it is not uncommon for patients to have asymptomatic bacteriuria after RC.”

Moreover, whether fluoroquinolones are ideal for antibiotic prophylaxis remains unclear. Prior studies have found significant resistance to this suppressive antibiotic in this setting. [World J Urol 2018; 36:775-781; J Endourol 2021;35:62-70]

Recommendation

The American Urological Association (AUA) recommends a single dose of antibiotics at induction for prophylaxis for RC and urinary diversion, regardless of the approach. However, the AUA said that the choice of antibiotic must be based on local resistance patterns, antibiograms, and institutional policies. [J Urol 2020;203:351-356]

"Although ertapenem has been recommended when large bowel is used for urinary diversion, it has been the recommendation of our colorectal and Infectious Diseases Departments to use it for RARC,” the researchers said. “Nevertheless, UTIs remain among the most common early complications after RARC.”