Are antibiotics safe and effective for preventing infection in women with stress urinary incontinence who are undergoing continence surgery?
Stress urinary incontinence (SUI) is defined as uncontrolled leakage of urine when the pressure inside the abdomen increases suddenly, such as during coughing, sneezing or laughing. Continence surgery is one treatment for SUI. There are two types of procedures: open surgery, such as colposuspension (an incision in the abdomen to place stitches in the vagina on either side of the urethra, the tube by which urine is drained from your bladder), or less invasive procedures, such as laparoscopic colposuspension (using small incisions to insert the stitches), a sling procedure (using tape or mesh to form a sling around the urethra to lift it back into a normal position and attach to the abdominal wall), or an injection of bulking agent (e.g. collagen) into the bladder neck. Infections of the surgery site or urinary tract are common complications following all continence surgeries. Preventive antibiotics have the potential to prevent postoperative wound infection, but the supporting evidence is still limited.
How up to date is this review?
We searched for randomised controlled trials (RCTs; everyone has the same chance of receiving the treatment being tested), and quasi-RCTs (a treatment is being tested but not everyone has the same chance of receiving it) up to 18 March 2021.
We included three studies (in seven reports) involving a total of 390 women who underwent one of two different continence surgeries and were given one of three different doses of antibiotics (cefazolin) or placebo or no treatment. The sample sizes in the trials ranged from 26 to 305 women. None of the included studies clearly indicated the timing of the outcome assessment. The average age of the women ranged from 45 to 54 years.
Study funding sources
Two studies received no funding; the third study did not provide funding information.
Preventive antibiotics may have little to no effect on surgical site infections, urinary tract infections or bacteriuria (presence of bacteria in the urine), fever after surgery or the appearance of the artificial tape or mesh used in the surgery through the skin beneath the urethra, but we are very uncertain about the results.
None of the included studies reported data on adverse effects, sepsis or bacteraemia related to taking antibiotics, or bacterial antibiotic resistance.
Certainty of the evidence
We are uncertain about our findings as they are based on only three small studies. Each study assessed the effectiveness of preventive antibiotics in different surgical procedures, antibiotic dosages and outcomes. In addition, each included study had a small sample size and some were conducted in ways that might incorporate flaws into their results. Our findings may alter when results from better quality and large RCTs become available.
Only limited data are available from the three included studies and, overall, the certainty of evidence was very low. Moreover, the three included studies evaluated different surgical procedures and dosages of antibiotic administration.
Thus, there is insufficient evidence to support or refute the use of prophylactic antibiotics to prevent infection following anti-incontinence surgery. In addition, there were no data regarding adverse effects of prophylactic antibiotics. More RCTs are required.
Surgical options for treating stress urinary incontinence (SUI) are usually explored after conservative interventions have failed. Surgeries fall into two categories: traditional techniques (open surgery) and minimally invasive procedures, such as laparoscopic procedures, midurethral sling and injections with urethral bulking agents. Postsurgery infections, such as infections of the surgical site or urinary tract, are common complications. To minimise the risk of postoperative bacterial infections, prophylactic antibiotics may be given before or during surgery.
To assess the effects of prophylactic antibiotics for preventing infection following continence surgery in women with stress urinary incontinence.
We searched the Cochrane Incontinence Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov and WHO ICTRP; and handsearched journals and conference proceedings to 18 March 2021. We also searched the reference lists of relevant articles.
We included randomised controlled trials (RCTs) and quasi-RCTs assessing prophylactic antibiotics in women undergoing continence surgery to treat SUI.
Two review authors selected potentially eligible trials, extracted data and assessed risk of bias. We expressed results as risk ratios (RR) for dichotomous outcomes and as mean differences (MD) for continuous outcomes, both with 95% confidence intervals (CIs). We assessed the certainty of evidence using the GRADE approach.
We identified one quasi-RCT and two RCTs, involving a total of 390 women. One study performed retropubic urethropexy surgery requiring a transverse suprapubic incision, while the other two studies performed midurethral sling surgery. It should be noted that none of the included studies clearly specified the timing of outcome assessment.
We are very uncertain whether prophylactic antibiotics (cefazolin) have an effect on surgical site infections (RR 0.56, 95% CI 0.03 to 12.35; 2 studies, 85 women; very low-certainty evidence) or urinary tract infections or bacteriuria (RR 0.84, 95% CI 0.05 to 13.24; 2 studies, 85 women; very low-certainty evidence). The effect of prophylactic antibiotics (cefazolin) on febrile morbidity is also uncertain (RR 0.08, 95% CI 0.00 to 1.29; 2 studies, 85 women; very low-certainty evidence). We are very uncertain whether prophylactic antibiotics (cefazolin) have any effect on mesh exposure (RR 0.32, 95% CI 0.01 to 7.61; 1 study, 59 women; very low-certainty evidence). None of the three included studies described the assessment of adverse events from antibiotic use, sepsis or bacteraemia in their reports.