Preoperative assessment of the patient and risk factors for infectious complications and tentative classification of surgical field contamination of urological procedures

Reducing candidaemia risk in urology patients: Revised algorithm & Pharmacist-Led Implementation

BACKGROUND

Candidaemia is an invasive infection with high morbidity and mortality. All urology procedures carry risk of post-operative infection. Risk mitigation strategies include preoperative urine culture and treatment of cultured organism(s) regardless of symptoms. After zero cases of candidaemia for two years, there were five cases in elective urology patients within 15 weeks between June - September 2021. This increased incidence of candidaemia amongst these patients prompted multidisciplinary investigation.

METHODS

Single centre case series, in a 250-bed hospital which annually performs 2000-2500 elective urology surgeries. Affected patients were elderly with multiple comorbidities. Notably, four of five patients had prior indwelling ureteral stents. All five patients had preoperative bacteriuria requiring antibiotics and one patient had pre-operative candiduria.

RESULTS

Hypotheses including sterilisation failure, surgical instrument contamination, or surgical technique issues were unfounded. We propose that pre-operative duration of antibacterial therapy, particularly in the setting of ureteral stent biofilm, is a significant factor for candiduria. A new prescribing algorithm for urology patients was devised. Antibiotic treatment duration in asymptomatic patients with indwelling urinary tract foreign material was reduced from 14 to 3 days, and from 14 to 7 days in symptomatic patients. Dedicated pharmacist resources were allocated to support this change and pre-operatively manage these patients. These interventions led to zero candidaemia cases over the subsequent 21 months, along with zero post-operative bacterial bloodstream infections.

CONCLUSIONS

Prolonged pre-operative antibacterial therapy poses a risk for post-operative candidaemia, especially in patients with ureteral stents. Shortening pre-operative antibiotic courses, coupled with increased pharmacist involvement, effectively reduced candidaemia incidence.

Perioperative Antibiotic Prophylaxis Duration in Patients Undergoing Cystectomy With Urinary Diversion: A Randomized Clinical Trial

Importance

Perioperative antibiotic prophylaxis (PAP) reduces the incidence of surgical site infections (SSIs). Guidelines recommend 24 hours or less of PAP for cystectomy with urinary diversion; however, evidence specifying optimal PAP duration for this surgery is lacking, and prolonged administration of PAP is common practice.

Objective

To establish noninferiority of 24-hour PAP vs extended-duration PAP in preventing SSIs within 90 days after cystectomy with urinary diversion.

Design, Setting, and Participants

This single-center, noninferiority randomized clinical trial was performed from April 18, 2018, to August 18, 2022, in patients aged older than 18 years undergoing elective open cystectomy with urinary diversion. Exclusion criteria were contraindications to administered drugs and inability to follow study procedures.

Intervention

PAP administered for 24 hours (24-hour PAP group) vs PAP until all catheters and stents were removed (extended PAP group).

Main Outcome and Measures

The primary end point was the rate of SSI, and the secondary end points included all-cause mortality, both within 90 days after surgery. Noninferiority of the 24-hour PAP treatment was assessed by comparing the 90% CI (corresponding to a significance level of α = .05) with the predefined noninferiority margin of 10%.

Results

A total of 95 patients were randomly assigned to the 24-hour PAP group (median [IQR] age, 69.3 [63.1-76.8] years; 66 males [69.5%]) and 98 to the extended PAP group (median [IQR] age, 69.5 [60.8-75.5] years; 68 males [69.4%]). Patients in the 24-hour PAP group received PAP for a median of 1 day (IQR, 1-1 day), and patients in the extended PAP group received PAP for a median of 8 days (IQR, 7-10 days). No significant differences in SSIs occurring within 90 days were found (24-hour PAP group, 8 patients [8.4%]; extended PAP group, 12 patients [12.2%]; P = .53). The risk difference for 90-day cumulative SSI incidence was -3.8% (90% CI, -11.1% to 3.4%), establishing noninferiority of 24-hour PAP vs extended PAP to prevent SSI. Mortality was not significantly different between groups.

Conclusions and Relevance

The findings of this randomized clinical trial demonstrate noninferiority of 24-hour PAP vs extended-duration PAP in preventing SSIs within 90 days after cystectomy with urinary diversion and may contribute to antibiotic stewardship efforts in urology.

Trial Registration

ClinicalTrials.gov Identifier: NCT03305627.

