Not all patients need antibiotics before shockwave lithotripsy for urolithiasis

Urolithiasis, or a urinary stone, is a common and painful condition that is often treated with extracorporeal shockwave lithotripsy. In the procedure, precisely targeted sound waves are directed at the stone from outside the body, breaking up the stone into smaller pieces, which are then passed out of the body in the urine. The procedure exposes the patient to urinary tract infections.

Extensive evidence on antibiotic use in shockwave lithotripsy for urolithiasis

An international research group led by Professor Kari Tikkinen from the University of Helsinki, who works as a urologist at HUS, examined the benefits and harms of antibiotic prophylaxis, or the use of antibiotics to prevent infections, in shockwave lithotripsy for urolithiasis.

The study covered over 1700 patients from nine countries, including over 360 HUS patients. The patients were randomized into two groups, one of which received ciprofloxazin and the other placebo before the shockwave lithotripsy procedure. A total of 1.3% of the patients in the antibiotic group and 2.7% of the patients in the placebo group were diagnosed with symptomatic urinary tract infection. Pyelonephritis only occurred in the placebo group with no cases reported in the antibiotic group. Urosepsis was not observed, and no severe adverse effects were reported.

The global threat of antibiotic resistance must be taken into account, and antibiotics should be used with consideration

“One dose of ciprofloxazin can reduce the risk of serious infection, but as the absolute benefit is low, the decision on the use of antibiotic prophylaxis should be made on a case-by-case basis, taking into account the patient’s risk factors, what the patient wants, and the prevention of antibiotic resistance,” Tikkinen says.

The results of the APPEAL trial led by Tikkinen provide a basis for updating international treatment guidelines. Tikkinen points out that healthcare needs to develop better ways of identifying the patients who benefit the most from the use of antibiotic prophylaxis. A dose of antibiotics before a shockwave lithotripsy procedure may prevent rare but severe infections, but it is not needed for most low-risk patients.

Link to the research article: A Multicenter Randomized Controlled Trial of Antimicrobial Prophylaxis to Prevent Urinary Tract Infections after Shockwave Lithotripsy for Urolithiasis: The APPEAL Trial