Prevention and treatment of infection is a crucial part of the care of patients in the perioperative period of PCNL [4, 5]. The present study firstly reveals the current practice of perioperative antibiotics in patients treated with PCNL among Chinese urologists.

Preoperative use of prophylactic antibiotics is supposed to reduce the potential bacterial load in urine [9]. Single-dose administration was recommended in AUA and EAU guidelines [4, 5], as well as a joint guideline of the EAU Section of Urolithiasis and International Alliance of Urolithiasis [10]. In a recent multicenter RCT, Chew et al. also concluded that a preoperative single dose of prophylactic antibiotics was sufficient in UC− patients, compared with courses of more than 7 days [11]. It is worth noting that the positive leukocyte reaction combined with positive nitrite in preoperative UM was an early predictor of post-PCNL urosepsis [12]. He et al. reported that UC-UM+ patients should be treated with extended period of antibiotic administration [13]. In our study, most urologists prescribed multiple-dose antibiotics of 1–3 days of cephalosporins for UC− patients, irrespective of the UM results. However, recent studies showed that multi-dose antibiotics could not reduce the rate of postoperative infections in UC-UM+ patients [14, 15], even though the frequency of positive urine nitrite and leukocyte reaction could be decreased significantly following preoperative antibiotic therapy [14]. Therefore, the benefits of multi-dose antibiotics before PCNL for UC-UM+ patients are controversial. It was a common strategy to identify the risk factors of infections and start antimicrobial treatment as early as possible [4, 5]. A prolonged duration of pre-PCNL antibiotics might of value in patients with high risk factors for postoperative infections, such as indwelling urinary drainage tubes, diabetes, and hydronephrosis [3, 6, 16].

Preoperative routine UC is of great importance for recognizing UTIs in stone patients and as a guide for selecting perioperative antibiotics. Despite the recommendations for the duration of perioperative antibiotics is lack in AUA and EAU guidelines for UC+ patients, recent studies showed that those patients should be treated at least 7 days preoperatively with appropriate antibiotics [15,16,17,18]. Similarly, the CUA guideline recommends a 1–2 week-course of antibiotics for UC+ patients [3]. However, 59% of the urologists in this study chose less than one week.

An antibiotic course less than 24 h was recommended for healthy individuals postoperatively in AUA guidelines [5, 19]. In this study, 53.5% of the urologists reported a relatively long protocol of postoperative antibiotics (3–6 days). However, long-term antibiotics after PCNL have not been found beneficial to prevent infections [2]. Prolonged antibiotic treatment after PCNL could be attributed to the consideration of high risk of infections. Notably, we found that the hospital grade, geographical location and surgical experience making a difference in urologist’s antibiotic practice patterns in PCNL. The insufficient awareness of guideline recommendations among Chinese urologists might be an important reason for the discretionary use of antibiotics.

In PCNL, a stone specimen collection was strongly recommended by EAU and AUA for SC after lithotripsy in order to guide selection of postoperative antibiotics [4, 5]. In this study, respondents seemed to be aware enough of the significance in SC (88.2%), but only 18.5% of the urologists carried out SC in clinical routines. Promoting SC among Chinese urologists apparently is urgently needed, as a positive SC is closely associated with post-PCNL infections even when UC− [17, 20].

The types of antibiotics for PCNL could also have an impact on the incidence of post-PCNL infections. In our investigation, the cephalosporin agents were most frequently used by Chinese urologists before PCNL, followed by quinolones. However, many studies from different regions of China have showed that the majority of uropathogens isolated from urine or stone in patients with urinary stones were in high resistance to the cephalosporin agents (e.g., cefuroxime and ceftriaxone) and quinolones (e.g., ciprofloxacin and levofloxacin) [21,22,23,24]. The EAU guideline exactly suggest that antibiotics should be selected based on local bacterial profiles and drug sensitivity. Therefore, it is recommended that every stone patient should be given UC before PCNL and SC postoperatively, since it was reported that taking antibiotics based on SC results could reduce the incidence of post-PCNL infections [15].

The survey was limited by several factors. Firstly, we cannot estimate the response rate, since we failed to figure out how many subjects received and opened the link of investigation. Secondly, the association between antibiotic behavior and postoperative infections was not explored. However, the survey revealed the current antibiotic strategies of PCNL in China are different with the urological guidelines.

In conclusion, compared with the guidelines this study showed that UC− patients are more likely to receive pre-PCNL antibiotics for 1–3 days irrespective of the UM results, while those with UC+ frequently are given an course < 7 days. For patients without post-PCNL infection, the duration of postoperative antibiotics was undoubtedly longer than that in the guideline recommendations. Moreover, there was a low rate of SC, which needs further attention in the clinical practice. In our opinion, single-dose antibiotic is enough for UC-UM- patients. The antibiotic strategies for the UC− patients but with high risk factors of infection, such as staghorn stone, diabetes, UM+ or existing indwelling urinary drainage tube should be studied further. The selection of antibiotic for UC− patients should be based on the local bacterial spectrum. For UC+ patients, it is necessary to prescribe antibiotics according to the drug sensitivity test and it is better to use them for more than 1 week. Meanwhile, SC is helpful to guide the postoperative antibiotic regimen. Therefore, it is suggested to take measures such as strengthening the Continuing Medical Education for graduated urologists to standardize the application of antibiotics.