Antibiotic Prophylaxis for Onabotulinum Toxin A injections: Systematic Review and Meta-analysis

Objectives: Antibiotics are routinely administered prior to intradetrusor onabotulinum toxin type A (BTX) injections for prevention of urinary tract infection (UTI), however there are currently no evidence-based recommendations regarding optimal antibiotic regimen to prevent infection at the time of BTX injection. A systematic review and meta-analysis was performed to investigate optimal peri-procedural antibiotics to decrease the risk of UTI in patients undergoing BTX for overactive bladder syndrome (OAB).

Methods: A systematic search of Medline, Embase, Cinahl, and Web of Science was conducted from inception through 6/30/2022. All randomized controlled trials (RCTs) and non-randomized prospective trials with >20 subjects undergoing BTX injections for idiopathic or neurogenic OAB were included. Studies had to report both the prophylactic antibiotic regimen and UTI rates post-procedure. Studies of pediatric patients, non-English language and abstract-only studies were excluded. Standard systematic review methodology was used for screening, data extraction and risk of bias assessment. Meta-analysis was performed using inverse variance method for pooling. Cochran's Q test was performed to test heterogeneity.

Results: 6,329 abstracts were retrieved, 285 full-text manuscripts assessed, and 27 full-length articles (9 RCTs, 18 prospective) were included representing 2,100 patients (69% women, 31% men). There were 19 studies of idiopathic OAB patients only, 6 studies of neurogenic only and 2 studies included both. Overall, no studies directly compared antibiotic regimens for prevention of UTI and 2 studies (both prospective, N=303, all neurogenic) did not use antibiotic prophylaxis. For neurogenic patients, 7 studies (1 RCT, N=478) were included and 39% (N=184) of patients did not receive prophylactic antibiotics while 61% (N=294) did with 90% receiving antibiotics day of procedure versus 10% continuing 2-3 days after (Table 1). For patients with idiopathic OAB, 20 studies (7 RCTs, N=1,521) were included and all patients received prophylactic antibiotics with only 11 studies (3 RCTs; N=1,016) using only one antibiotic regimen. Of these 1,016 patients, 55% received fluoroquinolones, 27% cephalosporins, and 18% trimethoprim with 40% (N=406) receiving antibiotics the day of procedure only and 60% (N=610) continuing 2-3 days after procedure (Table 1). Given heterogeneity of the data, direct comparisons of antibiotic type or duration for either patient population was unable to be performed. Meta-analysis was performed to assess UTI rates in patients with idiopathic OAB with 10% UTI rate at 4-week follow-up and 15% at 12-week follow-up (Figure 1).

Conclusions: While a specific antibiotic regimen cannot be recommended at this time given the heterogeneity of the data, available studies favor the use of antibiotics in patients with idiopathic OAB undergoing BTX injection and favor continuing antibiotics for 2-3 days after the procedure for prevention of UTI. Future randomized trials comparing antibiotic regimens are needed to determine optimal methods to prevent UTI in patients undergoing BTX injection.