National Adherence to Guidelines for Antimicrobial Prophylaxis for Patients Undergoing Radical Cystectomy

Abstract

Purpose: The sentinel reference for antibiotic prophylaxis for radical cystectomy with ileal conduit in the AUA Guidelines reports data from 2003-2013 and has not been updated in the interim. Here, we assess adherence to antibiotic prophylaxis guidelines among patients undergoing radical cystectomy with ileal conduit for bladder cancer using a large national database. As a secondary objective, we assess the association between antimicrobial use and postoperative infection during the index admission following cystectomy. Materials and Methods: The Premier Healthcare Database was queried for all patients undergoing cystectomy with ileal conduit with diagnosis of bladder cancer between 2015 and 2020. Antibiotics used and the duration of use was determined by charge codes and grouped as guidelines-based or not according to 2019 AUA Guidelines. Association with infectious complications was assessed by logistic mixed effects regression models. Results: Among 6,708 patients undergoing cystectomy with ileal conduit, only 28% (1,843/6,708) were given prophylaxis according to AUA guidelines; 1.8% (121/6,708) of patients received an antifungal and 37% (2,482/6,708) received extended duration prophylaxis beyond postoperative day 1. Patients who received guidelines-based prophylaxis were less likely to be diagnosed with a urinary tract infection (21% vs 24%, P [ .04), pyelonephritis (5.1% vs 7.7%, P < .001), bacterial infection (24% vs 27%, P [ .03), or pneumonia (12% vs 17%, P < .001). There was no statistically significant difference in clostridium difficile infection between guidelines-based and nonguidelines-based prophylaxis (3.2% vs 3.7%, P [ .32). In a multivariable logistic regression adjusting for age, race, insurance, and hospital and provider characteristics, nonguideline antibiotic prophylaxis (OR 1.27 [1.12, 1.43], P < .001) was associated with an increased odds of infectious events, whereas a robotic approach (OR 0.82 [0.73, 0.92], P < .001) was associated with lower odds. Conclusions: Seventy-three percent of patients fail to receive guideline-based antibiotic prophylaxis when undergoing radical cystectomy with conduit, which was largely driven by extended duration antibiotic use. Despite the shorter duration of antibiotics, we found that guideline-based prophylaxis was associated with a 25% decrease in the odds of infectious complications. While residual confounding is possible, these data support current AUA guidelines and suggest a need for outreach to improve guideline adherence.

Prevention and management of urinary tract infections after cystectomy

“…Prunty et al [40 ▪▪ ] showed that 73% of patients fail to receive guideline-based antibiotic prophylaxis when undergoing radical cystectomy with conduit, which was largely driven by extended duration antibiotic use. Among 6708 patients undergoing cystectomy with ileal conduit, only 28% were given prophylaxis according to AUA guidelines.…”

National Adherence to Guidelines for Antimicrobial Prophylaxis for Patients Undergoing Radical Cystectomy. Letter.

“…To the Editor: Prunty et al present data on the low adherence to antimicrobial prophylaxis guidelines in patients undergoing radical cystectomy and ileal conduit. 1 More specifically, they queried the Premier Healthcare Database and found that only 28% of patients between January 2015 and March 2020 received guideline-concordant prophylaxis. Furthermore, they found an association of increased antibiotic usage with a greater risk of any infectious event, including urinary tract infection, pyelonephritis, bacteremia, and pneumonia.…”

“…Prunty et al stratified guideline discordance by failed adherence to antibiotic duration and/or selection; they found that 37% of the cases of nonadherence were due to prolonged duration, defined as antibiotics extending into postoperative day 2. 1 This duration, however, corresponds to the 2008 American Urological Association best practice statement. 2 More recently, published in 2019, the guidelines were updated to recommend a single perioperative dose of antibiotics for radical cystectomy and ileal conduit.…”

Leading Antimicrobial Stewardship From the Operating Room

“…Prunty et al recently reported that among almost 7,000 patients from a large insurance claims database undergoing radical cystectomy over a 5-year period, only 28% were given perioperative prophylaxis considered adherent to the AUA best practice guideline on antimicrobial prophylaxis. 4 The most common disqualifier from guideline adherence was prolonged periprocedural antibiotic use, defined as prophylaxis longer than 24 hours, which was seen in 37% of patients. Patients with guideline-discordant regimens were more likely to suffer from postoperative infections including pyelonephritis and pneumonia.…”