149 The quality of the evidence was variable, with a high risk of selection and attrition bias in most studies reviewed. Chapter 95. Additionally, there has been a steady increase in resistance rates of Escherichia coli to fluoroquinolones. 29 The use of penicillin and -lactams in the setting of a true Type I hypersensitivity reaction is contraindicated due to the risks of anaphylaxis and death. The recommended dose of fluconazole is 400 mg (6 mg/kg) orally daily, and amphotericin B deoxycholate is 0.30.6 mg/kg intravenously daily. Neutropenic patients are at risk for bacterial sepsis from both gram-positive and gram-negative organisms, especially Pseudomonas species. Clin Infect Dis 2000; 30: 14. 146,147 Placement of a drain is associated with an increased risk of SSI, 99 but should be utilized when surgically appropriate. Other combinations for colorectal AP have included ampicillinsulbactam or amoxicillinclavulanate, both reported in small studies to be as effective in reducing SSI as have combinations of gentamicin and metronidazole, gentamicin and clindamycin, and cefotaxime and metronidazole. While most bacteria possess the capacity to cause disease, the ability to do so (pathogenicity) varies by organism and its speciation. Surgical Site Infection (SSI) Guideline for Prevention of Surgical Site Infection (2017) Centers for Disease Control and Prevention Guideline for the Prevention of Surgical 61. 152. It is unclear whether nail picks and brushes have an impact on the number of colony forming units remaining on the skin. Munday GS, Deveaux P, Roberts H, et al: Impact of implementation of the surgical care improvement project and future strategies for improving quality in surgery. Henderson A and Nimmo GR: Control of healthcare- and community-associated MRSA: recent progress and persisting challenges. Clin Gastroenterol Hepatol 2011; 9: 1044. Cochrane Database of Syst Rev 2016; 1: cd004288. Moses RA, Ghali FM, Pais VM, Jr., et al: Unplanned hospital return for infection following ureteroscopy- can we identify modifiable risk factors? Picchio M, De Angelis F, Zazza S, et al: Drain after elective laparoscopic cholecystectomy. Van Hecke O, Wang K, Lee JJ, et al: The implications of antibiotic resistance for patients' recovery from common infections in the community: a systematic review and meta-analysis. Microscopy positive for pyuria and/or bacteriuria on a catheterized urine sample for microscopy or positive cultures >10 3 CFU/mL of common or expected uropathogens are highly predictive of infection but do not discriminate from colonization. Lamagni T, Elgohari S, and Harrington P: Trends in surgical site infections following orthopaedic surgery. Harbarth S, Samore MH, Lichtenberg D, et al: Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Furthermore, there is moderate-quality evidence from multiple RCTs that do not show a benefit of prolonging AP beyond the case completion, 41 and, according to a World Health Organization (WHO) systematic review, the benefit of intraoperative coverage is undetermined at this time. In lower-risk Class II/clean-contaminated procedures such as office cystoscopy, AP does not provide a risk/benefit ratio supporting routine AP use. Ainscow DA and Denham RA: The risk of haematogenous infection in total joint replacements. Cai T, Verze P, Brugnolli A, et al: Adherence to european association of urology guidelines on prophylactic antibiotics: an important step in antimicrobial stewardship. Dis Colon Rectum 2017; 60: 761. Dieter AA, Amundsen CL, Edenfield AL, et al. 14 For many clinicians, SCIP adherence is an exercise in documentation or checking a box. We Repeated urinalysis and cultures are not required in the low-risk patient if effective and appropriate symptom response has occurred. A systemic review of the few studies of ASB available does not support the use of multiple doses of antimicrobials, 114 nor of repeated urinalysis to demonstrate clearing of ASB. This is the 3rd Edition of National Antimicrobial Guideline (NAG). 22,23 The BPS on urodynamic AP from the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) 24 is incorporated into this document. Symptoms associated with the infection should have resolved prior to proceeding. WebPerformance measures are essential to the credibility of any health care organization and are required of an accredited or certified organization. For example, while the risk of SSI with implantation of prosthetic materials and devices is intermediate, the consequences of an SSI in this setting are high. Anaya DA, Cormier JN, Xing Y, et al: Development and validation of a novel stratification tool for identifying cancer patients at increased risk of surgical site infection. Cochrane Database of Syst Rev 2014; 3: Cd009573. Mui LM, Ng CS, Wong SK, et al: Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis. 145. evaluated bacteriuria with rate of positive urine cultures after cystoscopy: the prevalence was 1% with AP, 2% with placebo. Int Urol Nephrol 2017; 49: 1311. Lancet Infect Dis 2017; 17: 50. 