Septicemia after transurethral prostatectomy

SEPTICEMIA

AFTER

TRANSURETHRAL

PROSTATECTOMY D. M. MURPHY, F.R.C.S.I. F. R. FALKINER, PH.D. M. CARR, B.A. (MOD.) M. T. CAFFERKEY, M.D. W. A. GILLESPIE, ER.C.PATH. From the Department of Urology, Meath Hospital, and Central Microbiology Laboratory, St. James’sHospital, Dublin, Ireland

ABSTRACT-Septicemia occurred in 18 of 1,604 patients subjected to transurethral resection (TUR) of the prostate. Six patients died postoperatively, 4 of septicemia. In 11 patients septicemia was provoked by TUR in the presence of urinary infection and in the absence of appropriate antibiotic cover. Septicemia was provoked by catheter removal in 2 similarly injected patients. In the remaining 5 patients the urine was sterile at operation but became infected prior to catheter removal, and this maneuver precipitated septicemia.

Transurethral resection (TUR) is the preferred method of prostatectomy. This technique was so well established in the 1920s and 193Os,particularly in the United States, that by 1938 the postoperative mortality had fallen to about 1 per cent in a seriesof 2,894 operations. l Most of the subsequently published serieshave recorded little or no further improvement though some have reported even lower figures.2,3However, there has been an increase in the proportions of patients aged over eighty and in patients with co-existing medical diseases.2,4,5The greater mortality associated with both these factors may have masked improvements in the reSUltS.4~5 Urologic operations are among the most common causes of postoperative septicemiae6 We believe this complication is preventable.’ Septicemia occurs mostly in patients who come to operation with urine already infected, often due to previous catheterization for the relief of acute retention. The risk of septicemia can be greatly reduced by appropriate antibiotic “cover” of operations on such infected patients, UROLOGY

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based on a rapid preoperative urine test.7 The proportion of patients at risk for septicemia and so requiring antibiotic cover, could be reduced by performing’ prostatectomy before acute retention develops, and in those with retention, by keeping the period of catheterization asshort as possible.8*9To demonstrate the improvement that the adoption of these policies might bring about, we analyzed the causes of death after transurethral prostatectomy during a threeyear period in this hospital, and we studied the incidence of urinary infection in relation to preoperative catheterization. Septicemia was defined as protracted bacteremia, confirmed by positive blood culture, with fever or hypothermia, rigor, or shock. Material and Methods The causes of death within four weeks of TUR of the prostate were analyzed during the three years (beginning on January 1, 1977) before our system of appropriate antibiotic cover was introduced.’ The incidence of preoperative bacteriuria and its relationship to previous 2

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Predisposing causes of urinary injection at admission to Meath Hospital for TUR (1980-l 981)

TARI.K I.

Indwelling Catheter

Previous Catheterization Urologic Operation During Previous 12 Months

No No Yes Yes

Yes No Yes

Results leading

to septicemia

In three years from January 1, 1977, 1,604 patients underwent TUR of the prostate at Meath Hospital. Six patients (0.34%) died within four weeks after the operation. Four of the deaths were caused by septicemia, one by pulmonary embolism, and one by myocardial infarction. Altogether postoperative septicemia developed in 18 patients (1.1% ) . The urine was infected before operation in 13 of these patients, and sterile in 5. Of the 13 septicemic patients with infected preoperative urine, 2 recently had undergone urologic procedures, and 7 others had been catheterized for relief of urinary retention before operation. Ten had received no antibiotics in the perioperative period. Inappropriate antibiotics, inactive against the organisms in the urine, had been given to 2. One patient had received a urinary antiseptic (nitrofurantoin) that could not provide an antibacterial level in the serum. In 11 patients, the septicemia occurred immediately after operation, and in 2 it was

TABLE

II.

indwelling Urine at Admission Infected Not infected

27 50 95 17

134

(7.9) (46.7) (79.8) (89.5)

precipitated by subsequent catheter removal. Three of the 13 patients died. In the 5 patients with sterile preoperative urine, septicemia was provoked by the removal of the catheter after operation. In 4, the urine had become infected after operation but before catheter removal; in the fifth patient, the urine had not been cultured after the operation. One of these 5 patients died of septicemia. Preoperative causes

urinary

infection:

predisposing

In patients admitted for prostatectomy and other transurethral operations, the incidence of preoperative urinary infection was closely related to recent urologic operation and/or indwelling catheterization (Table I). Information about the duration of indwelling catheterization before admission was not always available from the patient’s history; and when it was known, it was clear that the risk of infection is greater, the longer the period of catheterization (Table II). Comment About 10 per cent of men who reach the age of forty will require treatment for benign hypertrophy of the prostate by eighty.lO Treatment by transurethral resection has a postoperative mortality rate of about 1 per cent or less, admirably low for an operation in elderly men. However, this mortality could be reduced still

Preoperative urinary infection in relation to duration of catheterization (1981-1982), excluding patients with previous operations Patients Not Catheterized

l-5

25 16’7

Catheterization 6-10 11-20

26 24

44 17

20 0

50

61

20

- - -

Total

Urine Infected at Admission (‘5)

343 107 119 19

NO

catheterization or other urologic procedures were determined in men admitted for transurethral resection during 1979 and 1980. The relationship between preoperative bacteriuria and duration of previous catheterization was studied in men admitted between August, 1981, and June, 1982.

