Abstract
The American Urological Association guidelines recommend 24 or fewer hours of antimicrobial prophylaxis for most urologic procedures. Continuing antimicrobial therapy beyond 24 hours may carry more risks than advantages. To assess guideline discordance of antimicrobial prophylaxis for common urologic endoscopic procedures, and to identify opportunities for improving antimicrobial prescribing through future stewardship interventions. This multicenter cohort study conducted manual audits of medical records of 375 patients who underwent 1 of 3 urologic procedures (transurethral resection of bladder tumor [TURBT], transurethral resection of the prostate [TURP], and ureteroscopy [URS]) at 5 Veterans Health Administration facilities from January 1, 2016, to June 30, 2017. Antimicrobial prescribing practices across the national Veterans Health Administration system were assessed using the administrative data for 29 530 records. Guideline discordance was assessed in the medical record review. Excessive postprocedural antimicrobial use was measured in the national administrative data analysis. The medical records of a total of 375 patients were manually reviewed. Among the 375 patients, 366 (97.6%) were male and 9 (2.4%) were female, with a mean (SD) age of 64.2 (10.9) years and a predominantly white race/ethnicity (289 [77.1%]). In addition, 29 530 patient records in the national administrative database were assessed. Among the patient records, 28 938 (98.0%) were male and 592 (2.0%) were female with a mean (SD) age of 69.1 (10.2) years and a predominantly white race/ethnicity (23 297 [78.9%]). Among the manually reviewed medical records, periprocedural or postprocedural antimicrobial prescribing was guideline discordant in 217 patients (57.9%). Postprocedural antimicrobial agents were continued beyond 24 hours in 211 patients (56.3%) and were guideline discordant in 177 patients (83.9%), with a median (interquartile range) duration of 3 (3-5) days of unnecessary antimicrobial therapy. In the analysis of national administrative data, excessive postprocedural antimicrobial agents were prescribed in 10 988 of 29 350 patient records (37.2%), with a median (interquartile range) of 3 (2-6) excess days. For any given facility, a statistically significant correlation was observed in the frequency of postprocedural antimicrobial prescribing between any 2 procedures, indicating that facilities with higher rates of excessive use for 1 procedure also had higher rates for another procedure: TURP and TURBT (ρ = 0.719; 95% CI, 0.603-0.803; P < .001), TURP and URS (ρ = 0.629; 95% CI, 0.476-0.741; P < .001), and TURBT and URS (ρ = 0.813; 95% CI, 0.724-0.873; P < .001). In this study of patients who underwent common urologic procedures, the rate of guideline-discordant antimicrobial use was high mostly because of overprescribing of postprocedural antimicrobial agents; future antimicrobial stewardship interventions should target the postprocedural period.
Highlights
Antimicrobial misuse and overuse are key factors in the emergence of antimicrobial-resistant bacteria,[1] creating a need to improve antimicrobial prescribing.[2]
Postprocedural antimicrobial agents were continued beyond 24 hours in 211 patients (56.3%) and were guideline discordant in 177 patients (83.9%), with a median duration of 3 (3-5) days of unnecessary antimicrobial therapy
A statistically significant correlation was observed in the frequency of postprocedural antimicrobial prescribing between any 2 procedures, indicating that facilities with higher rates of excessive use for 1 procedure had higher rates for another procedure: transurethral resection of the prostate (TURP) and transurethral resection of bladder tumor (TURBT) (ρ = 0.719; 95% CI, 0.603-0.803; P < .001), TURP and URS (ρ = 0.629; 95% CI, 0.476-0.741; P < .001), and TURBT and URS (ρ = 0.813; 95% CI, 0.724-0.873; P < .001)
Summary
Antimicrobial misuse and overuse are key factors in the emergence of antimicrobial-resistant bacteria,[1] creating a need to improve antimicrobial prescribing.[2]. Antimicrobial use in surgical specialties is a potential target for antimicrobial stewardship efforts because certain subspecialties prescribe large quantities of antimicrobial agents. Urologists prescribed 6 million antimicrobial prescriptions in the United States in 2011 alone.[4] urologists represented only 1.06% (9 210) of all prescribing providers in 2015, they were the eighth highest prescribers of outpatient antimicrobial agents among all specialties.[5]. The Best Practice Policy Statement on Urologic Surgery and Antimicrobial Prophylaxis, published by the American Urological Association (AUA) in 2008, recommends the administration of antimicrobial prophylaxis for 24 or fewer hours during the perioperative period.[6] Exceptions to this recommendation apply to patients with an infection present at the time of the procedure. The AUA guidelines note that, in the absence of preexisting and untreated bacterial colonization, there is “no evidence that prophylaxis should extend beyond 24 hours following a procedure.”6(p13)
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