Nitrofurantoin Administration for the Prevention of Short-Term Catheter Associated Urinary Tract Infection After Pelvic Surgery
| Status: | Recruiting |
|---|---|
| Conditions: | Infectious Disease, Urology |
| Therapuetic Areas: | Immunology / Infectious Diseases, Nephrology / Urology |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 10/5/2017 |
| Start Date: | September 29, 2017 |
| End Date: | June 2019 |
| Contact: | Dina Bastawros, MD |
| Email: | Dina.Bastawros@carolinashealthcare.org |
| Phone: | 704-304-1160 |
Nitrofurantoin Administration for the Prevention of Short-Term Catheter Associated Urinary Tract Infection After Pelvic Surgery (NAUTICA): A Randomized Controlled Trial
The specific aim of this randomized double-blind placebo-controlled trial is to evaluate the
efficacy of administration of nitrofurantoin prophylaxis after catheter discontinuation for
the prevention of catheter-associated urinary tract infections in patients with postoperative
short-term catheterization following pelvic reconstructive surgery and/or urinary
incontinence surgery.
Patients that undergo pelvic organ prolapse and/or urinary incontinence surgery and fail
their post-operative voiding trial will be included in the study. Upon successfully passing
and in-office voiding trial at the time of catheter removal, they will be randomized to
either nitrofurantoin 100mg twice daily or an identical appearing placebo capsule twice daily
for 5 days following catheter removal. The primary outcome will be the treatment of
clinically suspected and/or culture-proven UTI within 30 days of surgery. Secondary outcomes
include adverse events associated with nitrofurantoin use and medication compliance.
Primary and secondary outcomes will be evaluated with Student t test and chi squared or
Fisher exact test as appropriate. Assuming a decrease in symptomatic UTIs attributable to
nitrofurantoin prophylaxis from 32% to 14%, with 80% power, and a two-sided alpha of 0.05,
and a 10% dropout rate, we should recruit a total of 180 patients.
efficacy of administration of nitrofurantoin prophylaxis after catheter discontinuation for
the prevention of catheter-associated urinary tract infections in patients with postoperative
short-term catheterization following pelvic reconstructive surgery and/or urinary
incontinence surgery.
Patients that undergo pelvic organ prolapse and/or urinary incontinence surgery and fail
their post-operative voiding trial will be included in the study. Upon successfully passing
and in-office voiding trial at the time of catheter removal, they will be randomized to
either nitrofurantoin 100mg twice daily or an identical appearing placebo capsule twice daily
for 5 days following catheter removal. The primary outcome will be the treatment of
clinically suspected and/or culture-proven UTI within 30 days of surgery. Secondary outcomes
include adverse events associated with nitrofurantoin use and medication compliance.
Primary and secondary outcomes will be evaluated with Student t test and chi squared or
Fisher exact test as appropriate. Assuming a decrease in symptomatic UTIs attributable to
nitrofurantoin prophylaxis from 32% to 14%, with 80% power, and a two-sided alpha of 0.05,
and a 10% dropout rate, we should recruit a total of 180 patients.
Urinary tract infections (UTI) are the most common hospital-acquired infections, accounting
for nearly 30% of cases of nosocomial infections and affecting nearly 1 million people per
year.
Following pelvic reconstructive and urinary incontinence surgery, UTIs are one of the most
common complications with a risk between 8.9%-34%. The baseline risk of UTI associated with
pelvic floor surgery ranges between 5-35%, increasing greatly with catheterization.
Postoperative voiding dysfunction and incomplete bladder emptying is common following pelvic
reconstructive and incontinence surgeries, with incidence ranging from 2.5 % to 31%. As a
result, these women may have additional catheterization for a short period of time, which
increases the risk of UTI. There is a 15-20% risk of developing a postoperative UTI with
short-term catheterization, even if the catheter remains in place for merely 24 hours. The
risk of UTI increases 5-10% each day the catheter is left in place.
Numerous studies have been conducted to evaluate different prophylactic antibiotic regimens
to help decrease the rate of postoperative catheter-associated UTIs. Many of these studies
have shown precedent for the use of antibiotic prophylaxis.
Nitrofurantoin has been evaluated as a prophylactic regimen for use during short-term
catheterization. These studies had favorable results, decreasing the incidence of UTI
postoperatively.
Although there are a few studies showing favorable results for the use of prophylactic
nitrofurantoin during catheterization after pelvic surgery, the optimal timing of antibiotic
administration and length of dosing regimen is not well defined. The American Urological
Association (AUA) recommends empiric antibiotic treatment at the time of external urinary
catheter removal in patients with risk factors, such as tobacco use, advanced age, and
anatomic abnormalities of the urinary tract. The AUA Panel does cite that bacteriuria in the
setting of noninfectious urinary tract disease is a risk factor for bacteremia, and, thus,
prophylactic antibiotic treatment at time the of catheter removal may be indicated. The AUA
does recommend empiric antibiotic treatment at the removal of an external urinary catheter in
patients with risk factors. However, there is no standardization concerning the type of
antibiotic to be used or treatment duration.
