Does Preoperative Sterilization of Multidrug-Resistant Bacteriuria Reduce Infectious Morbidity Following Percutaneous Nephrolithotomy?

Does Preoperative Sterilization of Multidrug-Resistant Bacteriuria Reduce Infectious Morbidity Following Percutaneous Nephrolithotomy? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Does Preoperative Sterilization of Multidrug-Resistant Bacteriuria Reduce Infectious Morbidity Following Percutaneous Nephrolithotomy? Thiraphat Saengmearnuparp, Pawin Wiroonrach, Kittisak Sutibud, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9322728/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background The rising prevalence of multidrug-resistant (MDR) bacteriuria in percutaneous nephrolithotomy (PCNL) shows significant challenges, especially the risk of postoperative infectious complications. This study aimed to evaluate risk factors for MDR bacteriuria and its impact on infectious complications following PCNL. Methods A total of 601 patients who underwent standard PCNL were categorized into three groups based on their preoperative urine culture results: MDR-positive, non-MDR bacteriuria, and negative urine culture. Patient demographics, stone characteristics, and intraoperative data were analyzed. A binary logistic regression model was used to identify risks for positive MDR bacteriuria and predictors of sepsis. Results Preoperative MDR bacteriuria was significantly associated with an increased risk of urosepsis. Recent antibiotic use within 90 days before PCNL and female sex were significant risk factors for MDR bacteriuria. Multivariate analysis identified several predictors of sepsis, including staghorn stone (OR 2.77, p = 0.02), positive preoperative urine culture for MDR (OR 6.14, p < 0.001), and positive stone culture for MDR (OR 3.42, p = 0.017). Conversely, complete stone clearance (OR 0.07, p < 0.001) and concordance between preoperative urine and intraoperative stone culture (OR 0.25, p = 0.014) were strongly associated with a protective effect. Conclusions Despite achieving preoperative sterilization, the risk of postoperative infectious complications following PCNL was not significantly reduced in the MDR group. Stone culture is essential for comprehensive risk stratification. Achieving stone-free status and targeted antibiotic therapy are key strategies for preventing infectious complications, even in MDR cases. Trial registration: SUR-2566-0333, approval number 376/2023, Institutional Review Board of Research Ethics Committee, Faculty of Medicine, Chiang Mai University. Infectious complications MDR Multidrug-resistant bacteriuria Percutaneous nephrolithotomy Sepsis Introduction Percutaneous nephrolithotomy (PCNL) is the gold standard procedure for managing large (> 2 cm) stones in the kidney and upper ureter[ 1 ]. Despite its efficacy, PCNL presents significant challenges, particularly concerning infectious complications. Postoperative fever is a common occurrence, with reported rates ranging from 15% to 30%, while urosepsis has been documented in 0.9–4.7% of PCNL procedures [ 2 ]. Patients with renal calculi often present with bacteriuria; thus, preoperative antibiotic administration is standard practice [ 3 ]. However, treatments become more complex in patients with multidrug-resistant (MDR) bacteriuria [ 4 ]. MDR is defined as non-susceptibility to at least one agent in three or more different antimicrobial categories [ 5 ]. It has become more prevalent causes of community-acquired infections increasing worldwide [ 6 ]. The presence of MDR bacteriuria is associated with an increased risk of postoperative infectious complications in patients undergoing PCNL [ 7 , 8 ]. Standard prophylactic antibiotic regimens may be ineffective against these resistant strains, resulting in increased rates of infectious complications and a higher risk of adverse outcomes [ 3 , 9 , 10 ]. In the setting of positive cultures, a duration of 7 days is recommended to be an appropriate duration microbial burden within calculi [ 11 ] and recent guidelines do not explicitly recommend a repeat negative urine culture before PCNL [ 1 , 3 ]. This study comprehensively evaluates the relationship between MDR bacteriuria and postoperative infectious complications in patients undergoing PCNL. Specifically, we aimed to identify patient-related risk factors associated with MDR bacteriuria, analyze the correlation between preoperative urine cultures and intraoperative stone cultures, and identify potential predictors of infection-related morbidity, including postoperative urosepsis. The findings will contribute to the development of evidence-based interventions for prevention among patients undergoing PCNL with MDR bacteriuria. Materials and Methods All patients with renal calculi who underwent PCNL at Chiang Mai University Hospital between January 2015 and January 2023 were recruited. Patients were excluded if they had undergone second-look nephroscopy, urinary diversion, experienced failed PCNL, or were taking anticoagulant medications. Preoperative urine samples were collected via midstream clean catch or catheterization. Patients with preoperative urine culture (UC) showing bacterial growth exceeding 100,000 CFU/ml were classified into the positive UC group. Additionally, if the identified bacterial strain met the criteria for MDR, patients were categorized into the positive MDR group. These positive UC patients in the non-MDR and MDR groups received appropriate, targeted antibiotic therapy until a negative UC was documented or for at least 7 days before surgery. Patients with negative preoperative UC received standard prophylactic antibiotics 60 minutes prior to surgery. The regimen consisted of a second- or third-generation cephalosporin, or an aminoglycoside for patients with a history of drug allergies. Standard PCNL was performed as mentioned in a previous study [ 12 ]. Briefly, 24 Fr. nephroscopy was used in the prone position under fluoroscopy guidance in all cases. Stone disintegration was performed with either ultrasonic, pneumatic, or combined lithotripsy. Regarding the stone culture, renal stones were retrieved using a tripod grasper, immediately immersed in sterile saline, and then pulverized into a fine suspension. This suspension was subsequently incubated for aerobic bacterial culture. Stone culture results were categorized into three groups: no growth, MDR, and non-MDR. Concordance culture was defined as the identical antibiotic sensitivity of an identical species found in both preoperative UC and intraoperative stone culture, or the same negative culture or any preoperative UC result with negative stone culture. Patients lacking either preoperative UC or perioperative stone culture were excluded from the analysis. Demographic data were collected, including age, gender, body mass index (BMI), history of diabetes mellitus, previous stone treatment, antibiotic use within 90 days prior to surgery, and preoperative creatinine levels. Stone characteristics, such as stone burden, number of stones, and the presence of staghorn calculi, were recorded. Intraoperative details, including the site of puncture, number of access tracts, intraoperative blood loss, and postoperative outcomes such as stone-free status at post-operative days 30–90, clinically insignificant residual fragments (CIRF), and length of hospital stay, were collected. CIRF was defined as a residual fragment with a diameter of 2 millimeters or less, asymptomatic, and not obstructive [ 13 ]. Postoperative urosepsis was defined as meeting two or more criteria of the quick sepsis-related organ failure assessment (qSOFA) (14) and confirmation of a urinary pathogen in blood cultures. All patients with signs of sepsis underwent plain chest X-rays to rule out pulmonary causes, and further diagnostic tests were performed if other sources of sepsis were clinically suspected. The sample size was determined to achieve 80% power to detect clinically significant differences in the risk of postoperative infectious complications, by comparing the Odds Ratio (OR) among the no-growth, positive non MDR and MDR culture groups. Statistical analysis was performed using STATA version 17.0 (StataCorp LP, College Station, TX, USA). Categorical variables were presented as counts and percentages and compared across the three groups using either Fisher’s exact test or the Chi-square test, as appropriate. Continuous variables were presented as the mean with standard deviation (SD) for normally distributed data, or the median with interquartile range (IQR) for non-normally distributed data; these were compared using one-way ANOVA or the Kruskal–Wallis test, respectively. Factors associated with postoperative sepsis were identified using a binary logistic regression model. All statistical tests were two-tailed, and a p-value < 0.05 was considered statistically significant. The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Research Ethics Committee, Faculty of Medicine, Chiang Mai University, Research ID 0333/Study Code: SUR-2566-0333, approval number 376/2023, with a waiver for written informed consent due to the retrospective nature of the study. Results After excluding 3 patients due to incomplete culture data and 19 who met other exclusion criteria, this study included 601 patients who underwent standard PCNL. Applying the ellipsoid formula, the mean calculated stone burden in this cohort was 3.75 (1.24) cm 2 and nearly 64% was staghorn calculi. Based on preoperative UC results, patients were categorized into three groups: those positive for MDR bacteria (n = 122), those positive for non-MDR bacteria (n = 95), and those with a negative UC (n = 384). The prevalence of MDR bacteria was 20% in preoperative urine cultures and 12% in intraoperative stone cultures. The median age and age distribution were comparable across the three groups. A statistically significant female predominance was observed in the positive UC groups compared to the negative UC group. A higher percentage of patients in the positive MDR group (98%) and the positive non-MDR group (40%) had received antibiotics within 90 days prior to surgery compared to the negative culture group (26%). Furthermore, the positive MDR group had a higher prevalence of prior nephrolithotomy compared to the other groups. Regarding the positive stone culture result, only three patients presented with discordant findings of a positive non-MDR UC but a positive MDR stone culture. Interestingly, 12% of patients with negative preoperative UC yielded positive non-MDR stone cultures. The mean follow-up time for assessing success rate was 30 days. The incidence of postoperative fever and the rate of postoperative sepsis also differed significantly, with the highest incidence in the positive MDR group, followed by the positive non-MDR group, and the lowest in the negative UC group. The length of hospital stay was significantly longer in the positive MDR group compared to both the positive non-MDR and negative UC groups ( Table 1) Analysis of microbial isolates from preoperative urine samples in the MDR group revealed that Escherichia coli was the most prevalent pathogen, accounting for 56% of cases. Pseudomonas aeruginosa and Klebsiella pneumoniae were the next most isolated ( Supplement Figure 1). Multivariable analysis identified two independent risk factors for MDR bacteriuria. The strongest independent predictor was a history of antibiotic use within 90 days before surgery, demonstrating a remarkably high odds ratio (OR = 40.91). Female sex was also significantly associated with MDR bacteriuria (Table 2). The univariable analysis identified three preoperative factors significantly associated with postoperative sepsis: female sex, staghorn stones, and positive preoperative UC for any organism. After adjusting for potential confounders in the multivariable model, both staghorn stones and positive preoperative UC remained independent predictors of sepsis. Positive preoperative UC for MDR organisms was associated with the highest risk of 6.17 (Table 3). Regarding postoperative predictors associated with urosepsis, multiple access tracts, high blood loss, and positive stone culture for any organism were associated with increased risk. On the other hand, achieving stone-free status and having a concordant culture result were associated with significantly lower odds of developing postoperative sepsis. Similar to preoperative findings, a stone culture positive for MDR organisms was the most significant postoperative risk factor, with an odds ratio of 3.42 (Table 4). Analysis of combined culture results revealed a synergistic risk profile (Supplemental Table 1) . Positive non-MDR bacteriuria paired with a negative stone culture showed no clinical significance in increasing sepsis risk. In contrast, the presence of MDR organisms in preoperative urine and positive any organism in stone cultures represented the increased risk for urosepsis, with an odds ratio of 15.52. The highest odds of sepsis were observed in patients with positive preoperative non-MDR bacteriuria and positive any organism in stone cultures (OR 23.31). Discussion Among patients undergoing PCNL, infectious complications are a common and serious concern. To our knowledge, this study represents one of the largest reported cohorts assessing outcomes in PCNL patients with documented MDR bacteriuria and the first to report the independent risk factors associated with the cause of MDR bacteriuria in this patient group. Data from this cohort demonstrated several key findings: 1) Despite achieving preoperative sterilization with sensitivity-targeted antibiotic therapy, the risk of postoperative infectious complications following PCNL was not significantly reduced in MDR group; 2) Preoperative MDR bacteriuria was a significant risk factor for postoperative urosepsis and extended hospital stays; 3) Preoperative MDR bacteriuria was highly prevalent in patients with a history of antibiotic use within 90 days before surgery; 4) Routine intraoperative stone culture is strongly recommended for comprehensive risk stratification and detection of occult MDR pathogens; 5) Achieving stone-free status and ensuring precisely targeted antibiotic therapy are key strategies for preventing infectious complications. The increasing prevalence of MDR urinary tract infection showed a substantial public health threat globally, especially in developing countries [ 14 ]. In Thailand, mortality rates linked to MDR infection exceed 54 per 100,000 population [ 15 ] and were reported to be three to five times higher than those in the United States and the European Union [ 16 ]. A key pathogen of MDR was Escherichia coli , the most common strain associated with urinary tract infections, with rates reaching 35% in community-acquired and 63% in hospital-acquired bacteremia [ 16 ]. In line with the report, this study also found Escherichia coli was the most prevalent pathogen, accounting for 56% of MDR cases. This challenging situation is further exacerbated by the widespread availability of over-the-counter antibiotics and over-prescribing practices in hospitals [ 15 ], as evidenced by the 43% of cases in this study having a history of antibiotic use within 90 days before surgery. Multivariable analysis identified two factors associated with higher MDR bacteriuria. First was the history of antibiotic use within 90 days before surgery. Despite its high odds ratio, antibiotic use within 90 days was retained in our multivariable final model due to its strong clinical relevance as a predictor of MDR bacteriuria. Moreover, its multicollinearity was minimal and did not affect model stability. Excluding this variable would result in omitted-variable bias and lead to increased magnitudes and statistical significance for the other covariates. Our findings showed that approximately 98% of patients with positive MDR urine cultures, compared to 26% of those with negative UC, had a recent history of antibiotic exposure. This notable difference demonstrates the crucial role of recent antimicrobial exposure in the development of resistance, underscoring the importance of responsible antimicrobial stewardship [ 17 ]. The second significant predictor was female sex. Female patients exhibited around twofold higher odds of MDR-positive urine cultures. This finding was consistent with their anatomical susceptibility to urinary tract infections and increased exposure to healthcare and antimicrobial agents [ 18 ]. Patients with MDR bacteriuria experienced significantly higher postoperative complication rates, with sepsis occurring at 15%, compared to 3% in the negative UC group. Multivariable analysis indicated that positive preoperative MDR bacteriuria was associated with a sixfold increase in the risk of urosepsis. Moreover, patients with MDR bacteriuria experienced a notably more extended hospitalization compared to those with non-MDR bacteriuria and negative UC. The longer hospital stay in MDR-positive patients was attributed to the requirement for extended intravenous antibiotic therapy, closer surveillance for infectious sequelae, and a potentially delayed resolution of the infection [ 8 , 9 ]. In line with the meta-analysis and review article, the patient's age and sex did not increase the risk of infectious complications [ 10 , 19 ]. The presence of staghorn stones was associated with a higher risk of infectious complications [ 20 , 21 ], supporting the hypothesis that these large, complex calculi act as reservoirs for bacteria, thereby promoting persistent infections despite antibiotic treatment [ 7 , 22 ]. However, complete stone clearance was the strongest protective factor in minimizing infectious complications, reinforcing the importance of meticulous stone removal [ 9 ]. Multiple access tracts and high-volume blood loss have been identified as risk factors for postoperative sepsis [ 10 , 19 , 20 ]. While high-volume blood loss increased sepsis risk in both univariable and multivariable analyses, multiple percutaneous procedures did not show significance in the multivariable analysis. Although a greater number of access tracts and increased blood loss indicate a more complex procedure, the greater volume of blood loss appears to be more strongly associated with infectious complications. This is likely because blood loss often results from traumatic disruption of the urothelial lining, which can allow bacteria and endotoxins to enter the bloodstream directly [ 23 ]. The role of intraoperative stone cultures in predicting postoperative infectious outcomes is crucial. 12% of patients with negative preoperative UC yielded positive non-MDR stone cultures. Importantly, only three patients presented with discordant findings of a positive preoperative non-MDR urine culture but a positive MDR stone culture, yet all of these cases experienced MDR urosepsis complications. Our study also demonstrated that both positive preoperative urine cultures and stone cultures for any organism were correlated with increased risk of urosepsis in patients undergoing PCNL. However, while non-MDR stone culture was a significant predictor of urosepsis in univariable analysis, it did not remain an independent risk factor in the multivariable model. In contrast, a positive MDR stone culture remained a potent independent predictor of sepsis. This discrepancy is likely attributable to the efficacy of standard perioperative antibiotic prophylaxis against non-resistant strains. Combined analysis of preoperative UC and stone cultures showed that isolated non-MDR bacteriuria did not significantly increase the odds of sepsis, likely because these patients received sensitivity-guided prophylaxis antibiotics. However, a discordant finding of a negative preoperative UC combined with a positive stone culture led to a 12.18-fold increase in the risk of sepsis. This risk was significantly higher in cases involving MDR bacteriuria. Specifically, a positive MDR urine culture was associated with a 12.95-fold risk when paired with a negative stone culture, and a 15.52-fold risk when paired with a positive stone culture. The highest risk of sepsis was found in patients with positive preoperative non-MDR bacteriuria and positive stone cultures. This increased risk is likely due to this group having the highest rate of antimicrobial discordance. These findings emphasize