1,12,43. SCIP 57,58, For prosthetic device implantation, AP coverage for skin flora, specifically coagulase negative staphylococci and also gram-negative bacilli, including Pseudomonas species, has been recommended. Srisung W, Teerakanok J, Tantrachoti P, et al: Surgical prophylaxis with gentamicin and acute kidney injury: a systematic review and meta-analysis. Can Urol Assoc J 2013; 7: E530. Duration Geneva: World Health Organization; 2016. While drain placement appears associated with a higher risk of SSI in most but not all studies, 99,100 none of these studies reported on urologic cases. Cameron AP, Campeau L, Brucker BM, et al: Best practice policy statement on urodynamic antibiotic prophylaxis in the non-index patient. For example, while compliance with AP measures enumerated in The Surgical Infection Prevention and Surgical Care Improvement Projects: National Initiatives to Improve Outcomes for Patients Having Surgery12,13 reduced the SSI risk by 18%, 14 increasing compliance with this measure alone did not closely correlate with the resulting decreases in infectious complications rates. As is the case with ASB, for these routine low-risk Class II/clean-contaminated procedures, fungal colonization, including biofilms on foreign bodies, do not require antifungal prophylaxis. Despite good evidence for the efficacy of these recommendations, the efforts of SCIP have not measurably improved the rates o Lancet Infect Dis 2016; 16: e276. government site. Selection of antimicrobials is best influenced by how well the agent penetrates the tissues/compartment of interest and is at minimum inhibitory concentrations or above at the time of the procedure. Urine culture should not be performed without an accompanying urine microscopy due to common sample contamination as well as bacterial colonization. Chen SC, Tong ZS, Lee OC, et al: Clinician response to candida organisms in the urine of patients attending hospital. 34, The U.S. Food and Drug Administration issued multiple Boxed Warnings regarding serious musculoskeletal, peripheral neuropathy, mental health, and most recently, hypoglycemic coma treatment-emergent adverse effects (TEAE) due to fluoroquinolones. Infect Control Hosp Epidemiol 2001; 22: 266. Liu LH, Wang NY, Wu AY, et al: Citrobacter freundii bacteremia: risk factors of mortality and prevalence of resistance genes. 9 Such concerns are magnified by the urgent need for enhanced antimicrobial stewardship worldwide wherein antimicrobials are rapidly diminishing in their coverage for common pathogens, and where adverse event risk reduction is paramount. For cystoscopy performed in patients without a concomitant urologic infection, no significant differences in post-cystoscopy UTIs were seen with or without AP 65,66 with moderate evidence allowing the establishment of a baseline rate of UTI of 3% in placebo-controlled cystoscopic trials. Population-based studies of infectious complications after AP for radical cystectomy similarly demonstrated that first-generation cephalosporins were most commonly used, but the authors noted that only 15% of patients received AP consistent with the current guidelines. Br J Neurosurg 2018; 32:177. 89. For procedures that enter the large bowel, gram-negative and anaerobic organisms pose a risk to patients. As examples, patients undergoing urologic procedures often have associated host-related factors that increase the risk of an SSI and bacteremia; a recent TURP study found that ASB occurred during the case in 23% of patients. Inpatient urine cultures are frequently performed without urinalysis or microscopy: findings from a large academic medical center. Kijima T, Masuda H, Yoshida S, et al: Antimicrobial prophylaxis is not necessary in clean category minimally invasive surgery for renal and adrenal tumors: a prospective study of 373 consecutive patients. BMJ 2008; 337: a1924. Wu X, Kubilay NZ, Ren J, et al: Antimicrobial-coated sutures to decrease surgical site infections: a systematic review and meta-analysis. Many studies are performed in more complicated clinical settings, on patients with higher risk of infections and serious complications from those infections. AP is not the use of antibiotics for treatment of a suspected infection; clinicians and surgeons may determine that the continuation of antibiotics is indicated where treatment, not prevention, of an infection is the goal of therapy. Makama JG, Okeme IM, Makama EJ, et al: Glove perforation rate in surgery: a randomized, controlled study to evaluate the efficacy of double gloving. 