Transcript 自我介紹

Presentor: R3 彭元宏
Supervisor: 李苑如 醫師
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Introduction
• SINCE its introduction in 1980, shock wave
lithotripsy has become a common treatment for
most renal and ureteral stones.
• The experience of SWL at several centers
resulted in positive urine culture and sepsis
after lithotripsy in approximately 5% and 1% of
patients
• To avoid infectious complications in these
patients, prophylactic antibiotics were usually
administered
Introduction
• The two largest academic associations
• EAU guideline: Does not recommend the
routine use of antibiotic prophylaxis,
except for patients with infection risk
such as the presence of an indwelling
stent, infectious stones, indwelling
catheter or nephrostomy tube.
Introduction
• AUA guideline: recommended
- Prophylaxis reduced postoperative
bacteriuria rates from a median of 5.7%
to 2.1%.
Pearle et al. Antimicrobial prophylaxis prior to shock wave lithotripsy in patients
with sterile urine before treatment: a meta-analysis and cost-effectiveness
analysis. Urology 1997
Aim
• To assess the effect of pretreatment
antibiotics in patients undergoing SWL,
• A systematic review and meta-analysis
comparing antibiotic prophylaxis with
placebo or no treatment in patients with
sterile urine before treatment.
Search
• Pubmed, Embase (from 1980-2011)
• Key words: lithotripsy, shock wave
lithotripsy, antibiotic, bacteriuria, infection
and randomized controlled trial (multiple
synonyms for each term)
• 9 publications (RCTs) involving 1,364
patients
Search
• Inclusion criteria:
- adult patients with renal or ureteral calculi
with sterile urine before treatment.
- SWL was suitable for all patients
• Exclusion criteria:
- patients who had inadvertently taken
antibiotics postoperatively
- patients with a history of antibiotic
administration within the last 10 days before
SWL
Statistical analysis
• Relative risk with 95% CI
• Fixed effects method: not significant
heterogeneity
• Random effects method:significant
heterogeneity
• Heterogeneity assessment: I2 test and
significance set at p<0.05
Result
9 publications
(RCTs) involving 1,364 patients were included
9 publications
(RCTs) involving 1,364 patients were included
•
•
•
•
Fever
Positive urine culture
Urinary tract infection
Preoperative ureteral catheter
Fever
• The difference in fever rate between the 2
groups was not significant (random effects
model RR: 0.39, 95% CI 0.07–2.36, p= 0.31)
Positive urine culture – short term(<2 weeks)
• No significant differences between the 2 groups
in the rate of short-term positive UC (RR 0.67,
95% CI 0.44–1.02, p = 0.06)
Positive urine culture – mid-term(2wk-2mons)
• The rate of midterm positive UC (RR
1.24, 95% CI 0.59–2.61, p=0.58)
• The overall rate of positive UC (RR:0.77,
95% CI 0.54–1.11, p = 0.17)
UTI
• Incidence of positive urine culture(according
to 8 RCTs)
- Abx prophylaxis: 0% - 17.9%
- No medication: 0.7% - 20.0%
• Definition of UTI: Symptoms + positive
bacterial examinaion(bacturia or positive UC)
• Incidence of UTI:
- Abx prophylaxis: 0% - 12%
- No medication: 0% - 14%
UTI
Preoperative catheter
Discussion
Discussion
• Antibiotic prophylaxis involves a brief
course of antibiotics administered before
or at the start of a diagnostic and/or
therapeutic intervention, and it is used to
minimize possible infectious
complications
• The role of prophylactic antibiotics in
patients undergoing SWL for urinary
calculi has not been well-defined
Discussion
• EAU guideline: Does not recommend the
routine use of antibiotic prophylaxis,
except for patients with infection risk
such as the presence of an indwelling
stent, infectious stones, indwelling
catheter or nephrostomy tube.
• AUA guideline: recommended
- Prophylaxis reduced postoperative
bacteriuria rates from a median of 5.7%
to 2.1%. (Urology 1997)
Discussion
• Pearle and Roehrborn in 1997 included 8 RCTs, 5
RCTs was included to our meta-analysis. Another 3
RCTs excluded.
• 3 excluded RCTs: the incomplete description of
methodology and results.
• 2 RCTs released after their meta-analysis was
compiled and 2 RCTs not detected in their literature
search
•
Discussion
• Released before 1990
• With the remarkable technical
developments and medical achievements
in urology during the last 20 years, older
studies from the 1980s might have partly
lost their relevance
Limitations
• Most articles in this review were old, released before
the year 2000
• The numbers of participants in the RCTs were
small(Patient numbers: 60-300)
• There was a trend toward the reduction of overall UTI
incidence (RR 0.54, 95% CI 0.29 –1.01, p=0.05) and a
short-term positive UC rate (RR 0.67, 95% CI 0.44 –
1.02, p=0.06)
Conclusion
• Prophylaxis could neither decrease the
rate of fever and positive urine culture,
nor the incidence of UTI
• Antibiotic prophylaxis appears to be
unnecessary for SWL
Thanks for your attension
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