(046) An Approach to the Thoughtful Selection of Antimicrobial Prophylaxis for Inflatable Penile Prosthesis Surgery
Authors: Barham D , Loeb C , Azad B , Hammad M , Simhan J , Yafi F , Gross M 
Published: February 2024

Abstract

Introduction
There is a growing body of evidence questioning the efficacy of the antibiotic prophylaxis regimens recommended by the American Urological Association (AUA) Best Practice Statement (BPS) for IPP surgery. However, since publication of the BPS the use gentamicin and vancomycin use has increased substantially. This is potentially due to a lack of other specific prophylaxis recommendations making it difficult for surgeons to know which agents to select.

Objective
We sought to create a simple process to enable surgeons to select an individualized prophylaxis regimen which accounts for local antibiotic resistance patterns.

Methods
We retrospectively collected IPP infection history from 3 surgeons from 3 different regions of the United States between 2016 and 2021. Local hospital antibiograms were obtained for each surgeons’ institution. Each surgeons IPP infection history was crossed with the resistance patterns on the local antibiograms to identify prophylactic antimicrobial regimens providing the highest level of coverage.

Results
The organisms causing implant infections for each surgeon during the inclusion period are reported in Table 1. Vancomycin and fluconazole provided excellent Gram-positive and fungal coverage for all surgeons, however Gram-negative coverage varied. Surgeon A had a history of ESBL-producing E. Coli and no infections from Pseudomonas sp. Gentamicin and tobramycin have poor coverage of ESBL-producing E. coli (61% and 52% respectively). However, pipercillin/tazobactam covers 92% of ESBL-producing E. coli. The only Gram-negative organism that pipercillin/tazobactam has worse coverage of than the aminoglycosides is Pseudomonas (gentamicin-92%, tobramycin-96%, pipercilin/tazobactam-80%); however, Surgeon A had no history of Pseudomonas infections. Therefore, the greatest level of coverage can be obtained with vancomycin, pipercillin/tazobactam, and fluconazole. All of Surgeon B’s infections were caused by non-ESBL producing E. coli. Gentamicin, tobramycin, and pipercillin/tazobactam all have excellent coverage of E. coli (95%, 94%, and 95% respectively). Comparing these agents to other common pathogens shows superior coverage of tobramycin over gentamicin and pipercillin/tazobactom for Pseudomonas. The highest level of coverage for Surgeon B can be obtained with vancomycin, tobramycin, and fluconazole. Surgeon C’s infection history has a predominance of Klebsiella sp., but also includes Pseudomonas. Both gentamicin and tobramycin have excellent coverage (&gt;95%) of these Gram-negative organisms. The highest level of coverage can be obtained with vancomycin, an aminoglycoside, and fluconazole.

Conclusions
The use of local antibiograms and infection history is a simple strategy to tailor prophylaxis regimens to resistance patterns. We found a different regimen to be superior at each institution. Surgeon B’s experience demonstrates that all aminoglycosides may not be equal when factoring in local resistance patterns.

Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Cynosure, Antares Pharma, Clarus Pharmaceuticals, Acerus Pharma, Boston Scientific.