Do urologists adhere to antibiotic prophylaxis guidelines prior to cystoscopy?

INTRODUCTION: Flexible cystoscopy is a common urological procedure with a low infectious risk. Current guidelines recommend selective rather than routine antibiotic prophylaxis (AP), reserving its use for patients with well-defined risk factors. However, real-world adherence to these recommendations remains uncertain. The objective was to assess adherence of urologists to guideline-directed AP use before flexible cystoscopy and to identify physician-related predictors of non-compliance. METHODS: A nationwide anonymous questionnaire was distributed to all urology specialists practicing in Israel. The survey consisted of 18 structured items examining demographic, academic, and clinical characteristics, as well as AP prescribing patterns and risk-factor considerations. Descriptive statistics, chi-square tests, and multivariate logistic regression were used to evaluate associations between physician characteristics and prophylactic antibiotic use. RESULTS: Of 300 urologists, 75 responded (25%). Overall, 20% routinely prescribed AP for all patients undergoing cystoscopy, regardless of risk stratification. Academic rank was significantly associated with non-compliance; 41% of associate and full professors prescribed AP routinely (p = 0.012), and academic rank remained the only independent predictor on multivariate analysis (p = 0.009). Older age showed a trend toward increased non-adherence (p = 0.07), while gender, subspecialty, fellowship status, workplace, and procedure volume were not associated with prescribing practices. Guideline-based risk factors most frequently prompting AP use included immunosuppression (51%), chronic catheterization (48%), and recurrent urinary tract infections (37%). CONCLUSION: A significant number of urologists continue to prescribe AP prior to flexible cystoscopy, contrary to guideline recommendations. Academic rank was the strongest predictor of non-adherence, potentially reflecting workflow pressures and habitual practice patterns. Improved awareness, stewardship initiatives, and standardized protocols may enhance evidence-based AP utilization and reduce unnecessary antibiotic exposure.