Oxidized alginate-gelatin (ADA-GEL)/silk fibroin/Cu-Ag doped mesoporous bioactive glass nanoparticle-based hydrogels for potential wound care treatments

The present work focuses on developing 5% w/v oxidized alginate (alginate di aldehyde, ADA)-7.5% w/v gelatin (GEL) hydrogels incorporating 0.25% w/v silk fibroin (SF) and loaded with 0.3% w/v Cu-Ag doped mesoporous bioactive glass nanoparticles (Cu-Ag MBGNs). The microstructural, mechanical, and biological properties of the composite hydrogels were characterized in detail. The porous microstructure of the developed ADA-GEL based hydrogels was confirmed by scanning electron microscopy, while the presence of Cu-Ag MBGNs in the synthesized hydrogels was determined using energy dispersive x-ray spectroscopy. The incorporation of 0.3% w/v Cu-Ag MBGNs reduced the mechanical properties of the synthesized hydrogels, as investigated using micro-tensile testing. The synthesized ADA-GEL loaded with 0.25% w/v SF and 0.3% w/v Cu-Ag MBGNs showed a potent antibacterial effect againstEscherichia coliandStaphylococcus aureus. Cellular studies using the NIH3T3-E1 fibroblast cell line confirmed that ADA-GEL films incorporated with 0.3% w/v Cu-Ag MBGNs exhibited promising cellular viability as compared to pure ADA-GEL (determined by WST-8 assay). The addition of SF improved the biocompatibility, degradation rate, moisturizing effects, and stretchability of the developed hydrogels, as determinedin vitro. Such multimaterial hydrogels can stimulate angiogenesis and exhibit desirable antibacterial properties. Therefore further (in vivo) tests are justified to assess the hydrogels' potential for wound dressing and skin tissue healing applications.

Optimal Dwelling Time for Ureteral Stents Placed for Passive Dilation after Impassable Ureteroscopy

INTRODUCTION

The aim of the study was to determine the correlation between the dwelling time for a ureteral stent placed for passive dilation after impassable ureteroscopy and success and complications.

METHODS

A retrospective evaluation was made of patients who underwent stent placement after impassable ureteroscopy and a repeat ureteroscopy due to kidney stones. A total of 161 patients were included in the study between 2015 and 2022. Demographic, clinical, preoperative, and perioperative data were collected. Logistic regression analyses were performed on the data showing a significant difference in the univariate analyses performed to determine the predictive factors of ureteroscopy after the stent dwelling period in terms of stone-free status and perioperative complications.

RESULTS

Stone-free status was achieved in 110 (68.3%) of 161 patients, and perioperative complications were observed in 41 (25.4%). Factors that affected the stone-free status were determined as the dwelling time and the S-ReSC score, while factors affecting perioperative complications were the stent dwelling time and the operation time. The stone-free rates were observed to increase from 46.4% in the first 2 weeks to 72.9% after the 2nd week, an increase of 1.5-fold. Perioperative complications were determined at the rate of 17.5% during the first 5 weeks and increased 2.1-fold to 37.5% after the 5th week.

CONCLUSION

It can be recommended that great care is taken during the stent dwelling period and ureteroscopy should be performed within 5 weeks (14-35 days) but no earlier than 2 weeks, so as not to affect the success of the procedure.

Predictors of readmission and impact of same-day discharge in holmium laser enucleation of the prostate

Background

Holmium enucleation of the prostate (HoLEP) is becoming the gold standard for the treatment of benign prostatic hyperplasia (BPH). Our objective was to identify predictors of 30-day readmission and the impact of same-day discharge after HoLEP.

Methods

Using NSQIP data from 2011 to 2019, we identified men who underwent HoLEP for the treatment of BPH. We compared patients based on time of discharge and readmission status. We used multivariable logistic regression analysis (MLRA) to identify independent factors associated with 30-day readmission.

Results

A total of 3,489 patients met inclusion criteria with 833 (23.88%) being discharged within 24 hours and 2,656 (76.12%) discharged after 24 hours. There were 158 (4.53%) 30-day readmissions, mostly due to hematuria and urinary tract infection. Patients being readmitted were older (72 vs. 70 years old, P = 0.001), were more likely to have preoperative anemia (36.7% vs. 23.1%; P < 0.001), chronic kidney disease (29.7% vs. 19.7%; P < 0.001), bleeding disorder (10.8% vs. 2.8%; P < 0.001), higher American Society of Anesthesiologists (ASA) scores (≥3: 70.3% vs. 46.7%; P < 0.001) and a higher frailty burden (5-item modified frailty index [5i-mFI] ≥ 2: 36.1% vs. 19.1%; P < 0.001) compared to their counterparts. Factors independently associated with 30-day readmission were bleeding disorder (OR 2.89; 95% CI 1.63-5.11; P < 0.001), 5i-mFI ≥ 2 (OR 1.67; 95% CI 1.03-2.71; P = 0.038) and an ASA score ≥3 (OR 1.80; 95% CI 1.21-2.70; P = 0.004); however, same-day discharge was not found to be a significant predictor of 30-day readmissions.