Although there are a few studies showing favorable results for use of nitrofurantoin during
catheterization after pelvic surgery, there are no clearly defined recommendations regarding
its use for urinary tract infection prevention after catheter removal. Therefore, the
objective of our study is to examine the effects of administration of nitrofurantoin therapy
at the time of Foley catheter removal for the prevention of catheter-associated UTI in
patients undergoing POP and/or urinary incontinence surgery.
Primary Objective:
To evaluate the efficacy of administration of nitrofurantoin prophylaxis after catheter
discontinuation for the prevention of catheter-associated urinary tract infections in
patients with postoperative short-term catheterization following pelvic reconstructive
surgery. The primary outcome will be the treatment of clinically suspected and/or
culture-proven UTI within 30 days of surgery.
Secondary Objective:
To evaluate adverse outcomes related to study medications in each group and to evaluate
medication compliance
Null Hypothesis:
The null hypothesis is that the administration of nitrofurantoin will not reduce the rate of
UTI compared with placebo.
for nearly 30% of cases of nosocomial infections and affecting nearly 1 million people per
year.
Following pelvic reconstructive and urinary incontinence surgery, UTIs are one of the most
common complications with a risk between 8.9%-34%. The baseline risk of UTI associated with
pelvic floor surgery ranges between 5-35%, increasing greatly with catheterization.
Postoperative voiding dysfunction and incomplete bladder emptying is common following pelvic
reconstructive and incontinence surgeries, with incidence ranging from 2.5 % to 31%. As a
result, these women may have additional catheterization for a short period of time, which
increases the risk of UTI. There is a 15-20% risk of developing a postoperative UTI with
short-term catheterization, even if the catheter remains in place for merely 24 hours. The
risk of UTI increases 5-10% each day the catheter is left in place.
Numerous studies have been conducted to evaluate different prophylactic antibiotic regimens
to help decrease the rate of postoperative catheter-associated UTIs. Many of these studies
have shown precedent for the use of antibiotic prophylaxis.
Nitrofurantoin has been evaluated as a prophylactic regimen for use during short-term
catheterization. These studies had favorable results, decreasing the incidence of UTI
postoperatively.
Although there are a few studies showing favorable results for the use of prophylactic
nitrofurantoin during catheterization after pelvic surgery, the optimal timing of antibiotic
administration and length of dosing regimen is not well defined. The American Urological
Association (AUA) recommends empiric antibiotic treatment at the time of external urinary
catheter removal in patients with risk factors, such as tobacco use, advanced age, and
anatomic abnormalities of the urinary tract. The AUA Panel does cite that bacteriuria in the
setting of noninfectious urinary tract disease is a risk factor for bacteremia, and, thus,
prophylactic antibiotic treatment at time the of catheter removal may be indicated. The AUA
does recommend empiric antibiotic treatment at the removal of an external urinary catheter in
patients with risk factors. However, there is no standardization concerning the type of
antibiotic to be used or treatment duration.
Although there are a few studies showing favorable results for use of nitrofurantoin during
catheterization after pelvic surgery, there are no clearly defined recommendations regarding
its use for urinary tract infection prevention after catheter removal. Therefore, the
objective of our study is to examine the effects of administration of nitrofurantoin therapy
at the time of Foley catheter removal for the prevention of catheter-associated UTI in
patients undergoing POP and/or urinary incontinence surgery.
Primary Objective:
To evaluate the efficacy of administration of nitrofurantoin prophylaxis after catheter
discontinuation for the prevention of catheter-associated urinary tract infections in
patients with postoperative short-term catheterization following pelvic reconstructive
surgery. The primary outcome will be the treatment of clinically suspected and/or
culture-proven UTI within 30 days of surgery.
Secondary Objective:
To evaluate adverse outcomes related to study medications in each group and to evaluate
medication compliance
Null Hypothesis:
The null hypothesis is that the administration of nitrofurantoin will not reduce the rate of
UTI compared with placebo.
Inclusion Criteria:
- Age greater than 18
- Creatinine clearance greater than 30 ml/min
- Failed postoperative hospital voiding trial
Exclusion Criteria:
- Pregnant
- History of glucose-6-phosphate dehydrogenase deficiency
- History of renal insufficiency, renal transplant, or nephropathy
- Allergy to nitrofurantoin
- History of recurrent UTI (defined as greater than two culture-proven infections in six
months or three infections in one year)
- Urinary Tract Infection (UTI) within 14 days one month of surgery
- Non-English speaking
- Urinary tract infection while Foley catheter is in place
- On antibiotic therapy for other non-urological reasons
- Sustained intraoperative bladder injury requiring prolonged catheterization greater
than 5 days
- Undergoing mesh excision from within the bladder, fistula repair, cystotomy repair,
urethral diverticulectomy, sacral neuromodulation, urethral surgery, or any other
procedure requiring prolonged catheterization and bladder decompression
- Placement of a suprapubic catheter
- Participants that request intermittent self-catheterization
- Neurologic conditions affecting urinary tract system and normal voiding mechanisms
- History of hepatic impairment due to prior nitrofurantoin use
- Inability to provide consent/decisionally impaired
- More than two in-office voiding trials
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