150. In the surgical management of stones, a urine culture should be obtained if a UTI is suspected based on the urinalysis or clinical findings. Despite this, other guidelines suggest modifications of the antimicrobial dosing based on patient weight; there are neither RCTs nor systematic reviews that evaluate this question. 50 Hence, in the absence of high-quality research to suggest a benefit to continued AP beyond wound closure and literature to suggest specific harms, this BPS recommends that AP be limited to the duration of the procedure itself with no subsequent dosing after wound closure. Nishimura RA, Otto CM, Bonow RO, et al: 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the american college of cardiology/american heart sssociation task force on clinical practice guidelines. AP may be considered for other higher-risk individuals; Cameron et al. Surg Infect 2016; 17: 256. Carlson AL, Munigala S, Russo AJ, et al. Wang-Chan A, Gingert C, Angst E, et al: Clinical relevance and effect of surgical wound classification in appendicitis: retrospective evaluation of wound classification discrepancies between surgeons, Swissnoso-trained infection control nurse, and histology as well as surgical site infection rates by wound class. Cochrane Database of Syst Rev 2011; 11: cd004122. 55 Recent modifications to the NNIS risk index include a history of preoperative chemotherapy (OR=1.94), or groin incisions (OR=4.65). The WHO considers a conditional (moderate) recommendation for mechanical bowel preparation and oral antimicrobials prior to colorectal procedures, 75 consistent with most urologic practices using colorectal segments. Properly collected urine microscopy that does not reveal fungal forms appears adequate for screening for funguria and obviates the need for fungal cultures. Large MC, Kiriluk KJ, DeCastro GJ, et al: The impact of mechanical bowel preparation on postoperative complications for patients undergoing cystectomy and urinary diversion. Other host-specific factors such as drug allergy, intolerance, or a history of Clostridium difficile infection may influence the selection of an antimicrobial agent for prophylaxis. Based on the AUA Guideline on the Surgical Management of Stones, 62,63 AP should be administered prior to stone intervention for ureteroscopic stone removal, PCNL, open and laparoscopic/robotic stone surgery, using a single dose. Third, the IDSA cited evidence for a prolonged pre- and post-procedure treatment of asymptomatic funguria is of low quality and does not discriminate regarding the associated risks of specific GU procedures. Much has changed in AP in recent years, with specific concerns regarding minimizing infectious complications in patients with community versus nosocomial acquired colonization; those with anaerobic 6 or gram-positive organisms, 7 which are not covered by standard genitourinary (GU) prophylaxis regimen; those with previously placed indwelling stents and catheters; 8 or those recently prescribed antimicrobials given that increasing resistance to common pathogens may occur after a single dose of a fluoroquinolone. Greene DJ, Gill BC, Hinck B, et al: American Urological Association antibiotic best practice statement and ureteroscopy: does antibiotic stewardship help? Ramos JA, Salinas DF, Osorio J, et al: Antibiotic prophylaxis and its appropriate timing for urological surgical procedures in patients with asymptomatic bacteriuria: a systematic review. J Am Coll Surg 2016; 222: 431. have demonstrated no increase in infectious rates using an evidence-based protocol to select those undergoing outpatient cystoscopy who are at highest risk of an infectious complication and thereby, limiting AP specifically to those individuals. Virulence factors include vector-produced lipopolysaccharides, proteins, and/or carbohydrates that might promote bacterial attachment, such as diffusely adherent E. coli, those that enclose and protect the bacterium from attack, toxins capable of inciting a counterproductive inflammatory response, or proteolytic enzymes and other products that attack the host organisms defenses and are thereby capable of subverting the hosts metabolic processes. Colonization, as well as accompanying pyuria, is expected for those with long-term indwelling urinary catheters, or those who have had diversions or augmentative procedures involving bowel segments. 