Conclusion

The overall readmission rate after HoLEP is low. Patients discharged within 24 hours have similar rates of readmission compared to patients discharged after 24 hours. We found bleeding disorder, frailty burden, and ASA score to be independent predictors of 30-day readmission.

Primary versus delayed ureteroscopy for ureteric stones: A systematic review and meta-analysis

Background:

Ureteric colic is a major clinical and economic burden on the National Health Service. There has been a recent paradigm shift to consider definitive surgery as the primary intervention at the time of initial presentation.

Objective:

To systematically evaluate the outcomes of primary/emergency ureteroscopy versus delayed/elective ureteroscopy.

Methods:

We performed a critical review of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials–CENTRAL, CINAHL, Clinicaltrials.gov, Google Scholar and individual urological journals in April 2020. A robust database search was performed using a combination of the terms ‘primary ureteroscopy’, ‘immediate ureteroscopy’, ‘delayed ureteroscopy’ and ‘emergency ureteroscopy’. Adult patients (> 16 years) with ureteric stones presenting as an emergency were included.

Results:

Twelve studies met the inclusion criteria, with 4 studies directly comparing primary/emergency to delayed/elective ureteroscopy for an acute presentation of ureteric colic. Across the studies, 1708 patients underwent primary/emergency ureteroscopy for ureteric calculi and 990 underwent delayed ureteroscopy. No significant differences in stone-free rates were found between both groups with primary/emergency achieving 85% and delayed/elective 91% ( p = 0.68). The majority of stones treated were located in the distal ureter in both groups. Overall, there were no differences in complications between the groups ( p = 0.42) or major complications (0.17). However, there were fewer minor complications in the primary URS group ( p = 0.02). Ureteral catheter or double-J stent insertion was used in 71% of delayed/elective ureteroscopy cases, compared to 46.8% of primary/emergency cases (p = 0.001). For patients undergoing primary/emergency ureteroscopy, 6.4% patients required auxiliary procedures. In the delayed/elective group, 7.6% required further definitive treatment (NS).

Conclusion:

Primary ureteroscopy is a safe and feasible procedure, when performed in suitable patients in the acute setting. It is associated with significantly lower stent usage, equivalent stone clearance, no increase in overall or major complications including sepsis, and fewer minor complications when compared to delayed/elective ureteroscopy. Prospective studies will do well to explore this area further but on current evidence, primary ureteroscopy is the safe procedure.

Level of evidence:

Not applicable

Open versus minimally invasive ureteroneocystostomy: trends and outcomes in a NSQIP-P cohort

Although surgical intervention has commonly been performed using an open approach for vesicoureteral reflux (VUR), this is rapidly changing due to adoption of minimally invasive surgery (MIS). Success rates with MIS are similar to open for re-implantation (> 90%); however, open ureteral re-implantation is still widely considered the gold standard. Using national surgical quality improvement program-pediatric (NSQIP-P) data, this manuscript evaluates recent large population trends of open versus robotic-assisted and laparoscopic ureteroneocystostomy for complications and factors associated with worse outcomes. Cases were identified in the 2012-2019 NSQIP-P database using the ureteroneocystostomy operative codes and vesicoureteral reflux post-operative diagnosis codes. A 1:1 propensity score match (PSM) analysis was performed comparing surgical outcomes while matching patients with similar characteristics to reduce bias. A total of 4183 patients were included; 621 patients with MIS and 3562 with open approach. Patients in the MIS approach tended to be older (67 months vs. 53 months) and non-Caucasian (12.9% vs. 6.3%) with no differences in other demographics. After 1:1 PSM, 30-day complications after ureteroneocystostomy showed no significant differences in readmission, reoperation, or extended hospital stay. A multivariate analysis found patients with CNS structural abnormalities (such as spina bifida) had 4.5 times greater odds of experiencing a reoperation (p value < 0.05). Similarly, patients with an ASA above two had 2.0 times greater odds of an UTI (p value < 0.05). The cohorts undergoing open and MIS approaches are well matched overall, without profound differences in outcomes overall.

Healthcare-associated urinary tract infections in urology

The purpose of the present review is to report the incidence and characteristics of healthcare-associated urinary tract infections (HAUTIs) in urology with their microbiological and resistance patterns. Urinary tract infections are the main type of healthcare-associated infection in patients hospitalized in a urology ward. Patients admitted to urology departments report a high prevalence of urinary tract catheterization, up to 75% during the hospitalization period, and up to 20% had a urinary catheter before admission. An endourological surgical procedure is another risk factor for HAUTIs. Other risk factors for HAUTIs are the presence of immunosuppression and previous urinary tract infections.

