Prunty Megan, Rhodes Stephen, Rivero Marco-Jose, Callegari Michael, Jesse Erin, Arenas-Gallo Camilo, Brant Aaron, Calaway Adam, Scherr Douglas, Shoag Jonathan E
Department of Urology, Case Western Reserve University School of Medicine, Cleveland, Ohio.
University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio.
J Urol. 2023 Feb;209(2):329-336. doi: 10.1097/JU.0000000000003069. Epub 2022 Nov 16.
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.
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.
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%, = .04), pyelonephritis (5.1% vs 7.7%, < .001), bacterial infection (24% vs 27%, = .03), or pneumonia (12% vs 17%, < .001). There was no statistically significant difference in clostridium difficile infection between guidelines-based and nonguidelines-based prophylaxis (3.2% vs 3.7%, = .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], < .001) was associated with an increased odds of infectious events, whereas a robotic approach (OR 0.82 [0.73, 0.92], < .001) was associated with lower odds.
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.
美国泌尿外科学会（AUA）指南中关于回肠代膀胱根治性膀胱切除术抗生素预防的哨兵参考报告了2003 - 2013年的数据，在此期间未更新。在此，我们使用一个大型国家数据库评估接受膀胱癌回肠代膀胱根治性膀胱切除术患者对抗生素预防指南的依从性。作为次要目标，我们评估膀胱切除术后首次住院期间抗菌药物使用与术后感染之间的关联。
查询Premier医疗保健数据库中2015年至2020年间所有诊断为膀胱癌并接受回肠代膀胱膀胱切除术的患者。使用的抗生素及其使用时长通过收费代码确定，并根据2019年AUA指南分为基于指南或非基于指南两类。通过逻辑混合效应回归模型评估与感染并发症的关联。
在6708例接受回肠代膀胱膀胱切除术的患者中，只有28%（1843/6708）按照AUA指南进行了预防；1.8%（121/6708）的患者接受了抗真菌药物治疗，37%（2482/6708）的患者术后第1天之后接受了延长时长的预防。接受基于指南预防的患者被诊断为尿路感染（21%对24%，P = 0.04）、肾盂肾炎（5.1%对7.7%，P < 0.001）、细菌感染（24%对27%，P = 0.03）或肺炎（12%对17%，P < 0.001）的可能性较小。基于指南和非基于指南的预防在艰难梭菌感染方面无统计学显著差异（3.2%对3.7%，P = 0.32）。在对年龄、种族、保险以及医院和医疗服务提供者特征进行调整的多变量逻辑回归分析中，非指南性抗生素预防（比值比1.27 [1.12, 1.43]，P < 0.001）与感染事件发生几率增加相关，而机器人手术方式（比值比0.82 [0.73, 0.92]，P < 0.001）与较低几率相关。
73%的患者在接受带导管根治性膀胱切除术时未接受基于指南的抗生素预防，这在很大程度上是由延长抗生素使用时长导致的。尽管抗生素使用时长较短，但我们发现基于指南的预防与感染并发症发生几率降低25%相关。虽然可能存在残余混杂因素，但这些数据支持当前的AUA指南，并表明需要进行推广以提高指南依从性。