that a preoperative non-MDR UC may give a false sense of reliability, potentially masking an occult stone colonization with a discordant or more resistant microbial profile that standard prophylactic regimens fail to cover (Supplemental Table 1) . Our study also showed that the concordance of preoperative UC and intraoperative stone culture was another significant protective factor against infectious complications. This implies that providing precise preoperative antibiotic coverage, targeting organisms present in both the urine and the stone, can reduce the risk of urosepsis, even in cases involving MDR pathogens. Preoperative UC often does not accurately predict the results of stone and renal pelvis urine cultures. Discordance between preoperative urine culture and intraoperative stone culture was reported to occur in approximately 20–40% of cases [ 24 – 26 ], placing a greater risk of postoperative urosepsis [ 27 , 28 ]. In summary, routine stone culture should be strongly considered as part of the standard of care in patients undergoing PCNL, particularly those at high risk for MDR infection [ 29 ]. The limitations of this study include its single-center and retrospective design, which may introduce historical and recall bias. Another limitation is that our culture relies on standard techniques rather than newer-generation methods (e.g., Next-Generation Sequencing or PCR-based approaches). Consequently, our study was unable to provide a more detailed understanding of MDR bacterial characteristics or their comprehensive antibiotic resistance profiles, including heteroresistance and underlying tolerance mechanisms. Forecasting culture results accurately before surgery is the most effective way to reduce sepsis risk. Nevertheless, a non-invasive tool for this purpose is unavailable. Advanced genomic methods would help elucidate the relationship between these MDR bacteria and clinical infectious outcomes and answer why they sometimes do not respond to targeted antibiotics, leading to urosepsis. Conclusions Despite achieving preoperative sterilization, the risk of postoperative infectious complications following PCNL was not significantly reduced in MDR group. Preoperative MDR bacteriuria significantly impacts the risk of infectious complications and contributes to longer hospital stays. Our findings identified recent antibiotic use, and female sex as key predictors of MDR bacteriuria. Both preoperative urine culture and routine intraoperative stone culture should be strongly considered as integral components of the standard of care in patients undergoing PCNL, especially those at high risk for MDR infections. Ultimately, achieving stone-free status and ensuring precisely targeted antibiotic therapy are key strategies for preventing infectious complications. Abbreviations PCNL: Percutaneous Nephrolithotomy MDR: Multidrug-resistant CIRF: Clinically insignificant residual fragment ≤ 2 millimeters UC: Urine culture Fr.: French BMI: Body mass index mmHg: Millimeters of mercury OR: Odds ratio CI: Confidence interval Declarations Ethics Approval Statement The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Research Ethics Committee, Faculty of Medicine, Chiang Mai University, Research ID 0333/Study Code: SUR-2566-0333, approval number 376/2023, with a waiver for written informed consent due to the retrospective nature of the study. The approval date was October 11, 2023. Availability of Data and Materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Conflict of Interest The authors declare that they have no conflicts of interest. Funding This study was partially supported by the Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand. CRediT Author Contributions T.S. : Conceptualization (support); Data curation (support); Formal analysis (equal); Investigation (support); Methodology (lead); Project administration; Resources (support); Validation (equal); Visualization; Writing – original draft (lead); Writing – review & editing (equal). P.W. : Conceptualization (lead); Data curation (lead); Investigation (equal); Writing – original draft (support). K.S. : Data curation (support); Investigation (equal). P.K. : Conceptualization (support); Investigation (support); Supervision (support); Visualization; Writing – original draft (support). A.T. : Formal analysis (equal); Methodology (support); Writing – original draft (support). C.I. : Formal analysis (equal); Software. 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Clinical significance of stone culture during endourological procedures in predicting post-operative urinary sepsis: should it be a standard of care-evidence from a systematic review and meta-analysis from EAU section of Urolithiasis (EULIS). World J Urol. 2024;42(1):614. Tables Table 1. Patient demographics and operative outcome among those with positive MDR, positive non-MDR, and negative UC. Parameters Positive MDR (n=122) Positive non MDR (n=95) Negative UC (n=384) P-value Age (year), median [IQR] 56 [50, 64] 57 [49, 63] 56 [49, 63] 0.793 Sex; Female, n (%) 67 (54.92) 54 (56.84) 111 (28.91) <0.001 BMI (kg/m 2 ), median [IQR] 22.20 [19.95, 25.39] 24 [21.48, 26.61] 23.44 [21.3, 25.69] 0.023 Preop creatinine, median [IQR] 1.1 [0.85, 1.5] 1 [0.8, 1.3] 1.09 [0.9, 1.3] 0.091 Stone burden (cm), mean (SD) 3.65 (1.31) 3.97 (1.35) 3.72 (1.18) 0.137 Stone burden ≥ 2 (cm), n (%) 114 (93.44) 90 (94.74) 359 (93.49) 0.899 Staghorn stone, n (%) 76 (62.30) 63 (66.32) 248 (64.58) 0.822 Diabetes Mellitus, n (%) 17 (13.93) 6 (6.32) 48 (12.50) 0.178 Received antibiotic 90 days before PCNL, n (%) 119 (97.54) 38 (40.00) 99 (25.78) 1 (%) 14 (11.48) 7 (7.37) 34 (8.85) 0.551 Access tract, n (%) Upper pole Middle pole Lower pole 89 (72.95) 11 (9.02) 22 (18.03) 65 (68.42) 6 (6.32) 24 (25.26) 295 (76.82) 29 (7.55) 60 (15.63) 0.119 Point Access, n (%) Supracostal Subcostal 39 (31.97) 83 (68.03) 28 (29.47) 67 (70.53) 126 (32.81) 258 (67.19) 0.823 Success rate, n (%) Stone free CIRF 85 (69.67) 56 (45.90) 29 (23.77) 77 (81.05) 57 (60.00) 20 (21.05) 268 (69.79) 211 (54.95) 57 (14.84) 0.055 Blood loss (ml), median [IQR] 200 [100, 300] 100 [50, 300] 200 [100, 300] 0.256 Blood Transfusion, n (%) 7 (5.74) 3 (3.16) 9 (2.34) 0.176 Positive Stone culture, n (%) No growth MDR Non MDR 52 (42.62) 68 (55.74) 2 (1.64) 63 (66.32) 3 (3.16) 29 (30.53) 337 (87.76) 0 47 (12.24) <0.001 Postoperative fever, n (%) 85 (69.67) 60 (63.16) 176 (45.83) <0.001 Sepsis, n (%) 18 (14.75) 9 (9.47) 10 (2.60) <0.001 Length of stay, median [IQR] 6 [4, 8] 5 [4, 7] 5 [3, 7] 0.003 Abbreviations: MDR: Multidrug-resistant; UC: Urine culture; SD: standard deviation; IQR: interquartile range; PCNL: Percutaneous Nephrolithotomy; cm: centimeter; NL: Open Nephrolithotomy; CIRF: Clinically insignificant residual fragment Table 2. Univariable analysis and Multivariable analysis for MDR risk factors Parameters Univariable Analysis Multivariable Analysis OR 95% CI P-value OR 95% CI P-value Age (Year) 1.01 0.99-1.03 0.342 1.00 0.98-1.02 0.827 Sex, Female 2.32 1.55-3.47 <0.001 1.73 1.07-2.80 0.026 BMI 0.94 0.89-0.99 0.022 0.96 0.91-1.02 0.233 Preop creatinine 1.22 0.98-1.52 0.076 1.23 0.95-1.58 0.112 Stone number 1.01 0.93-1.09 0.848 0.95 0.87-1.04 0.294 Staghorn stone 0.89 0.59-1.35 0.588 0.93 0.57-1.51 0.766 Diabetes mellitus 1.27 0.71-2.29 0.417 1.79 0.88-3.63 0.108 History of previous PCNL No History of surgery History of PCNL History of NL 1.00 1.46 2.19 - 0.57-3.78 1.23-3.92 [Reference] 0.434 0.008 1.00 1.24 1.55 - 0.43-3.61 0.80-2.98 [Reference] 0.692 0.192 Antibiotic prior 90-day 43.71 15.87-120.39 <0.001 39.78 14.28-110.81 <0.001 Abbreviations: MDR: Multidrug-resistant; UC: Urine culture; PCNL: Percutaneous Nephrolithotomy; NL: Open Nephrolithotomy; OR: Odds ratio; CI: Confidence interval Table 3. Univariable and Multivariable Analysis of Preoperative Factors Associated with Urosepsis Parameters Univariable Analysis Multivariable Analysis OR 95% CI P-value OR 95% CI P-value Age (Year) 1.02 0.99-1.05 0.262 1.02 0.98-1.05 0.343 Sex, Female 1.95 1.00-3.81 0.050 1.42 0.70-2.90 0.328 Staghorn stone 2.48 1.07-5.76 0.034 2.77 1.17-6.55 0.020 Diabetes mellitus 1.49 0.60-3.70 0.395 1.55 0.59-4.03 0.372 Urine Culture and MDR Status Negative urine culture Positive non-MDR Positive MDR 1.00 3.91 6.47 - 1.54-9.93 2.90-14.45 [Reference] 0.004 <0.001 1.00 3.66 6.14 - 1.40-9.53 2.68-14.06 [Reference] 0.008 <0.001 Abbreviations: MDR: Multidrug-resistant; UC: Urine culture; OR: Odds ratio; CI: Confidence interval Table 4. Univariable and Multivariable Analysis of Postoperative Factors Associated with Urosepsis Parameters Univariable Analysis Multivariable Analysis OR 95% CI P-value OR 95% CI P-value Number of accesses; > 1 3.03 1.31-7.01 0.009 1.99 0.73-5.39 0.179 Blood loss (ml) 1.00 1.00-1.01 <0.001 1.00 1.00-1.01 0.014 Success rate Retain stone Stone free CIRF 1.00 0.05 0.46 - 0.02-0.17 0.20-1.05 [Reference] <0.001 0.064 1.00 0.07 0.36 - 0.02-0.26 0.15-0.89 [Reference] <0.001 0.026 Stone culture status No growth Positive non-MDR Positive MDR 1.00 4.97 8.29 - 2.10-11.77 3.71-18.53 [Reference] <0.001 <0.001 1.00 2.04 3.42 - 0.70-5.96 1.24-9.42 [Reference] 0.192 0.017 Concordance result 0.16 0.07-0.37 <0.001 0.25 0.08-0.75 0.014 Abbreviations: MDR: Multidrug-resistant; OR: Odds ratio; CI: Confidence interval; CIRF: Clinically insignificant residual fragment Additional Declarations No competing interests reported. Supplementary Files SupplementFigure1.tif Supplement Figure 1. Isolated multidrug-resistant pathogens from preoperative urine culture. SupplementTable1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 13 May, 2026 Reviews received at journal 22 Apr, 2026 Reviews received at journal 20 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers agreed at journal 19 Apr, 2026 Reviewers invited by journal 19 Apr, 2026 Editor assigned by journal 13 Apr, 2026 Submission checks completed at journal 13 Apr, 2026 First submitted to journal 04 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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University","correspondingAuthor":false,"prefix":"","firstName":"Pawin","middleName":"","lastName":"Wiroonrach","suffix":""},{"id":627981916,"identity":"1e309dfa-f159-42a9-8d27-3a5e1a11c943","order_by":2,"name":"Kittisak