One week of nitrofurantoin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: A prospective controlled study - Editor's Commentary

BERKELEY, CA (UroToday.com) - In this PROSPECTIVE RANDOMIZED STUDY of a 101 patients with stones ≥2.5 cm. and/or hydronephrosis plus sterile urine, percutaneous nephrostolithotomy (PCNL) preceded by one week of oral nitrofurantoin 100 mg/BID resulted in a statistically significant decrease in positive pelvic urine cultures (0% vs. 10%), positive stone cultures (8% vs. 30%), endotoxemia (18% vs. 42%), and systemic inflammatory response (fever, leucocytosis) (19% vs. 49%).

In addition, in the study group there were no instances of life-threatening septicemia, whereas this occurred in one patient in the control group (2%). Of note, all patients received a single dose of intravenous cephalosporin prior to the PCNL procedure. Among the 101 patients, the most commonly isolated pathogen from pelvic urine or from stone culture was E. coli (19%) followed by Klebsiella (8%) and Pseudomonas (6%); all isolated bacterium were sensitive to nitrofurantoin.

These results are very similar to earlier results from a prospective randomized trial using ciprofloxacin for a week prior to PCNL.1 Of note, the cost of a week of ciprofloxacin at our hospital is only $11 vs. $20 for nitrofurantoin. Regardless, the avoidance of even one bout of urosepsis and its attendant treatment would more than pay for the administration of nitrofurantoin to the entire study group!

The authors sagely caution that in the face of a complete staghorn stone in which a Proteus or Pseudomonas infection is more likely, prophylaxis with a fluoroquinolone is preferable, especially if there was a positive urine culture for either bacterium in the past.

Of note, nitrofurantoin does not penetrate tissue, unlike the fluoroquniolones or cephalosporins. This leads one to hypothesize that a single dose of cephalosporin prior to PCNL is not sufficient and what is needed is not so much high tissue levels of an antibiotic as much as a prolonged course of an antibiotic sufficient to render the urine and stone sterile prior to nephrostomy tract creation and in situ lithotripsy.

Perhaps it is time to look at the large renal stone as though it were a “petrified abscess” lying within the kidney; as with other abscesses deep within the body, prudence would lead to appropriate antibiotic therapy to protect from systemic sepsis prior to proceeding with “lancing/drainage.” “An ounce of prevention is worth a pound of cure” in both a physical and fiscal sense.

Reference:

1Mariappan, P., Smith, G., Moussa, S. A., and Tolley, D. A.: One week of ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study. BJU Int. 98: 1075-1079, 2006

Bag S, Kumar S, Taneja N, Sharma V, Mandal AK, Singh SK

 

Urology. 2011 Jan;77(1):45-9
10.1016/j.urology.2010.03.025

PubMed Abstract
PMID: 20570319

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