Pyeloplasty with Ureteral Stent Placement in Children: Do Prophylactic Antibiotics Serve a Purpose?

Background: the need for antibiotic prophylaxis to prevent urinary tract infections after pyeloplasties are unclear

Ureteropelvic junction obstruction (UPJO) occurs in about 1 in 500 children screened with an antenatal ultrasound. It accounts for about two-thirds of all cases of prenatal hydronephrosis. Surgical correction of UPJO by pyeloplasty can be open or laparoscopic and typically involves placing a temporary stent to ensure adequate drainage and tissue healing.

The reported incidence of postoperative urinary tract infections (UTIs) after pyeloplasty ranges from 2 percent to 15 percent. Clinically insignificant stent biofilms may form on 28 percent to 90 percent of stents. Clear evidence-based guidelines are not available to guide decision-making on whether to prescribe prophylactic antibiotics before stent placement. Two small, single-institution retrospective studies found no significant benefit to prophylactic antibiotic use after pyeloplasty in children.

Children's Hospital Colorado pediatric urology researchers were part of a multi-institution group that reviewed patient records to determine if antibiotic prophylaxis during ureteral stent catheterization decreased the number of stent UTIs.

Methods: comparing outcomes after antibiotic prophylaxis post-pyeloplasty versus no antibiotics

Study authors received records of patients from seven U.S. institutions under age 22 who underwent UPJO and had an internal ureteral stent placed between January 2010 and July 2018.

Data collected included:

• Gender
• Race
• Age at surgery
  • under age 4 years (assume diaper use)
  • over age 4 years (assume no diaper use)
• Surgical approach
• Prophylactic antibiotic use
• Stent duration
• Foley catheter duration
• Urine culture results
  • intraoperative
  • stent removal

The primary outcome tested was the incidence of stent UTI defined by:

• Fever
• Urinary symptoms
• Positive urine culture
  • while the stent is in place
  • at the time of stent removal

Results: comparing the use of antibiotic prophylaxis for pyeloplasty versus no antibiotic prophylaxis

• 338 (50.3%) received antibiotic prophylaxis
  • 3.91 years mean age
  • 212 (62.7%) likely used diapers
  • 180 (53.25) underwent open pyeloplasty
  • 102 (30.18%) females
  • 38.5 days mean stent duration
  • 52/338 (15.4%) had Foley catheter durations longer than two days
  • 203/338(60%) received antibiotics during stent removal
  • 31/338 (9.17%) had a stent UTI
• 334 (49.7%) no antibiotic prophylaxis
  • 6.91 years mean age
  • 145 (43.4%) likely used diapers
  • 107 (32.04%) underwent open pyeloplasty
  • 99 (29.64%) females
  • 35.52 days mean stent duration
  • 26/334 (7.7%) had Foley catheter durations longer than two days
  • 267/334 (79%) received antibiotics during stent removal
  • 20/334 (5.99%) had a stent UTI
• 68.65% non-white children received prophylaxis
• 509/672 (75.7%) had ureteral stents removed after four to eight weeks, irrespective of antibiotic use

Overall incidence of stent UTI

• 51 (7.59%) patients in study had stent UTI
• 26 (51%) patients with stent UTIs were female
  • 12.9% of females in study had stent UTI
  • 5.3% of males in study had stent UTI
• Mean age distribution
  • 3.46 years, stent UTI
  • 5.56 years, no stent UTI
• Diaper usage
  • 10.64% likely using diapers
  • 4.13% not likely using diapers
• Positive intraoperative urine culture
  • 40% had stent UTI
  • 7.12% no stent UTI
• Foley catheter not significantly associated with a stent UTI
• Ureteral stent duration is not significantly associated with a stent UTI

Discussion: prophylactic antibiotics not beneficial to patients after pyeloplasty

Approximately 67 percent of pediatric urologists prescribe prophylactic antibiotics following pyeloplasty without clear patient benefit. In this study, the overall rate of stent UTI was 7.59 percent, including 9.17 percent of children who received antibiotics and 5.99 percent of children who did not. Antibiotic prophylaxis did not reduce the rate of stent UTIs.

Antibiotic prophylaxis did not reduce the risk of stent UTI in these cases.

Factors increasing the percentage of patients receiving antibiotic prophylaxis:

• Younger age
• Diaper use
• Black race
• Open pyeloplasty

Factors not associated with an increase in stent UTIs:

• Surgical approach
• Race
• Stent duration, most removed within four to eight weeks
• Foley catheter duration, most removed on postoperative day one

Conclusion: Prophylactic antibiotics did not reduce the risk of stent UTIs

This is the largest known multi-institutional study of the utility of prophylactic antibiotics after pyeloplasty with ureteral stent insertion. The incidence of stent UTIs in the study population was 7.59 percent. The use of prophylactic antibiotics did not reduce the rate of stent UTI even after controlling for risk factors such as female sex, the use of diapers and a positive intraoperative urine culture. Excessive use of antibiotics exposes patients to unnecessary side effects and complications.