Antibiotic prophylaxis before shock wave lithotripsy in patients with sterile urine: a systematic review and meta-analysis.

Whether routine antibiotic prophylaxis (AP) should be administered before shockwave lithotripsy (SWL) in patients with sterile urine remains controversial. We aimed to evaluate the effect of AP in this population. We systematically searched Web of Science, Embase, the Cochrane Library, and PubMed through November 20, 2025. The primary outcome was the composite overall infection risk, and secondary outcomes included symptomatic urinary tract infection (UTI), asymptomatic bacteriuria (AB), pyelonephritis, and sepsis. Ten randomized controlled trials involving 3,298 patients were included. AP did not significantly reduce the composite overall infection risk (RR, 0.82; 95% CI, 0.54-1.25; p = 0.35) or AB (RR, 0.80; 95% CI, 0.57-1.13; p = 0.21), but reduced symptomatic UTI (RR, 0.53; 95% CI, 0.29-0.97; p = 0.04). In the only trial reporting pyelonephritis, AP reduced the of pyelonephritis (RR, 0.05; 95% CI, 0.003-0.93; p = 0.04). No sepsis events were reported. Prediction interval and TSA analyses indicated that the symptomatic UTI finding was not definitive. These findings do not support routine universal prophylaxis in all patients with sterile urine undergoing SWL, but may support individualized use in selected patients after considering baseline infection risk, antimicrobial resistance, and antimicrobial stewardship.