In urological patients, Enterobacterales are the principal causative agent of HAUTIs, and E. coli is the most frequently isolated microorganism. However, there is also a high rate of microorganisms other than E. coli such as Klebsiella spp. and Enterococcus spp. Non-E. coli microorganisms show a higher prevalence in immunosuppressed patients and those with urinary catheters before admission. High resistance patterns are reported in patients with HAUTIs, and ESBL-producing bacteria are frequently described. Moreover, the isolation of multidrug-resistant microorganisms is more common in immunosuppressed patients, those with previous urinary tract infections, and urinary catheters into the upper urinary tract. Treatment must be tailored according to patient characteristics and patient profiles, bearing in mind the ORENUC classification for risk factors (no risk factors (O), recurrent urinary tract infections risk factors (R), extraurogenital risk factors (E), nephropathic disease (N), urological risk factors (U), permanent urinary catheter and non-resolvable urological risk factors (C)).

Prevention and Management of Infectious Complications of Retrograde Intrarenal Surgery

Kidney stone disease (KSD) is a commonly encountered ailment in urologic practice. Urinary tract infection (UTI) is commonly associated with KSD, both as an etiology (e.g., struvite and carbonate apatite stones), and as a complication (i.e., obstructive pyelonephritis and post-operative UTI). Indeed, a significant portion of the economic burden of KSD is skewed toward stones associated with infection. UTI is the most common post-operative complication related to stone intervention with progression to urosepsis as a rare but serious consequence. Risk for infection is influenced by a variety of factors including co-morbid conditions, anatomic abnormalities, prior surgical procedures, and local anti-microbial susceptibility. Understanding these risks and the proper steps to mitigate them is an essential component in reducing post-operative morbidity and mortality. Retrograde intrarenal surgery is routinely used for the treatment of KSD. The objective of this review article is to examine the current literature and guidelines for the prevention and management of stone-related infectious complications associated with retrograde intrarenal surgery. Special attention will be given to the incidence, etiology, and antibiotic prophylaxis choice in the management of stone-related infections. Intraoperative risk mitigation techniques will be discussed in conjunction with the management of post-operative infections. Antibiotic stewardship and the potential benefits of reduced empiric antibiotic treatment will also be discussed.

[Antibiotic prophylaxis for endourological interventions considering antibiotic stewardship]

Perioperative antibiotic prophylaxis in endourology is used to reduce or avoid postoperative surgical site infections and complicated urinary tract infections. Special attention is paid to antibiotic stewardship strategies to avoid the continuing selection of antibiotics and multidrug-resistant uropathogens as well as collateral damage to the microbiome. The individual risk profile, the local resistance situation, the expected pathogen spectrum, the pharmacokinetics and the approval of each substance are important aspects to be considered in the indications and selection of perioperative antibiotic prophylaxis. Furthermore, applicable hygiene regulations and the surgical care of an intervention must be observed.

Antibiotic prophylaxis for urodynamic testing in women: a systematic review

INTRODUCTION AND HYPOTHESIS

Urinary tract infection is the most common complication after urodynamic studies (UDS). Practice guidelines recommend against antibiotic prophylaxis based on an outdated review of the literature, which advised on the premise of "a lack of good quality studies" and based on an assumed low incidence not consistently supported by the literature.

OBJECTIVES

This systematic review aims to update the assessment of the efficacy of antibiotic prophylaxis compared with placebo or no treatment for prevention of urinary tract infection in females over the age of 18 years undergoing UDS.

METHODS

MEDLINE, EMBASE, COCHRANE, DISSERTATIONS, conference proceedings and clinical trial registries were searched for relevant randomized controlled trials. Two authors independently screened and selected articles, assessed these for quality according to Cochrane guidelines and extracted their data.

RESULTS

A total of 2633 records were screened, identifying three relevant randomized controlled trials. The one study that was critically appraised as being the least likely biased showed a statistically significant effect of antibiotic prophylaxis in reducing bacteriuria post UDS in female patients. The other two studies included in the review did not. None of the studies included were powered to show a significant change in the incidence of urinary tract infection following UDS in female patients receiving antibiotic prophylaxis versus no prophylaxis.

CONCLUSIONS

Similar to the 2012 Cochrane review on this subject, this systematic review demonstrated that antibiotic prophylaxis may decrease bacteriuria in women post UDS; however, further research is required to assess its effect on urinary tract infections in this context.