Sutibud","email":"","orcid":"","institution":"Chiang Mai University","correspondingAuthor":false,"prefix":"","firstName":"Kittisak","middleName":"","lastName":"Sutibud","suffix":""},{"id":627981917,"identity":"4eaebb0f-b74a-4c25-abbb-3f69e4435eef","order_by":3,"name":"Pruit Kitirattrakarn","email":"","orcid":"","institution":"Chiang Mai University","correspondingAuthor":false,"prefix":"","firstName":"Pruit","middleName":"","lastName":"Kitirattrakarn","suffix":""},{"id":627981918,"identity":"5bf53d7c-c299-4d87-8b82-f4ffc11fa4f9","order_by":4,"name":"Apichat Tantraworasin Tantraworasin","email":"","orcid":"","institution":"Chiang Mai University","correspondingAuthor":false,"prefix":"","firstName":"Apichat","middleName":"Tantraworasin","lastName":"Tantraworasin","suffix":""},{"id":627981919,"identity":"a401f088-016b-4a15-a06f-378204e897d4","order_by":5,"name":"Chutjongkol Intatong","email":"","orcid":"","institution":"Chiang Mai University","correspondingAuthor":false,"prefix":"","firstName":"Chutjongkol","middleName":"","lastName":"Intatong","suffix":""},{"id":627981920,"identity":"60a49bcd-f0aa-48fa-b2a9-efc9c6994684","order_by":6,"name":"Bannakij Lojanapiwat","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYDCCAwxsYFqCmSHxAZDm4SNFS7IBSAsb8VoYGNgkQAyCWvhuH2B78HPHHXnJdoZnlV9z7GTYGJgfPrqBR4vkuQR2w94zzwxnMzOk3Zbdlgx0GJuxcQ4eLQZngO7hbTvMOA+kRXIbM1ALD5s0IS2Sf9sO24O0FEtuqydOizTQlkSQwxg/bjtMWIvkGcZ2Y9m2w8kzmxmSpRm3HedhYybgF74zzMcevm07bDvj/JnEjz+3Vdvzszc/fIxPCwMDYwOUwZPAzAOimfEqRwHsBxh/EK96FIyCUTAKRhAAAMlEQ/gpIaiBAAAAAElFTkSuQmCC","orcid":"","institution":"Chiang Mai University","correspondingAuthor":true,"prefix":"","firstName":"Bannakij","middleName":"","lastName":"Lojanapiwat","suffix":""}],"badges":[],"createdAt":"2026-04-04 19:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9322728/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9322728/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108007444,"identity":"e6611169-fddb-4874-b874-5be5dfc7332b","added_by":"auto","created_at":"2026-04-28 13:00:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":422817,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9322728/v1/b850de63-ff56-4a9d-9fbb-366e158e8db0.pdf"},{"id":107901622,"identity":"89af5964-e0fe-49f6-b369-83a165666a84","added_by":"auto","created_at":"2026-04-27 11:48:22","extension":"tif","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":79660,"visible":true,"origin":"","legend":"\u003cp\u003eSupplement Figure 1. \u0026nbsp;Isolated multidrug-resistant pathogens from preoperative urine culture.\u003c/p\u003e","description":"","filename":"SupplementFigure1.tif","url":"https://assets-eu.researchsquare.com/files/rs-9322728/v1/d6f856e1f24ae3202a8c1959.tif"},{"id":107901623,"identity":"4ff926a7-8af5-4c58-970f-50db4da6cbc8","added_by":"auto","created_at":"2026-04-27 11:48:22","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":16759,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9322728/v1/7a4c5d5de2da333cfc14e5a7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does Preoperative Sterilization of Multidrug-Resistant Bacteriuria Reduce Infectious Morbidity Following Percutaneous Nephrolithotomy?","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePercutaneous nephrolithotomy (PCNL) is the gold standard procedure for managing large (\u0026gt;\u0026thinsp;2 cm) stones in the kidney and upper ureter[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite its efficacy, PCNL presents significant challenges, particularly concerning infectious complications. Postoperative fever is a common occurrence, with reported rates ranging from 15% to 30%, while urosepsis has been documented in 0.9\u0026ndash;4.7% of PCNL procedures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Patients with renal calculi often present with bacteriuria; thus, preoperative antibiotic administration is standard practice [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, treatments become more complex in patients with multidrug-resistant (MDR) bacteriuria [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMDR is defined as non-susceptibility to at least one agent in three or more different antimicrobial categories [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It has become more prevalent causes of community-acquired infections increasing worldwide [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The presence of MDR bacteriuria is associated with an increased risk of postoperative infectious complications in patients undergoing PCNL [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Standard prophylactic antibiotic regimens may be ineffective against these resistant strains, resulting in increased rates of infectious complications and a higher risk of adverse outcomes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In the setting of positive cultures, a duration of 7 days is recommended to be an appropriate duration microbial burden within calculi [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and recent guidelines do not explicitly recommend a repeat negative urine culture before PCNL [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study comprehensively evaluates the relationship between MDR bacteriuria and postoperative infectious complications in patients undergoing PCNL. Specifically, we aimed to identify patient-related risk factors associated with MDR bacteriuria, analyze the correlation between preoperative urine cultures and intraoperative stone cultures, and identify potential predictors of infection-related morbidity, including postoperative urosepsis. The findings will contribute to the development of evidence-based interventions for prevention among patients undergoing PCNL with MDR bacteriuria.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eAll patients with renal calculi who underwent PCNL at Chiang Mai University Hospital between January 2015 and January 2023 were recruited. Patients were excluded if they had undergone second-look nephroscopy, urinary diversion, experienced failed PCNL, or were taking anticoagulant medications.\u003c/p\u003e \u003cp\u003ePreoperative urine samples were collected via midstream clean catch or catheterization. Patients with preoperative urine culture (UC) showing bacterial growth exceeding 100,000 CFU/ml were classified into the positive UC group. Additionally, if the identified bacterial strain met the criteria for MDR, patients were categorized into the positive MDR group. These positive UC patients in the non-MDR and MDR groups received appropriate, targeted antibiotic therapy until a negative UC was documented or for at least 7 days before surgery. Patients with negative preoperative UC received standard prophylactic antibiotics 60 minutes prior to surgery. The regimen consisted of a second- or third-generation cephalosporin, or an aminoglycoside for patients with a history of drug allergies.\u003c/p\u003e \u003cp\u003eStandard PCNL was performed as mentioned in a previous study [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Briefly, 24 Fr. nephroscopy was used in the prone position under fluoroscopy guidance in all cases. Stone disintegration was performed with either ultrasonic, pneumatic, or combined lithotripsy. Regarding the stone culture, renal stones were retrieved using a tripod grasper, immediately immersed in sterile saline, and then pulverized into a fine suspension. This suspension was subsequently incubated for aerobic bacterial culture. Stone culture results were categorized into three groups: no growth, MDR, and non-MDR.\u003c/p\u003e \u003cp\u003eConcordance culture was defined as the identical antibiotic sensitivity of an identical species found in both preoperative UC and intraoperative stone culture, or the same negative culture or any preoperative UC result with negative stone culture. Patients lacking either preoperative UC or perioperative stone culture were excluded from the analysis.\u003c/p\u003e \u003cp\u003eDemographic data were collected, including age, gender, body mass index (BMI), history of diabetes mellitus, previous stone treatment, antibiotic use within 90 days prior to surgery, and preoperative creatinine levels. Stone characteristics, such as stone burden, number of stones, and the presence of staghorn calculi, were recorded. Intraoperative details, including the site of puncture, number of access tracts, intraoperative blood loss, and postoperative outcomes such as stone-free status at post-operative days 30\u0026ndash;90, clinically insignificant residual fragments (CIRF), and length of hospital stay, were collected.\u003c/p\u003e \u003cp\u003eCIRF was defined as a residual fragment with a diameter of 2 millimeters or less, asymptomatic, and not obstructive [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Postoperative urosepsis was defined as meeting two or more criteria of the quick sepsis-related organ failure assessment (qSOFA) (14) and confirmation of a urinary pathogen in blood cultures. All patients with signs of sepsis underwent plain chest X-rays to rule out pulmonary causes, and further diagnostic tests were performed if other sources of sepsis were clinically suspected.\u003c/p\u003e \u003cp\u003eThe sample size was determined to achieve 80% power to detect clinically significant differences in the risk of postoperative infectious complications, by comparing the Odds Ratio (OR) among the no-growth, positive non MDR and MDR culture groups. Statistical analysis was performed using STATA version 17.0 (StataCorp LP, College Station, TX, USA). Categorical variables were presented as counts and percentages and compared across the three groups using either Fisher\u0026rsquo;s exact test or the Chi-square test, as appropriate. Continuous variables were presented as the mean with standard deviation (SD) for normally distributed data, or the median with interquartile range (IQR) for non-normally distributed data; these were compared using one-way ANOVA or the Kruskal\u0026ndash;Wallis test, respectively. Factors associated with postoperative sepsis were identified using a binary logistic regression model. All statistical tests were two-tailed, and a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003e The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Research Ethics Committee, Faculty of Medicine, Chiang Mai University, Research ID 0333/Study Code: SUR-2566-0333, approval number 376/2023, with a waiver for written informed consent due to the retrospective nature of the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAfter excluding 3 patients due to incomplete culture data and 19 who met other exclusion criteria, this study included 601 patients who underwent standard PCNL. \u0026nbsp;Applying the ellipsoid formula, the mean calculated stone burden in this cohort was 3.75 (1.24) cm\u003csup\u003e2\u003c/sup\u003e and nearly 64% was staghorn calculi.