125 Instruments should only be passed within the operative field in front of all surgeons and assistants. J Urol 2007;178:1328. WebAntibiotic Guidelines: Gustilo Type I and II: Cefazolin 2g IV immediately and q8 hours x 3 total doses If penicillin allergic: clindamycin 900mg IV immediately and q8 hours x 3 total doses Gustilo Type III: Ceftriaxone 2g IV immediately x 1 total dose Vancomycin 1g IV immediately and q12 hours x 2 total doses Class II procedures include those entering into pulmonary, gastrointestinal (GI), or GU under controlled conditions and without other contamination. Simple outpatient diagnostic tests, which do not normally break either the mucosal or skin barrier, likely do not require AP in the healthy individual. Patients undergoing treatment of fungal balls (mycetoma) require organism speciation with antifungal sensitivities, antifungal therapy at the time of the procedure, and continued antifungal treatment for an as yet undetermined length of therapy; the majority opinion is five to seven days. Curr Opin Infect Dis 2014; 27: 90. AP is not recommended for simple outpatient cystoscopy and/or urodynamic procedures, catheterization, or catheter changes. 1, Mechanical bowel prep using oral antimicrobials is recommended prior to elective colorectal surgical procedures. Background: Manifestations of gallbladder disease range from intermittent abdominal pain (symptomatic cholelithiasis) to potentially life-threatening illness (gangrenous cholecystitis). Many more of these trials are needed, specifically comparing single-dose AP for Class I skin incisions versus no antibiotics and comparing single-dose AP versus multiple-doses for higher-risk patients and procedures. J Clin Lab Anal 2017; 31: e22080. Would you like email updates of new search results? However, there are rare circumstances when concomitant GU and oral mucosal procedures are performed (e.g. Procedures with durations greater than three hours have been found to have a significantly increased risk of SSI; as such, it is now standard practice for re-dosing of antimicrobials if the procedure extends beyond two half-lives of the initial dose. Recent or current antimicrobial therapy for another indication would also need to be considered, as it is preferable to select an antimicrobial of another class due to the likely change in the microbial flora and susceptibilities. Gregg JR, Bhalla RG, Cook JP, et al: an evidence-based protocol for antibiotic use prior to cystoscopy decreases antibiotic usage without impacting post-procedural symptomatic urinary tract infection rates. WebABX 1. The weakness of the evidence for many of these recommendations should be interpreted as meaning that these recommendations are subject to change as stronger evidence becomes available. 143,144, The most recent statement by the American Academy of Orthopedic Surgeons (AAOS) in February 2009 Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements asserts that given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bacteremia., Surveillance systems for hospital-acquired infections do not record lower incident SSI, such as post-GU procedure associated periprosthetic joint infections, but rather are concerned with more common problems including CAUTI or infections with MDR organisms, as examples. 72 This simple regimen is not appropriate in obstructed small bowel nor with prior bypass nor biliary stenting. 15 It is known that the achievement of therapeutic levels of cefazolin and cefepime are significantly delayed in the morbidly obese patients undergoing bariatric surgery. 2012. https://www.rcpi.ie/news/publication/preventing-surgical-site-infections-key-recommendations-for-practice/. Baron S. Galveston, TX: University of Texas Medical Branch at Galveston; 1996. Host-related abilities to defend against bacterial invasion are also related to the local environment, including the preservation of the cell wall barrier, local tissue oxygenation, healthy vascularity and lymphatic drainage, and more recently recognized, the hosts own microbiota profile. Deborah J. Lightner, MD; Mayo Clinic; Kevin Wymer, MD; Mayo Clinic; Joyce Sanchez, MD; Medical College of Wisconsin; Louis Kavoussi, MD; Northwell Health, Table I: Hostrelated factors affecting SSI risk a[pdf] Table II: Proposed Procedureassociated Risk Probabilty of SSI c,d,e,f [pdf] Table III: Recommended Definitions for a Surgical Site Infection (SSI), Hospital Acquired Infection (HAI), and Periprocedural Urinary Tract Infections (UTI) b,c,d[pdf] Table IV: Wound Classifications k [pdf] Table V: Recommended antimicrobial prophylaxis for urologic procedures [pdf] Table VI: End of Case Assesment of Wound Class f [pdf]. While reducing contamination through either microperforations or frank perforations, double-gloving does not appear to confer a reduction in SSI, 123,124 although many surgeons continue this practice to reduce their own exposure. The more invasive the procedure, the more contaminated the operating field, the longer the procedure, the greater the risk of a post-procedural infection. Standardized definitions for SSI, sepsis, and post-procedural UTI (see Table III) should be used for reporting by the surgeon, who is the most accurate observer of the wound class and of any subsequent infectious complications. Prostate biopsy and periprocedural management of stones were likewise excluded; however, relevant guideline recommendations and white paper statements current at the time of this publication are included and referenced. Data Element Name: Antibiotic Administration Date. Neugut AI, Ghatak AT, and Miller RL. Study design: Retrospective case series. 