Encrusted Urinary Tract Infections Due to Corynebacteria Species

Introduction

Encrusted pyelitis and cystitis are peculiar disorders characterized by the calcification of the vesical, the pyelic, and/or the ureteral walls. These calcifications are composed of struvite and calcium carbonate‒apatite due to the presence of Corynebacterium urealyticum.

Methods

We have identified the clinical features and outcomes of 17 patients with encrusted pyelitis (n = 15) or encrusted cystitis (n = 2). Diagnosis was based on computed tomography scan and sonography including thickening and calcified lesions of the urinary tract.

Results

The main clinical presentation was suggestive of subacute urinary tract infection with fever and urologic symptoms, mostly gross hematuria. Biologic features were characterized by the presence of struvite crystals and alkaline urine. Acute kidney injury was reported in 70.6% of cases. Predisposing factors were mostly due to urologic background (82.4%) with a history of urologic procedure (71%) and prior exposure to antibiotics (59%). All patients received appropriate antibiotherapy and 15 were treated with topical urinary acidification. A significant reduction of encrusted calcifications was observed in 88% of cases. Renal function improved in 71% of the patients. Nevertheless, poor tolerance of the treatment and side effects were common, affecting 71% of patients, with Gram-negative bacilli urinary tract infections (53%) being the most frequent. At last follow-up, 4 patients (23.5%) progressed to end-stage renal disease and only 1 had a clinical relapse.

Conclusions

Encrusted urinary tract infections are rare, characterized by a severe renal and overall prognosis in the absence of appropriate treatment. Topical urinary acidification and appropriate antibiotherapy are efficient but may be burdened by significant adverse events.

Clinical significance of DJ stent culture in patients with indwelling ureteral stents prior to endourological intervention

BACKGROUND

Ureteral stents are placed to relieve ureteral obstruction in various endourological surgery. As soon as it is inserted it is rapidly colonized by host of microorganism. Culture and sensitivity pattern of these growing microorganism on the stent may provide us an insight to treat postoperative urosepsis in high risk patients with indwelling DJ stents.

MATERIALS AND METHODS

Prospective study between September 2018 and August 2019 with enrollment of 100 patients to determine the ability of urine culture (UC) to predict stent culture (SC) status, to identify associated infectious pathogens with their antibiotic sensitivity patterns and to evaluate the association between SC and post-endourological intervention sepsis.

RESULTS

Colonization of bacteria on stent culture (SC) was identified in 53 out of 100 patients (53%). Most of the organism grown on SC were multidrug resistant and they were resistant to most commonly prescribed antibiotics like fluroquinolones, cephalosporins, and aminoglycosides .These organisms were only sensitive to newer antibiotics. Indwelling time of ureteral stent was directly proportional with SC positivity (p < 0.05). Association of Urine culture at DJ Removal and DJ stent culture was not statistically significant.

CONCLUSION

Very low rates of colonization within 6 weeks after the insertion of stents. Sterile culture of urine does not rule out colonization of the stent. Most of the urinary pathogens as well as the organisms grown on DJ stent are resistant to fluroquinolones and cephalosporins.

The Continuing Plague of Extended-Spectrum β-Lactamase Producing Enterbacterales Infections: An Update

Antimicrobial resistance is a common iatrogenic complication of modern life and medical care. One of the most demonstrative examples is the exponential increase in the incidence of extended-spectrum β-lactamases (ESBLs) production among Enterobacteriaceae, that is, the most common human pathogens outside of the hospital setting. Infections resulting from ESBL-producing bacteria are associated with devastating outcomes, now affecting even previously healthy individuals. This poses an enormous burden and threat to public health. This article aims to narrate the evolving epidemiology of ESBL infections and highlights current challenges in terms of management and prevention of these common infections.

[Bladder cancer - complications related to urinary diversion]

Even today, radical cystectomy with urinary diversion is one of the most complicated procedures in uro-oncology. Particularly in the long-term course, but also perioperatively, problems caused by urinary diversion play a significant role.Perioperatively, gastrointestinal problems such as an ileus, but also infections and early complications of the different anastomoses are most important. While ileus and perioperative infections can usually be treated conservatively, failure of the intestinal or ureteroileal anastomoses require regular surgical revisions.In the long-term follow-up, scarring can lead to chronic obstruction of urinary flow and, in the case of continental urinary diversions, to stone formation. These complications, as well as parastomal hernias in patients with poor conduits, may require further therapy. Functional bowel disorders may impair patients' quality of life significantly.Improved preoperative preparation and accompanying measures during the inpatient stay can significantly reduce non-surgical complications.Cystectomy with therapy-associated morbidity is a classical example of when surgery must be performed at specialised centers to reduce complications perioperatively as well as in follow-up.

Sepsis in urology - where are we now? And where are we going?

