[Perioperative and peri-interventional antibiotic prophylaxis: general and urology-specific recommendations from the German Interdisciplinary S3 guideline].

Abstract

Background: Perioperative and peri-interventional antibiotic prophylaxis (PAP) is a central instrument for the prevention of infectious complications, yet it has to consider concerns of individual and general patient safety, antibiotic stewardship, and antibiotic resistance dynamics. The interdisciplinary AWMF (Arbeitsgemeinschaft Medizinisch-Wissenschaftlicher Fachgesellschaften) S3 guideline finalized in 2024 (AWMF S3, 2024) provides a comprehensive, evidence-based framework for indication, substance selection, dosing, timing, and quality assurance of PAP across all surgical disciplines, with a dedicated chapter for preselected urological procedures.

Methods: The guideline was developed in accordance with the AWMF standards, employing systematic literature searches with GRADE evaluation, operationalizing recommendations, statements, and expert consensus, and anchoring implementation in structure-, process-, and outcome-oriented quality indicators. Urological procedures were defined using the PICOS framework and furnished with evidence-based recommendations. In addition, the recommendations are compared with those of the 2025 EAU Guideline on Urological Infections.

Results: General key statements are precise indication for antibiotic use, intravenous administration 30-60 min before incision, single-dose application for the majority of interventions, redosing only in case of extended operating time or major blood loss, and termination of PAP at the end of surgery. For urology, the following apply: for transrectal prostate biopsy, PAP shall be administered, ideally targeted according to rectal swab findings. For transperineal biopsy, PAP may be omitted if urinary tract infection has been excluded and adequate skin antisepsis ensured; in high-risk patients, PAP should be administered. For elective transurethral resection of the prostate (TURP), PAP is mandatory, whereas for transurethral resection of the bladder (TURB), prophylaxis is recommended only in patients at increased risk. For radical cystectomy, PAP shall be administered in all cases. For extracorporeal shock wave lithotripsy (ESWL), routine prophylaxis should not be used, although it may be considered in high-risk situations. For minimally invasive tumor ablations and interventional radiological procedures such as prostatic artery embolization (PAE) routine prophylaxis is not indicated, although selective use may be justified in patients at risk.

Conclusion: The 2024 AWMF S3 guideline on PAP provides a robust foundation for interventional and operative urology, uniting infection prevention and antibiotic stewardship. It enables risk-adapted reduction of unnecessary antibiotic use without compromising safety and shows broad consistency with the EAU recommendations on prophylaxis in urological procedures.