2012. PloS one 2013; 8: e68618. endoscopic procedures for benign prostatic hypertrophy). Scottish Intercollegiate Guidelines Network (SIGN). For instance, a neutropenic patient undergoing a simple cystoscopy may require AP, whereas a healthy patient does not. It should be noted that not all GU literature has found a statistically significant increase in SSI with patient frailty (mFI). Smith BP, Fox N, Fakhro A, et al: "SCIP"ping antibiotic prophylaxis guidelines in trauma: the consequences of noncompliance. Please enable it to take advantage of the complete set of features! Hawn MT, Richman JS, Vick CC, et al: Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. In Class III/contaminated cases, the surrounding tissue is exposed to pathogens routinely. This BPS strongly recommends that future studies use standardized definitions of SSI 18,19 suggested in Table III as outcome measures, even as healthcare professionals work to determine the best definitions within specialties and procedures. Infect Control Hosp Epidemiol 2014; 35: 1013. 105. Infect Control Hosp Epidemiol 2014; 35: 605. WebGuidelines on Antimicrobial Prophylaxis in Surgery, 1 as well as guidelines from IDSA and SIS.2,3 The guidelines are in-tended to provide practitioners with a standardized approach to the rational, safe, and effective use of antimicrobial agents for the prevention of WebAntimicrobial agent infusion should begin 15-60 minutes before the incision with the exception of vancomycin, levofloxacin, ciprofloxacin, gentamicin, azithromycin and fluconazole. Personal protective eyewear should also be worn to protect the team from body fluids. Wolf JS, Jr., Bennett CJ, Dmochowski RR, et al: Best practice policy statement on urologic surgery antimicrobial prophylaxis. 71 For surgical procedures including unobstructed small bowel, patients should receive a first-generation cephalosporin (cefazolin) as the upper GI tract flora is relatively sparse and intense colonization unusual in the healthy individual. 120 The operative field is prepared by removing soil and eliminating transient bacteria. Nicolle LE: Asymptomatic bacteriuria. 111 Similarly, a urinalysis is not indicated in open heart surgical procedures. Garcia-Perdomo HA, Jimenez-Mejias E, and Lopez-Ramos H: Efficacy of antibiotic prophylaxis in cystoscopy to prevent urinary tract infection: a systematic review and meta-analysis. If large bowel spillage occurs at the time of a reconstruction, then anaerobic antibiotic coverage is now indicated. official website and that any information you provide is encrypted Urol Clin North Am 2015; 42: 441. The patients biome plays a role in the proper selection of AP: patients with colonization with MRSA may need an additional agent for reduction of invasive MRSA skin/soft tissue infections. Dellinger EP, Gross PA, Barrett TL, et al: Quality standard for antimicrobial prophylaxis in surgical procedures. Mayne AIW, Davies PSE, and Simpson JM: Antibiotic treatment of asymptomatic bacteriuria prior to hip and knee arthroplasty; a systematic review of the literature. Bethesda, MD 20894, Web Policies Saraswat MK, Magruder JT, Crawford TC, et al: Preoperative staphylococcus aureus screening and targeted decolonization in cardiac surgery. All antimicrobials have the potential for causing adverse reactions. 40,41 The concerns regarding limiting AP doses beyond wound closure is not unique to urologic practice. Ann Surg 2012; 255: 134. Ann Vasc Surg 2018; 49: 277. 106 While controversial data exist, 107,108 pregnant patients with ASB are being treated with AP throughout pregnancy and delivery. An SSI associated with a vaginal hysterectomy is often polymicrobial; without antimicrobial coverage, SSI incidence ranges widely from 14% to 57%. Procedures may be classified into low-, intermediate-, and high-risks, and as yet undetermined probability for an associated SSI, with a proposed procedural-associated risk probability for GU procedures is presented in Table II. HHS Vulnerability Disclosure, Help 2015; 21: 130. 