CONTEXT

There has been heightened public awareness of the important issue of sepsis in the lay press in recent years with a focus on rapid detection and treatment. Within the field of Urology, how good are we at identifying, preventing and managing sepsis? Review: Reducing the morbidity and mortality associated with sepsis requires a multi-faceted approach including heightening awareness, prevention, early recognition of deterioration, escalation of care when necessary, implementation of antibiotic stewardship and the development of novel anti-microbial treatment strategies.

DISCUSSION

We review some of the aspects of sepsis management within our field that are working effectively and others that could potentially be optimised.

Preoperative urine culture - Is it necessary to prevent infectious complications following ureterorenoscopy?

To prevent postoperative infectious complications, a urinary tract infection should be either diagnostically excluded or treated prior to ureterorenoscopy (URS). URS is a frequently performed endoscopic surgery for urological stone removal. Although the urinary dipstick test represents a simple and cost-effective method to gain information about the presence of urinary tract infection, the prevailing procedure is the more expensive and more time-consuming method of urine culture. The aim of this retrospective single-center study was to compare two strategies of perioperative prophylaxes prior to URS and to evaluate their impact on postoperative infectious complications: I) Obtaining a urine culture in every patient prior to URS or II) only in case of a positive dipstick test. Therefore, we retrospectively compared 201 patients in two cohorts undergoing URS. In one cohort a urine culture was obtained only in case of a positive dipstick test of midstream urine sample and in the second cohort a urine culture was prepared for every patient regardless of the dipstick's test results. The study's end point was determined as "infectious failure" (IF), if more than one of the following criteria are fulfilled: postoperative fever, elevation of inflammation laboratory values, significant prolongation of hospital stay and readmission within short-notice. Simple and multiple logistic regressions were performed to evaluate the influence of patient characteristics and preoperative urine analysis strategy on the occurrence of IF. Patients with a score of the American Society of Anesthesiologists (ASA) > 2 had a nearly statistically higher risk (p = .09) to develop an IF than healthier patients with an ASA score ≤ 2. Prestenting was determined as a significant predictive factor (p = .04) for a postoperative IF. No difference in patients with or without IF was detected regarding the two preoperative urine analysis strategies. Sensitivity of dipstick test was 87.5% and the negative predictive value was 89.66%. We found that a negative urine dipstick test result obtained prior to URS eliminated the need for urine culturing in predicting postoperative infectious complication. This approach can reduce preoperative preparation-time and costs without affecting postoperative complication outcomes.

Infectious complications of prostate biopsy: winning battles but not war

BACKGROUND

Prostate biopsy is a standard tool for diagnosing prostate cancer, with more than 4 million procedures performed worldwide each year. Infectious complications and economic burden are reportedly rising with continued use of trans-rectal ultrasound-guided biopsy, despite the transperineal approach being associated with less infectious complications.

OBJECTIVE AND METHODS

In this review, the contemporary literature on pathophysiology, epidemiology, risk factors, causative organisms and emerging approaches for prevention of infectious complications are outlined.

RESULTS

Management of infectious complications after TRUSB has caused significant financial burden on health systems. The most frequent causative agents of infectious complications after prostate biopsy are Gram-negative bacilli are particularly concerning in the era of antibiotic resistance. Increasing resistance to fluoroquinolones and beta-lactam antibiotics has complicated traditional preventive measures. Patient- and procedure-related risk factors, reported by individual studies, can contribute to infectious complications after prostate biopsy.

CONCLUSIONS

Recent literature shows that the transrectal ultrasound-guided prostate biopsy results in higher infectious complication rate than the transperineal prostate biopsy. NAATs, recently introduced technique to detect FQr may detect all antibiotic-resistant rectal microbiota members-included MDRs-although the technique still has limitations and economical burdens. Transient solutions are escalating antibiotic prophylaxis and widening the indications for TPB.

Antibiotic resistance, hospitalizations, and mortality related to prostate biopsy: first report from the Norwegian Patient Registry

BACKGROUND

A 68-year-old man died of cerebral arterial embolism 6 days after transrectal prostate biopsy with a single p.o. dose of trimethoprim sulfamethoxazole (TMP-SMX) as prophylaxis. The case precipitated analysis of local antibiotic resistance and complication rates.

MATERIALS AND METHODS

Data on E. coli resistance from Oslo University Hospital and national data on hospitalizations and mortality after biopsy were retrieved from local microbiology files and the Norwegian Patient Registry (NPR) 2011-2017.

