Safety and effectiveness of zero antimicrobial prophylaxis protocol for outpatient cystourethroscopy

Abstract

Objectives To examine compliance and clinical outcomes after implementation of a zero antimicrobial prophylaxis protocol for outpatient cystoscopy in an academic centre. Patients and Methods Medical records of all patients who underwent diagnostic cystoscopy in the year preceding and year following protocol implementation were evaluated for urinary tract infection (UTI) diagnosis within 30 days of cystoscopy. Variables compared between groups included age, sex, smoking history, benign prostatic hyperplasia (BPH) diagnosis, diabetes mellitus, immunosuppression, catheter use (indwelling, suprapubic, or intermittent), and previous lower urinary tract reconstruction (augmentation cystoplasty or neobladder). UTI was defined using the National Surgical Quality Improvement Program definition. Rates were compared between groups, and statistical analyses were performed using chi‐squared and Fisher's exact tests and multivariable logistic regression, with significance defined as α < 0.05. Results In total, 941 patients were included in the analysis (72% men), 513 before protocol initiation, and 427 after. Groups were similar with regard to demographic variables and potential risk factors for infection. After protocol implementation, there was a significant reduction in patients receiving procedural antimicrobial prophylaxis (30% vs 15%; P < 0.001). The incidence of UTI after cystoscopy was slightly higher in the post‐protocol group (2.9–3.7%), but the difference was not statistically significant (chi‐squared = 0.56, P = 0.45). The incidence of UTI did not significantly differ with procedural antibiotic prophylaxis or with other antibiotic use at time of cystoscopy. Five out of a total of 31 UTIs (16%) over the study period resulted in fever, and four (13%) resulted in urosepsis. The probability of neither complication differed significantly between pre‐ and post‐protocol groups. The only significant patient‐level predictor of post‐cystoscopy UTI was catheter use (odds ratio 1.48, 95% confidence interval 1.06–2.06). Conclusion Protocol implementation led to a significant decrease in procedural antimicrobial prophylaxis, indicating protocols may be effective tools in promoting antibiotic stewardship. UTI incidence did not change significantly under the protocol, and antibiotic prophylaxis did not decrease infection rate. Our results support catheter use as a risk factor for post‐cystoscopy infection, but other patient variables, including those present in the American Urological Association Best Practice statement, were not predictive. In total, this analysis suggests that decreasing antibiotic prophylaxis for cystourethroscopy is safe and can be effective in the outpatient setting.

Does Antimicrobial Prophylaxis in Patients with Specific Comorbidities Reduce the Risk of Infection after Simple Cystourethroscopy?

“…4 Clennon et al also found that catheter use significantly increased the risk of post-cystourethroscopy UTI. 13 Our methods did not allow us to assess for presence of indwelling catheter or clean intermittent catheterization at the time of cystourethroscopy. Cusumano et al found that age over 65 years was associated with UTI after flexible cystourethroscopy, regardless of whether AP was given.…”

Editorial Commentary

“…Notable limitations include the EMR-based UTI definition (which does not include symptomatic infections or those diagnosed at other facilities) and the inability to evaluate factors associated with UTI, such as catheter or recent antibiotic use. 2,3 Further studies are needed to define the population most at risk for post-cystourethroscopy UTI, thereby informing the use of risk-based prophylaxis that 1) targets those most at risk for UTI and 2) can be easily implemented in an outpatient urology setting, allowing for increased adherence to guideline recommendations.…”