74,116 Additionally, the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America, 42 the CDC118 and the WHO 75,119 have recently updated the appropriate non-antimicrobial intraoperative and post-operative procedures recommended for SSI prevention. Accordingly, this BPS included patient risk factors (who); diagnostic and treatment-associated urologic procedures, GU surgery, and prosthetics (what and where); as well as AP timing, re-dosing, and duration (when) in the search criteria. Berrios-Torres SI, Umscheid CA, Bratzler DW, et al: Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. still inhibited by penicillins; however, aminoglycosides and cephalosporins are also appropriate for most GU cases requiring AP. Surg Infect 2012; 13: 33. 2022 Medicare Promoting Interoperability Program Specification Sheets (ZIP) Scoring Methodology Fact Sheet (PDF) Electronic Prescribing Objective Fact Sheet (PDF) Health Information Exchange Objective Fact Sheet (PDF) Provider to Patient Exchange Objective Fact Sheet (PDF) Public Health and Clinical Data Exchange Objective Fact Sheet The extent of the operative field is determined by the surgeon based on the procedure being performed as well as anticipated emergencies that may require a larger sterile working area. The site is secure. Clin Infect Dis 2014; 59: 41. Kazemier BM, Koningstein FN, Schneeberger C, et al: Maternal and neonatal consequences of treated and untreated asymptomatic bacteriuria in pregnancy: a prospective cohort study with an embedded randomised controlled trial. 41, The type of procedure being performed dictates the prophylaxis. If a patient is considered at risk for an infectious complication due to the patients risk factors (Table I), the associated SSI risk of the procedure (Table II), or the potential morbidity of a subsequent infection, results of the urine microscopy (proceeding to urine culture and sensitivity as indicated) should be obtained prior to the selection of the AP for the procedure, thereby allowing for assessment of the likely infectious organism and its potential virulence. It must be emphasized that for oral administration, the achievement of adequate tissue levels of the selected antimicrobial may not occur within the one-hour time frame given for parenteral administration. Increased inspired FiO2 to optimize local tissue oxygenation, and adequate volume replacement are also important adjuncts to SSI risk reduction. Actual risk rates are poorly defined, highly variable, and dependent upon the trial design, case inclusion, source search and definitions, the population and their associated risks. Evaluation thereafter may also include a simple dipstick, laboratory performed microscopy, and/or formal culture, with assessed risks requiring higher levels of antimicrobial specificity and sensitivity. AP limited to the time of urinary catheter removal for general surgery, post-prostatectomy, and medical patients effectively reduced the incidence of symptomatic UTIs with a number needed to treat of 17. Tanner J, Dumville JC, Norman G, et al: Surgical hand antisepsis to reduce surgical site infection. 95 With major urologic oncologic surgery, 24% of radical cystectomy patients are reported to have developed either a SSI, sepsis, or UTI with operative times greater than or equal to 480 minutes, the strongest independent risk factor. Nonetheless, the associated risk of SSI when cystoscopy is performed in the setting of ASB is low. RCTs from non-urologic procedures demonstrate no decrease in SSI with antimicrobials continued during the period of drain utilization. An official website of the United States government. Culture results and sensitivities should dictate the antimicrobial agent in these settings. When applicable, the side of surgery is identified. This site needs JavaScript to work properly. Within urologic practice, transrectal prostate biopsy may still require consideration of fluoroquinolone AP in some centers and in some clinical conditions. J Urol 2014; 192: 1667. 53 Those risk criteria are included in Table I. Single-dose AP is recommended prior to all procedures for the treatment of benign prostatic hyperplasia (BPH), transurethral bladder tumor resections, vaginal procedures (excluding mucosal biopsy), stone intervention for ureteroscopic stone removal, percutaneous nephrolithotomy (PCNL), and open and laparoscopic/robotic stone surgery (see Table IV). For urologists, these include any opening into the GU tract, nephrectomy, cystectomy, endoscopic, and vaginal cases. Radical prostatectomy confers an intermediate risk, whereas the literature supports that transurethral prostate procedures confer a high risk of SSI without appropriate AP. Indian J Urol. 2013. Prevention of clostridium difficile infection: a systematic survey of clinical practice guidelines. Allegranzi B, Zayed B, Bischoff P, et al: New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Curr Opin Infect Dis 2015; 28: 125. High-level evidence assessing SSI risks in the presence of a drain versus no drain with single dose AP is sorely needed.