BERKELEY, CA (UroToday.com) - Identification of the optimal timing of antimicrobial prophylaxis has been extensively studied.[1, 2] The use of perioperative antimicrobial prophylaxis helps prevent surgical site infections. However, little attention has been devoted to the overuse of antibiotics and compliance with established antimicrobial prophylaxis guidelines.
Although the American Urologic Association has developed and distributed best practices that should provide direction regarding class and duration of antimicrobial use for a variety of urologic procedures,[3] considerable heterogeneity in practice patterns persists. We used a database of patients undergoing urologic cancer care at community hospitals and identified prolonged duration of antimicrobial prophylaxis among 18% of radical prostatectomy patients, 29% of partial and radical nephrectomy patients, and 56% of radical cystectomy patients. Varied physician training, differences in management styles, and variation in the complexity of patient populations likely contribute to the patterns of care that we identified. At times, this deviation is warranted. For example, preoperative urine cultures may identify a urinary tract infection that requires antimicrobial therapy that extends into the postoperative time period.
As hospitals transition toward electronic health records and computerized order entry systems, automated clinical pathways may help reduce variability in antimicrobial prophylaxis and improve adherence to best practices. These platforms are also capable of capturing reasons why a provider deviates from established guidelines when entering antimicrobial orders. This information can inform quality improvement initiatives and guide surveillance systems that assess antimicrobial compliance.
Improved attention to antimicrobial stewardship can reduce the occurrence of infectious sequalae that result from overuse of antimicrobials such as infectious colitis and the promotion of increasingly resistant organisms. We found that—among kidney cancer and radical cystectomy patients—prolonged antimicrobial prophylaxis was associated with an increased risk for hospital-acquired Clostridium difficile infections. Hospital-acquired infections are a major source of patient morbidity and mortality, and they contribute substantial financial burden on the health care system.[4] With institution-specific, electronic protocols, we can optimize the administration of antimicrobial prophylaxis to yield benefits to patient care and increase the value of health care delivery.
References:
- Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326:281-6. PMID: 1728731.
- Schaeffer EM. Prophylactic use of antimicrobials in commonly performed outpatient urologic procedures. Nature Clinical Practice Urology. 2006;3:24-31. PMID: 16474491.
- Wolf JS, Jr., Bennett CJ, Dmochowski RR, Hollenbeck BK, Pearle MS, Schaeffer AJ. Best practice policy statement on urologic surgery antimicrobial prophylaxis. Journal of Urology. 2008;179:1379-90. PMID: 18280509.
- Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al. Health Care-Associated Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Intern Med. 2013. PMID: 23999949.
Written by:
Matthew Mossanen, MD and John L. Gore, MD, MS, FACS as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Urology, University of Washington, Seattle, WA USA
Use and outcomes of extended antibiotic prophylaxis in urologic cancer surgery - Abstract
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