RESULTS

Urine E. coli resistance against TMP-SMX increased from 35% in 2013 to more than 60% in 2015. For ciprofloxacin, the resistance increased from 15% in 2013 to about 45% in 2016. The highest annual E. coli resistance in blood cultures for TMP-SMX and ciprofloxacin was 37% and 28%, respectively. 10% of patients were hospitalized with a diagnosis of infection within the first 60 days after biopsy and there was a relative increase in mortality rate of 261% within the first 30 days. Due to the severity of the figures, the story and the NPR data were published in Norway's leading newspaper and were succeeded by a series of chronicles and commentaries.

CONCLUSIONS

Several critical points of the biopsy procedure were not performed according to current standards. We believe that the patient might have died of septic embolism after biopsy. As a result of the findings and the debate, local practice was changed from transrectal to transperineal prostate biopsies.

Role of cultural analysis in patients with indwelling ureteral stent submitted to ureteroscopy for stones

BACKGROUND

Aim of our study is to analyze the incidence of postoperative infectious complications and to assess its predictors in patients with indwelling ureteral stent treated with ureteroscopy (URS).

METHODS

We retrospectively evaluated data of patients treated with URS from January 2017 to July 2018 at our center. We included 88 consecutive patients with available stent culture (SC) and urine culture (UC). Cefoxitin 2 g IV was given as prophylaxis in all patients with negative preoperative UC; otherwise, the choice of antibiotic was based on antibiogram. Ureteral stent was removed before URS procedure and analyzed. No postoperative antibiotic was given. Multivariable logistic regression analysis was built to assess preoperative predictors of postoperative infectious complications.

RESULTS

Nineteen patients (22%) developed postoperative infectious complications and fever was the most common one. E. faecalis, which is not responsive to common prophylaxis schemes in force in our institution, was the most frequent pathogen isolated. Overall, 26% of patients were found to have a discordance between SC and UC. At multivariable logistic regression analysis preoperative SC positivity (Odds Ratio [OR]: 11.00, 95% Confidence Interval [CI]:1.08-111.41, P=0.04) was the only significant predictor of postoperative infectious complications.

CONCLUSIONS

About one to five patients treated with URS developed an infectious complication and E. faecalis and E. coli were the most frequent pathogen isolated. A positive SC is the only independent risk factor for postoperative infection: consequently, an early SC analysis could allow a prompt antibiotic therapy in all patients with positive SC even if mildly symptomatic.

Prevention of healthcare-associated infections (HAIs) in a surgical urology ward: observational study-analysis of the problem and strategies for implementation

PURPOSE

Our purpose is to present the results of our working group, with a view to reduce the incidence and improve the management of healthcare-associated infections (HAIs) in a urology ward.

METHODS

The study consists on an observational database designed with the view to analyse the incidence and characteristics of HAIs in Urology. Based on the results obtained, a critical evaluation was carried out and specific measures put in place to reduce HAIs. Finally, the impact and results of the implemented measures were periodically evaluated.

RESULTS

The incidence of HAIs in urology decreased from 6.6 to 7.3% in 2012-2014 to 5.4-5.8% in 2016-2018. In patients with immunosuppression the incidence of HAIs decreased from 12.8 to 18% in 2012-2013 to 8.1-10.2% in 2017-2018, in those with a previous urinary infection fell from 13.6 to 4.8%, in those with a urinary catheter prior to admission from 12.6 to 10.8%, and in patients with a nephrostomy tube from 16 to 10.9%. The effect of the protocol also demonstrated a reduction in the percentage of patients with suspicion of HAIs for whom no culture was taken, from 6% in 2012 to zero in 2017 and 2018. Moreover, the implementation of protocols for empirical treatment has reduced the incidence of patients experiencing inadequate empirical antimicrobial therapy from 20 to 8.1%.

CONCLUSION

It is essential to monitor the incidence of HAIs, and preventive measures play a useful role in reducing the rate of infection and in optimising their management.

Clinical characteristics of postoperative febrile urinary tract infections after ureteroscopic lithotripsy

Purpose

Ureteroscopic lithotripsy (URS) is gaining popularity for the management of ureteral stones and even renal stones, with high efficacy and minimal invasiveness. Although this procedure is known to be safe and to have a low complication rate, febrile urinary tract infection (UTI) after URS is not rare. Therefore, we aimed to analyze the risk factors and causative pathogens of febrile UTI after URS.

Materials and Methods

Between January 2013 and June 2015, 304 patients underwent URS for ureteral or renal stones. The rate of postoperative febrile UTI and the causative pathogens were verified, and the risk factors for postoperative febrile UTI were analyzed using logistic regression analysis.

Results

Of 304 patients, postoperative febrile UTI occurred in 43 patients (14.1%). Of them, pathogens were cultured in blood or urine in 19 patients (44.2%), and definite pathogens were not identified in 24 patients (55.8%). In patients with an identified pathogen, Pseudomonas aeruginosa had the highest incidence. Multivariate analysis showed that the operation time (p<0.001) was an independent risk factor for febrile UTI after URS. The cut-off value of operation time for increased risk of febrile UTI was 70 minutes.