Circumstances

Total Patients

192

(Days) Over 20

Total

28 1

118 42

-

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more by avoiding septicemia, one of the remaining causesof postoperative death-and in our experience, perhaps the commonest. Postoperative septicemia is a protracted bacteremia with seriouseffects, sometimes fatal. It is an exceptionally severe manifestation of the bacteremia, usually transient and symptomless, that occurs during more than 50 per cent of urethral and bladder operations in patients with infected urine. l1 The bacteremia, whether transient or protracted, may be provoked by the operation itself or by the removal of the indwelling catheter subsequently.7~12 In our experience, the incidence of septicemia in such patients, unprotected by antibiotic cover, was approximately 6 per cent7 There is a smaller risk of septicemia in patients whose urine, though sterile at operation, becomes infected before the removal of the indwelling catheter subsequently.; For the prevention of postoperative septicemia, two things are important. First, since the risk is greatest in patients with infected preoperative urine, it is important to operate on patients before acute retention develops, necessitating the use of an indwelling catheter, the principal cause of preoperative urinary infection. If retention does occur, prostatectomy should be performed as soon as possible. There is a 5 to 10 per cent risk of bacteriuria developing with each day of catheter drainage, despite adequate catheter care.8,gThe findings in our present study are in accord with this statement. Second, patients with preoperative infection should be protected by appropriate antibiotic cover at opera.tion. In view of the variability of antibiotic sensitivity of the bacteria, often mixed, in the urine of infected catheterized patients, no one predetermined antibiotic can be reliable. An appropriate antibiotic should be selected from the result of a preoperative urine culture and sensitivity test performed on admission to hospital. The praticability of this system and its value in prevention of septicemia is evident from our results.7 The preoperative test should be done as close to the time of operation as possible since the bacteriology of urine may change

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in catheterized patients; it should be arranged to cause no delay in bringing patients to operation, With about 25,000 patients requiring prostatectomy annually in the United Kingdom,13 any prolongation of hospital stay could have serious implications for health care planning. Finally, the small risk of septicemia arising from urinary infection starting after operation but before catheter removal may be avoided by repeating the urine culture a day or two before catheter removal and, if necessary, covering removal with one or two dosesof an appropriate antibiotic. St. James Hospital PO. box 580 Dublin 8, Ireland (DR. MURPHY) ACKNOWLEDGMENT. To Mrs. J, M. Cobbe and Mrs. Mary Foody for secretarial assistance, and consultants and staff of urologic unit of Meath Hospital for their cooperation throughout the study.

References 1. Emmett JL: The “cold punch” type of prostatic resection, JAMA 110: 1807 (1938). 2. Lund BL, and Dingsor E: Benign obstructive prostatic enlargement, Stand J Urol Nephrol 10: 33 (1976). 3. MacKenzies AR: Results of transurethral resection of prostate, NY State J Med 73: 2561 (1973). 4. Melchior J, Valk WL, Foret JD, and Mebust WK: Transurethral prostatectomy: computed analysis of 2,223 consecutive cases, J Ural 112: 634 (1974). 5. Chilton CR et al: A critical evaluation of the results of transurethral resection of the prostate, Br J Urol 50: 542 (1978). 6. Svanbom M: Septicaemia: a prospective study of etiology, underlying factors and sources of infection, Stand J Infect Dis 11: 187 (1979). 7. Cafferkey MT, Falkiner FR, Gillespie WA, and Murphy DM: Antibiotics for the prevention of septicaemia in urology, -,. 1Antimicrob Chemother 6 471 (1982). 8. Kunin CM. and McCormack RC: Prevention of catheterinduced urinary tract infection by sterile closed drainage, N Engl J Med 274: 1155 (1966). 9. Garibaldi RA, Burke JP, Dickman ML, and Smith CB: Factors predisposing to bacteriuria during indwelling urethral catheterization, ibid. 291: 215 (1974). 10. Lytton B, Emery JM, and Harvard BM: The incidence of benign prostatic obstruction, J Urol99: 639 (1968). 11. Keighley MRB, and Burdon DN: Antimicrobial Prophylaxis in Surgery, Tunbridge Wells, England, Pitman Medical, 1979, pp 159-172. 12. Miller A., et al: Postoperative infection in urology, Lancet 2: 668 (1958). 13. Argyrou S, et al: Price of prostatectomy, Br Med J 3: 511 (1974).

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