Overuse of Antimicrobial Prophylaxis in Community Practice Urology

Abstract

Purpose We examined index urological surgeries to assess utilization patterns of antimicrobial prophylaxis in a large, community based population. Materials and Methods From the Premier Perspectives Database we identified patients who underwent inpatient urological surgeries that are considered index procedures by the ABU (American Board of Urology), including radical prostatectomy, partial or radical nephrectomy, radical cystectomy, ureteroscopy, shock wave lithotripsy, transurethral resection of the prostate, percutaneous nephrostolithotomy, transvaginal surgery, inflatable penile prosthesis, brachy-therapy, transurethral resection of bladder tumor and cystoscopy. Procedures were identified based on ICD-9 procedure codes for 2007 to 2012. Antimicrobial administration, class and duration were abstracted from patient billing data. The class and duration of antimicrobials concordant with the 2008 AUA Best Practice Policy Statement was used to determine compliance. Results The overall compliance rate was 53%, ranging from 0.6% for radical cystectomy to 97% for shock wave lithotripsy. Antimicrobial use consistent with AUA Best Practices included the appropriate class in 67% of cases (range 34% to 80%) and the recommended duration in 78% (range 1.2% to 98%). Average prophylaxis duration for procedures for which it is recommended ranged from 1.1 days after brachytherapy to 10.3 days after radical cystectomy. The compliance rate increased from 46% overall in 2007 to 59% overall in 2012. Conclusions We documented considerable variation in antimicrobial prophylaxis for urological surgery. Compliance with AUA Best Practices increased with time but overall rates remain less than 60%. Efforts are needed to better understand the reasons for variation from recommended antimicrobial prophylaxis for common inpatient urological procedures to help decrease resultant complications and improve outcomes.

Risk for Clostridium difficile infection after radical cystectomy for bladder cancer: Analysis of a contemporary series

“…10 Reasons for deviation from antimicrobial prophylaxis guidelines in RC patients include increased patient comorbidities, preoperative bacteriuria, difficult operations associated with fecal contamination, and indwelling hardware such as ureteral stents, catheters and/or surgical drains. 21 Limiting antibiotic use in the postoperative setting seems logical but is difficult to apply universally as the incidence of postoperative infectious complications after RC patients remains high, and is reported in 16% to 38% of patients. 22,23 Limiting the use of preoperative antimicrobials in RC patients should be a priority.…”

Assessment of Guideline Discordance With Antimicrobial Prophylaxis Best Practices for Common Urologic Procedures

“…None of these patients underwent the 3 procedures reviewed in the current study. Mossanen et al 10 reviewed data from the same 2007 to 2012 database used by Calvert et al 9 and found that the mean duration of antimicrobial prophylaxis exceeded 24 hours for multiple urologic procedures but not for TURP, TURBT, or URS. Unlike the current study, Mossanen et al 10 excluded a substantial proportion of patients because the prescribed antimicrobial class was changed within 24 hours of the procedure and thus may have underestimated the rate of guideline-discordant postprocedural antimicrobial use.…”

“…In contrast, the largest studies on this topic, both of which relied exclusively on the same administrative database, made several assumptions about what did and did not qualify as appropriate antimicrobial use. 9,10 Furthermore, the large sample size from the national data analysis was validated by medical record review. Overall, there was excellent agreement between these 2 data sources.…”

The importance of antibiotic stewardship

“…Although the effectiveness of antibiotic prophylaxis in reducing postoperative UTIs is well-established, there is evidence to suggest significant variation in utilization of antibiotic prophylaxis, including inappropriate selection of drugs, improper timing of administration, and excessive duration of prophylaxis. 3 We should all use these guidelines as a framework to plan our local strategies based on our hospital or communities' antibiogram, keeping in mind that proper antibiotic stewardship is critical to slowing the rise of resistant organisms and reducing significant future risk for our patients.…”