Editorial: Issues in Infection

The preceding 4 articles in this issue of the Journal ask that we reexamine some old controversies, and familiarize ourselves with new ideas and techniques in the world of urological infection, a subject that most of us tend to take for granted. Each article raises interesting points with regard to the new world of corporate medicine and managed care. Gasser et a1 (page 146) discuss a prospective trial to test the efficacy of antimicrobial prophylaxis in patients undergoing transurethral surgery. Patients with preoperatively sterile urine were randomized to receive either 400 mg. oral fleroxacin once daily or placebo as long as the catheter was in place. Postoperative urinary tract infection rates were significantly lower in the fleroxacin group (3%) compared to the placebo group (23%). The authors conclude that prophylaxis in patients with sterile urine makes sense. Looking at the data, one can see that only 4 of the 8 patients with positive cultures had clinical signs of infection, and 1 of these patients was on fleroxacin. Only 1 patient had a positive blood culture. In addition, 1 of the fleroxacin treated patients had unexplained fever with negative blood and urine cultures. Would it make more sense to treat the 4 of 75 patients with signs of infection rather than treat 75 patients with a new, presumably expensive, fluoroquinolone for 2 to 3 days routinely? The issue of unexpected preoperative urinary tract infections (9 of 75 in this study) is easily addressed if urine is cultured several days before the planned operation rather than during the preceding 24 hours. We studied the use of nitrofurantoin in patients undergoing transurethral prostatectomy with preoperative sterile urine cultures.' A total of 223 patients was randomly assigned to groups receiving placebo, and 5 and 10 days of treatment. While antibiotic administration decreased the incidence of short-term postoperative bacteriuria from 24 to 12%, there was no change in the 4-week postoperative incidence of infection. No patient had a positive blood culture, and the clinical course of patients was not altered by the routine use of antibiotics in this population. Slaa et a1 used trimethoprim-sulfamethoxazole prophylactically following laser coagulation of the prostate2 but this is a special circumstance manifested by the presence of necrotic tissue after the procedure and the need for prolonged catheterization in some patients. If we elect only to treat infected patients, potentially to save money and decrease the development of future antibiotic resistance from unnecessary treatment, the issue of office microbiology arises and is addressed in the challenging article by Gillenwater and Clark (page 149). This important study demonstrates beyond a reasonable doubt that tentative direct disk antibiotic susceptibility in bacteriuria provides comparable results 24 hours sooner compared to standard techniques. The article confronts a politicized issue in which the hidden agenda seems to be to prevent physicians from performing urine culture and sensitivity testing in their offices. Avoiding unnecessary antibiotics and choosing the proper, specific antibiotic depend on the availability, cost and timeliness of culture and sensitivity data. As Hodgson et al recently noted, the pace of emergence of resistant microorganisms has outstripped the rate of discovery of new antibioti~s.3 The last major antibiotic class, the carbapenems, is more than 20 years old. A decade may elapse before we can expect new approaches in infection treatment to become generally available. Pleas for the judicious use