\u0026nbsp;\u0026nbsp;Based on preoperative UC results, patients were categorized into three groups: those positive for MDR bacteria (n = 122), those positive for non-MDR bacteria (n = 95), and those with a negative UC (n = 384). \u0026nbsp;The prevalence of MDR bacteria was 20% in preoperative urine cultures and 12% in intraoperative stone cultures. \u0026nbsp;The median age and age distribution were comparable across the three groups. \u0026nbsp;A statistically significant female predominance was observed in the positive UC groups compared to the negative UC group. \u0026nbsp;A higher percentage of patients in the positive MDR group (98%) and the positive non-MDR group (40%) had received antibiotics within 90 days prior to surgery compared to the negative culture group (26%). \u0026nbsp;Furthermore, the positive MDR group had a higher prevalence of prior nephrolithotomy compared to the other groups. \u0026nbsp;Regarding the positive stone culture result, only three patients presented with discordant findings of a positive non-MDR UC but a positive MDR stone culture. \u0026nbsp;Interestingly, 12% of patients with negative preoperative UC yielded positive non-MDR stone cultures. \u0026nbsp;The mean follow-up time for assessing success rate was 30 days. \u0026nbsp;The incidence of postoperative fever and the rate of postoperative sepsis also differed significantly, with the highest incidence in the positive MDR group, followed by the positive non-MDR group, and the lowest in the negative UC group. \u0026nbsp;The length of hospital stay was significantly longer in the positive MDR group compared to both the positive non-MDR and negative UC groups (\u003cstrong\u003eTable 1)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of microbial isolates from preoperative urine samples in the MDR group revealed that \u003cem\u003eEscherichia coli\u003c/em\u003e was the most prevalent pathogen, accounting for 56% of cases. \u0026nbsp;\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e and \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e were the next most isolated \u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003eSupplement\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFigure 1).\u003c/strong\u003e\u0026nbsp; Multivariable analysis identified two independent risk factors for MDR bacteriuria. \u0026nbsp;The strongest independent predictor was a history of antibiotic use within 90 days before surgery, demonstrating a remarkably high odds ratio (OR = 40.91). \u0026nbsp;Female sex was also significantly associated with MDR bacteriuria \u003cstrong\u003e(Table 2).\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe univariable analysis identified three preoperative factors significantly associated with postoperative sepsis: female sex, staghorn stones, and positive preoperative UC for any organism. \u0026nbsp;After adjusting for potential confounders in the multivariable model, both staghorn stones and positive preoperative UC remained independent predictors of sepsis. Positive preoperative UC for MDR organisms was associated with the highest risk of 6.17 \u003cstrong\u003e(Table 3). \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding postoperative predictors associated with urosepsis, multiple access tracts, high blood loss, and positive stone culture for any organism were associated with increased risk. On the other hand, achieving stone-free status and having a concordant culture result were associated with significantly lower odds of developing postoperative sepsis. \u0026nbsp;Similar to preoperative findings, a stone culture positive for MDR organisms was the most significant postoperative risk factor, with an odds ratio of 3.42 \u003cstrong\u003e(Table 4).\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of combined culture results revealed a synergistic risk profile \u003cstrong\u003e(Supplemental Table 1)\u003c/strong\u003e. \u0026nbsp;Positive non-MDR bacteriuria paired with a negative stone culture showed no clinical significance in increasing sepsis risk. In contrast, the presence of MDR organisms in preoperative urine and positive any organism in stone cultures represented the increased risk for urosepsis, with an odds ratio of 15.52. \u0026nbsp;The highest odds of sepsis were observed in patients with positive preoperative non-MDR bacteriuria and positive any organism in stone cultures (OR 23.31).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAmong patients undergoing PCNL, infectious complications are a common and serious concern. To our knowledge, this study represents one of the largest reported cohorts assessing outcomes in PCNL patients with documented MDR bacteriuria and the first to report the independent risk factors associated with the cause of MDR bacteriuria in this patient group. Data from this cohort demonstrated several key findings: 1) Despite achieving preoperative sterilization with sensitivity-targeted antibiotic therapy, the risk of postoperative infectious complications following PCNL was not significantly reduced in MDR group; 2) Preoperative MDR bacteriuria was a significant risk factor for postoperative urosepsis and extended hospital stays; 3) Preoperative MDR bacteriuria was highly prevalent in patients with a history of antibiotic use within 90 days before surgery; 4) Routine intraoperative stone culture is strongly recommended for comprehensive risk stratification and detection of occult MDR pathogens; 5) Achieving stone-free status and ensuring precisely targeted antibiotic therapy are key strategies for preventing infectious complications.\u003c/p\u003e \u003cp\u003eThe increasing prevalence of MDR urinary tract infection showed a substantial public health threat globally, especially in developing countries [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In Thailand, mortality rates linked to MDR infection exceed 54 per 100,000 population [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and were reported to be three to five times higher than those in the United States and the European Union [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A key pathogen of MDR was \u003cem\u003eEscherichia coli\u003c/em\u003e, the most common strain associated with urinary tract infections, with rates reaching 35% in community-acquired and 63% in hospital-acquired bacteremia [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn line with the report, this study also found \u003cem\u003eEscherichia coli\u003c/em\u003e was the most prevalent pathogen, accounting for 56% of MDR cases. This challenging situation is further exacerbated by the widespread availability of over-the-counter antibiotics and over-prescribing practices in hospitals [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], as evidenced by the 43% of cases in this study having a history of antibiotic use within 90 days before surgery.\u003c/p\u003e \u003cp\u003eMultivariable analysis identified two factors associated with higher MDR bacteriuria. First was the history of antibiotic use within 90 days before surgery. Despite its high odds ratio, antibiotic use within 90 days was retained in our multivariable final model due to its strong clinical relevance as a predictor of MDR bacteriuria. Moreover, its multicollinearity was minimal and did not affect model stability. Excluding this variable would result in omitted-variable bias and lead to increased magnitudes and statistical significance for the other covariates. Our findings showed that approximately 98% of patients with positive MDR urine cultures, compared to 26% of those with negative UC, had a recent history of antibiotic exposure. This notable difference demonstrates the crucial role of recent antimicrobial exposure in the development of resistance, underscoring the importance of responsible antimicrobial stewardship [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The second significant predictor was female sex. Female patients exhibited around twofold higher odds of MDR-positive urine cultures. This finding was consistent with their anatomical susceptibility to urinary tract infections and increased exposure to healthcare and antimicrobial agents [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients with MDR bacteriuria experienced significantly higher postoperative complication rates, with sepsis occurring at 15%, compared to 3% in the negative UC group. Multivariable analysis indicated that positive preoperative MDR bacteriuria was associated with a sixfold increase in the risk of urosepsis. Moreover, patients with MDR bacteriuria experienced a notably more extended hospitalization compared to those with non-MDR bacteriuria and negative UC. The longer hospital stay in MDR-positive patients was attributed to the requirement for extended intravenous antibiotic therapy, closer surveillance for infectious sequelae, and a potentially delayed resolution of the infection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn line with the meta-analysis and review article, the patient's age and sex did not increase the risk of infectious complications [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The presence of staghorn stones was associated with a higher risk of infectious complications [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], supporting the hypothesis that these large, complex calculi act as reservoirs for bacteria, thereby promoting persistent infections despite antibiotic treatment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, complete stone clearance was the strongest protective factor in minimizing infectious complications, reinforcing the importance of meticulous stone removal [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMultiple access tracts and high-volume blood loss have been identified as risk factors for postoperative sepsis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. While high-volume blood loss increased sepsis risk in both univariable and multivariable analyses, multiple percutaneous procedures did not show significance in the multivariable analysis. Although a greater number of access tracts and increased blood loss indicate a more complex procedure, the greater volume of blood loss appears to be more strongly associated with infectious complications. This is likely because blood loss often results from traumatic disruption of the urothelial lining, which can allow bacteria and endotoxins to enter the bloodstream directly [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe role of intraoperative stone cultures in predicting postoperative infectious outcomes is crucial. 12% of patients with negative preoperative UC yielded positive non-MDR stone cultures. Importantly, only three patients presented with discordant findings of a positive preoperative non-MDR urine culture but a positive MDR stone culture, yet all of these cases experienced MDR urosepsis complications. Our study also demonstrated that both positive preoperative urine cultures and stone cultures for any organism were correlated with increased risk of urosepsis in patients undergoing PCNL. However, while non-MDR stone culture was a significant predictor of urosepsis in univariable analysis, it did not remain an independent risk factor in the multivariable model. In contrast, a positive MDR stone culture remained a potent independent predictor of sepsis. This discrepancy is likely attributable to the efficacy of standard perioperative antibiotic prophylaxis against non-resistant strains.\u003c/p\u003e \u003cp\u003e Combined analysis of preoperative UC and stone cultures showed that isolated non-MDR bacteriuria did not significantly increase the odds of sepsis, likely because these patients received sensitivity-guided prophylaxis antibiotics. However, a discordant finding of a negative preoperative UC combined with a positive stone culture led to a 12.18-fold increase in the risk of sepsis. This risk was significantly higher in cases involving MDR bacteriuria. Specifically, a positive MDR urine culture was associated with a 12.95-fold risk when paired with a negative stone culture, and a 15.52-fold risk when paired with a positive stone culture. The highest risk of sepsis was found in patients with positive preoperative non-MDR bacteriuria and positive stone cultures. This increased risk is likely due to this group having the highest rate of antimicrobial discordance. These findings emphasize that a preoperative non-MDR UC may give a false sense of reliability, potentially masking an occult stone colonization with a discordant or more resistant microbial profile that standard prophylactic regimens fail to cover \u003cb\u003e(Supplemental Table\u0026nbsp;1)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eOur study also showed that the concordance of preoperative UC and intraoperative stone culture was another significant protective factor against infectious complications. This implies that providing precise preoperative antibiotic coverage, targeting organisms present in both the urine and the stone, can reduce the risk of urosepsis, even in cases involving MDR pathogens. Preoperative UC often does not accurately predict the results of stone and renal pelvis urine cultures. Discordance between preoperative urine culture and intraoperative stone culture was reported to occur in approximately 20\u0026ndash;40% of cases [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], placing a greater risk of postoperative urosepsis [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In summary, routine stone culture should be strongly considered as part of the standard of care in patients undergoing PCNL, particularly those at high risk for MDR infection [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe limitations of this study include its single-center and retrospective design, which may introduce historical and recall bias. Another limitation is that our culture relies on standard techniques rather than newer-generation methods (e.g., Next-Generation Sequencing or PCR-based approaches). Consequently, our study was unable to provide a more detailed understanding of MDR bacterial characteristics or their comprehensive antibiotic resistance profiles, including heteroresistance and underlying tolerance mechanisms. Forecasting culture results accurately before surgery is the most effective way to reduce sepsis risk. Nevertheless, a non-invasive tool for this purpose is unavailable. Advanced genomic methods would help elucidate the relationship between these MDR bacteria and clinical infectious outcomes and answer why they sometimes do not respond to targeted antibiotics, leading to urosepsis.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDespite achieving preoperative sterilization, the risk of postoperative infectious complications following PCNL was not significantly reduced in MDR group. Preoperative MDR bacteriuria significantly impacts the risk of infectious complications and contributes to longer hospital stays. Our findings identified recent antibiotic use, and female sex as key predictors of MDR bacteriuria. Both preoperative urine culture and routine intraoperative stone culture should be strongly considered as integral components of the standard of care in patients undergoing PCNL, especially those at high risk for MDR infections. Ultimately, achieving stone-free status and ensuring precisely targeted antibiotic therapy are key strategies for preventing infectious complications.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePCNL: Percutaneous Nephrolithotomy\u003c/p\u003e\n\u003cp\u003eMDR: Multidrug-resistant\u003c/p\u003e\n\u003cp\u003eCIRF: Clinically insignificant residual fragment \u0026le; 2 millimeters\u003c/p\u003e\n\u003cp\u003eUC:\u0026nbsp;Urine culture\u003c/p\u003e\n\u003cp\u003eFr.: French\u003c/p\u003e\n\u003cp\u003eBMI: Body\u0026nbsp;mass index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003emmHg: Millimeters of mercury\u003c/p\u003e\n\u003cp\u003eOR: Odds ratio\u003c/p\u003e\n\u003cp\u003eCI: Confidence interval\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Research Ethics Committee, Faculty of Medicine, Chiang Mai University, Research ID 0333/Study Code: SUR-2566-0333, approval number 376/2023, with a waiver for written informed consent due to the retrospective nature of the study. \u0026nbsp;The approval date was October 11, 2023. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was partially supported by the Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT Author Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eT.S.\u003c/strong\u003e: Conceptualization (support); Data curation (support); Formal analysis (equal); Investigation (support); Methodology (lead); Project administration; Resources (support); Validation (equal); Visualization; Writing – original draft (lead); Writing – review \u0026amp; editing (equal). \u0026nbsp;\u003cstrong\u003eP.W.\u003c/strong\u003e: Conceptualization (lead); Data curation (lead); Investigation (equal); Writing – original draft (support). \u0026nbsp;\u003cstrong\u003eK.S.\u003c/strong\u003e: Data curation (support); Investigation (equal). \u0026nbsp;\u003cstrong\u003eP.K.\u003c/strong\u003e: Conceptualization (support); Investigation (support); Supervision (support); Visualization; Writing – original draft (support). \u0026nbsp;\u003cstrong\u003eA.T.\u003c/strong\u003e: Formal analysis (equal); Methodology (support); Writing – original draft (support). \u003cstrong\u003eC.I.\u003c/strong\u003e: Formal analysis (equal); Software. \u0026nbsp;\u003cstrong\u003eB.L.\u003c/strong\u003e: Supervision (lead); Validation (equal); Writing – original draft (equal); Writing – review \u0026amp; editing (equal).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZeng G, Zhong W, Pearle M, Choong S, Chew B, Skolarikos A, Liatsikos E, Pal SK, Lahme S, Durutovic O, et al. 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Urolithiasis. 2022;51(1):17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDegirmenci T, Bozkurt IH, Celik S, Yarimoglu S, Basmaci I, Sefik E. Does leaving residual fragments after percutaneous nephrolithotomy in patients with positive stone culture and/or renal pelvic urine culture increase the risk of infectious complications? \u003cem\u003eUrolithiasis\u003c/em\u003e 2019, 47(4):371\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLei M, Zhu W, Wan SP, Liu Y, Zeng G, Yuan J. The outcome of urine culture positive and culture negative staghorn calculi after minimally invasive percutaneous nephrolithotomy. Urolithiasis. 2014;42(3):235\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTroxel SA, Low RK. Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever. 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Clinical significance of stone culture during endourological procedures in predicting post-operative urinary sepsis: should it be a standard of care-evidence from a systematic review and meta-analysis from EAU section of Urolithiasis (EULIS). World J Urol. 2024;42(1):614.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. \u0026nbsp;Patient demographics and operative outcome among those with positive MDR, positive non-MDR, and negative UC.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive MDR\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=122)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive non MDR\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=95)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNegative UC\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=384)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eAge (year), median [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e56 [50, 64]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e57 [49, 63]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e56 [49, 63]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.793\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eSex; Female, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e67 (54.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e54 (56.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e111 (28.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e), median [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e22.20\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[19.95, 25.39]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e24\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[21.48, 26.61]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e23.44\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[21.3, 25.69]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003ePreop creatinine, median [IQR]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.1 [0.85, 1.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1 [0.8, 1.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e1.09 [0.9, 1.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.091\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eStone burden (cm), mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.65 (1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e3.97 (1.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e3.72 (1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.137\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eStone burden \u0026ge; 2 (cm), n (%) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e114 (93.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e90 (94.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e359 (93.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eStaghorn stone, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e76 (62.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e63 (66.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e248 (64.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.822\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eDiabetes Mellitus, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e17 (13.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e6 (6.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e48 (12.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.178\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eReceived antibiotic 90 days before PCNL, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e119 (97.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e38 (40.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e99 (25.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eHistory of Previous procedure, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;History of PCNL\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;History of NL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (4.92)\u003c/p\u003e\n \u003cp\u003e20 (16.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (5.26)\u003c/p\u003e\n \u003cp\u003e9 (9.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (3.39)\u003c/p\u003e\n \u003cp\u003e31 (8.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eNumber of accesses; \u0026gt; 1 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e14 (11.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e7 (7.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e34 (8.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.551\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eAccess tract, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Upper pole\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Middle pole\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Lower pole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e89 (72.95)\u003c/p\u003e\n \u003cp\u003e11 (9.02)\u003c/p\u003e\n \u003cp\u003e22 (18.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e65 (68.42)\u003c/p\u003e\n \u003cp\u003e6 (6.32)\u003c/p\u003e\n \u003cp\u003e24 (25.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e295 (76.82)\u003c/p\u003e\n \u003cp\u003e29 (7.55)\u003c/p\u003e\n \u003cp\u003e60 (15.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003ePoint Access, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Supracostal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Subcostal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e39 (31.97)\u003c/p\u003e\n \u003cp\u003e83 (68.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (29.47)\u003c/p\u003e\n \u003cp\u003e67 (70.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e126 (32.81)\u003c/p\u003e\n \u003cp\u003e258 (67.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.823\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eSuccess rate, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Stone free\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;CIRF\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e85 (69.67)\u003c/p\u003e\n \u003cp\u003e56 (45.90)\u003c/p\u003e\n \u003cp\u003e29 (23.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e77 (81.05)\u003c/p\u003e\n \u003cp\u003e57 (60.00)\u003c/p\u003e\n \u003cp\u003e20 (21.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e268 (69.79)\u003c/p\u003e\n \u003cp\u003e211 (54.95)\u003c/p\u003e\n \u003cp\u003e57 (14.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eBlood loss (ml), median [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e200 [100, 300]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e100 [50, 300]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e200 [100, 300]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eBlood Transfusion, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7 (5.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e3 (3.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e9 (2.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.176\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003ePositive Stone culture, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No growth\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;MDR\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Non MDR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e52 (42.62)\u003c/p\u003e\n \u003cp\u003e68 (55.74)\u003c/p\u003e\n \u003cp\u003e2 (1.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63 (66.32)\u003c/p\u003e\n \u003cp\u003e3 (3.16)\u003c/p\u003e\n \u003cp\u003e29 (30.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e337 (87.76)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e47 (12.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003ePostoperative fever, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e85 (69.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e60 (63.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e176 (45.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eSepsis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e18 (14.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e9 (9.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e10 (2.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eLength of stay, median [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6 [4, 8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e5 [4, 7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e5 [3, 7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003eAbbreviations:\u003c/sup\u003e\u003c/strong\u003e\u003csup\u003e\u0026nbsp;MDR: Multidrug-resistant; UC: Urine culture; SD: standard deviation; IQR: interquartile range; PCNL: Percutaneous Nephrolithotomy; cm: centimeter; NL: Open Nephrolithotomy; CIRF: Clinically insignificant residual fragment\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003cstrong\u003eTable 2. Univariable analysis and Multivariable analysis for MDR risk factors\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariable Analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariable Analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eAge (Year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.99-1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.98-1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.827\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSex, Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.55-3.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.07-2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eBMI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.89-0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.91-1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.233\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePreop creatinine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.98-1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.95-1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eStone number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.93-1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.848\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.87-1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.294\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eStaghorn stone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.59-1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.588\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.57-1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.766\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.71-2.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.417\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.88-3.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eHistory of previous PCNL\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No History of surgery\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;History of PCNL\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;History of NL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e1.46\u003c/p\u003e\n \u003cp\u003e2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.57-3.78\u003c/p\u003e\n \u003cp\u003e1.23-3.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[Reference]\u003c/p\u003e\n \u003cp\u003e0.434\u003c/p\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e1.24\u003c/p\u003e\n \u003cp\u003e1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.43-3.61\u003c/p\u003e\n \u003cp\u003e0.80-2.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[Reference]\u003c/p\u003e\n \u003cp\u003e0.692\u003c/p\u003e\n \u003cp\u003e0.192\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eAntibiotic prior 90-day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e43.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e15.87-120.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e39.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e14.28-110.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003eAbbreviations:\u003c/sup\u003e\u003c/strong\u003e\u003csup\u003e\u0026nbsp;MDR: Multidrug-resistant; UC: Urine culture; PCNL: Percutaneous Nephrolithotomy; NL: Open Nephrolithotomy; OR: Odds ratio; CI: Confidence interval\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. \u0026nbsp;Univariable and Multivariable Analysis of Preoperative Factors Associated with Urosepsis\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariable Analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 250px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariable Analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eAge (Year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.99-1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.262\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.98-1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.343\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSex, Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1.00-3.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.050\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.70-2.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.328\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eStaghorn stone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1.07-5.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.17-6.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.60-3.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.395\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.59-4.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.372\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eUrine Culture and MDR Status\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Negative urine culture\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Positive non-MDR\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Positive MDR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e3.91\u003c/p\u003e\n \u003cp\u003e6.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e1.54-9.93\u003c/p\u003e\n \u003cp\u003e2.90-14.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[Reference]\u003c/p\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e3.66\u003c/p\u003e\n \u003cp\u003e6.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e1.40-9.53\u003c/p\u003e\n \u003cp\u003e2.68-14.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[Reference]\u003c/p\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003eAbbreviations:\u003c/sup\u003e\u003c/strong\u003e\u003csup\u003e\u0026nbsp;MDR: Multidrug-resistant; UC: Urine culture; OR: Odds ratio; CI: Confidence interval\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. \u0026nbsp;Univariable and Multivariable Analysis of Postoperative Factors Associated with Urosepsis\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariable Analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariable Analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eNumber of accesses; \u0026gt; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e3.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1.31-7.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.73-5.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.179\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eBlood loss\u0026nbsp;(ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1.00-1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.00-1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSuccess rate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Retain stone\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Stone free\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; CIRF\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.02-0.17\u003c/p\u003e\n \u003cp\u003e0.20-1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[Reference]\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.02-0.26\u003c/p\u003e\n \u003cp\u003e0.15-0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[Reference]\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eStone culture status\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No growth\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Positive non-MDR\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Positive MDR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e4.97\u003c/p\u003e\n \u003cp\u003e8.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e2.10-11.77\u003c/p\u003e\n \u003cp\u003e3.71-18.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[Reference]\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e2.04\u003c/p\u003e\n \u003cp\u003e3.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.70-5.96\u003c/p\u003e\n \u003cp\u003e1.24-9.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[Reference]\u003c/p\u003e\n \u003cp\u003e0.192\u003c/p\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eConcordance result\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.07-0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.08-0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003eAbbreviations:\u003c/sup\u003e\u003c/strong\u003e\u003csup\u003e\u0026nbsp;MDR: Multidrug-resistant; OR: Odds ratio; CI: Confidence interval; CIRF: Clinically insignificant residual fragment\u003c/sup\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Infectious complications, MDR, Multidrug-resistant bacteriuria, Percutaneous nephrolithotomy, Sepsis","lastPublishedDoi":"10.21203/rs.3.rs-9322728/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9322728/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe rising prevalence of multidrug-resistant (MDR) bacteriuria in percutaneous nephrolithotomy (PCNL) shows significant challenges, especially the risk of postoperative infectious complications. This study aimed to evaluate risk factors for MDR bacteriuria and its impact on infectious complications following PCNL.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 601 patients who underwent standard PCNL were categorized into three groups based on their preoperative urine culture results: MDR-positive, non-MDR bacteriuria, and negative urine culture. Patient demographics, stone characteristics, and intraoperative data were analyzed. A binary logistic regression model was used to identify risks for positive MDR bacteriuria and predictors of sepsis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePreoperative MDR bacteriuria was significantly associated with an increased risk of urosepsis. Recent antibiotic use within 90 days before PCNL and female sex were significant risk factors for MDR bacteriuria. Multivariate analysis identified several predictors of sepsis, including staghorn stone (OR 2.77, p\u0026thinsp;=\u0026thinsp;0.02), positive preoperative urine culture for MDR (OR 6.14, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and positive stone culture for MDR (OR 3.42, p\u0026thinsp;=\u0026thinsp;0.017). Conversely, complete stone clearance (OR 0.07, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and concordance between preoperative urine and intraoperative stone culture (OR 0.25, p\u0026thinsp;=\u0026thinsp;0.014) were strongly associated with a protective effect.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite achieving preoperative sterilization, the risk of postoperative infectious complications following PCNL was not significantly reduced in the MDR group. Stone culture is essential for comprehensive risk stratification. Achieving stone-free status and targeted antibiotic therapy are key strategies for preventing infectious complications, even in MDR cases.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003e SUR-2566-0333, approval number 376/2023, Institutional Review Board of Research Ethics Committee, Faculty of Medicine, Chiang Mai University.\u003c/p\u003e","manuscriptTitle":"Does Preoperative Sterilization of Multidrug-Resistant Bacteriuria Reduce Infectious Morbidity Following Percutaneous Nephrolithotomy?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-27 11:48:18","doi":"10.21203/rs.3.rs-9322728/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-13T18:06:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-22T20:14:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-20T10:24:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187602462932975883942744847950653694567","date":"2026-04-20T10:10:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312635111289448379083585537362189892611","date":"2026-04-20T09:44:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47709049636807060083014629173083316069","date":"2026-04-19T18:23:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-19T08:47:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T08:59:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-13T08:59:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2026-04-04T19:36:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7b189c41-0066-4e38-98c0-aaddde4e2fe5","owner":[],"postedDate":"April 27th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-13T18:06:24+00:00","index":25,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T11:48:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-27 11:48:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9322728","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9322728","identity":"rs-9322728","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}