Conclusions

Overall, febrile UTI after URS occurred in 14.1% of patients, and the operation time was an independent predictive factor for this complication. Considering that more than 83.7% of febrile UTIs after URS were not controlled with fluoroquinolones, it may be more appropriate to use higher-level antibiotics for treatment, even in cases with unidentified pathogens.

Surgical site infection after trans urethral resection of the prostate (TURP): 2008-2013 French national SSI surveillance ISO-RAISIN

Objective

To describe surgical site infection (SSI) after transurethral resection of prostate (TURP) from the French national database.

Methods

A national SSI surveillance system was implemented in 1999. Each year, the network included urology departments that included at least two months plus one month follow-up, or at least 100 consecutive targeted surgical procedures. A dataset of patients who underwent urology procedures during the six-year period 2008-2013 was made available. SSI diagnosis was made according to standardised CDC criteria. Descriptive analyses were performed using SAS software version 9.4.

Results

A total of 12,897 TURPs were performed by 89 urology departments. The crude incidence SSI rate was 2.43 (95% confidence interval = 2.16-2.79). The mean delay for diagnosis was 11.9 ± 8.9 days. The treatment of the SSI required a new surgical intervention in 1.35%. In the multilevel multivariate analysis, ASA score and duration of follow-up were the only parameters correlated with the SSI rate.

Conclusions

On more than 12,000 TURPs surveyed, the SSI rate was 2.43. ASA score and duration of follow-up were the only parameters correlated with the SSI rate.

Effectiveness of a transrectal prostate needle biopsy protocol with risk-tailored antimicrobials in a veterans cohort

PURPOSE

To prospectively implement a prostate biopsy protocol to identify high-risk patients for bleeding or infectious complications and use risk-tailored antimicrobials, patient education, and postbiopsy monitoring with the objective of reducing complications.

MATERIALS AND METHODS

Overall, 637 consecutive patients from June 2014 to August 2016 underwent prostate biopsy at our Veterans Affairs hospital. In the protocol cohort, patients were screened before biopsy and prophylaxis was tailored (high risk = ceftriaxone; low risk = ciprofloxacin). Patients were also provided additional education about bleeding and monitored for up to 1-hour. We defined complications as any deviation from normal postbiopsy activities. Comparisons were made between preprotocol/postprotocol cohorts. Logistic regression was used to identify risk factors for admissions or complications.

RESULTS

Median age was 67 years (IQR: 64-69, P = 0.29) in both groups (pre n = 334, post n = 303). Preprotocol, 99% patients received ciprofloxacin; postprotocol, 86% received ciprofloxacin and 14% received ceftriaxone (P<0.001). There were no deaths in either group. There were decreased 30-day complication and hospitalization rates in the postprotocol group (pre 15% vs. post 8.9%, P = 0.025; 3.3% vs. 1.0%, P = 0.048). Sepsis occurred in 2 patients preprotocol and no patients postprotocol. Postprotocol group was associated with decreased 30-day complications on multivariable logistic regression (OR = 0.58, 95% CI: 0.35-0.95, P = 0.031).

CONCLUSIONS

A screening protocol before prostate biopsy is a targeted approach for selecting prophylactic antimicrobials and closer monitoring postbiopsy for bleeding. Our results suggest that the protocol has a favorable effect on complication and hospitalization rates.

Tailored perioperative antimicrobial prophylaxis in urological surgery: myth or reality?

PURPOSE OF REVIEW

The controversies surrounding perioperative antimicrobial prophylaxis (AMP) are about the use and especially misuse of antibiotics. The overall lack of evidence to facilitate a rational perioperative AMP policy in urological surgery and the postoperative infectious complications remain a challenge. Therefore, a basic tool to aid decision-making would be useful. A model based on the patients' risk factors, the level of contamination and grading of surgical procedures is discussed.

RECENT FINDINGS

A series of studies have shown that infectious complications and healthcare-associated infections remain consistently at an average of 10%, with a great variation in frequency dependent on the patients' preoperative status and the type, severity and contamination level of the surgical procedure. Preoperative patient assessment and preparation are key factors for well tolerated surgery and recovery. Adherence to the guidelines appears to reduce both the prescription of antimicrobials and the total costs without risking the patient outcome. Several studies of a series of interventions such as cystoscopy, endoscopic stone surgery and selected clean-contaminated interventions give support to the model. Bacteriuria, upgrading the patient to the contaminated level, requires preoperative control.

SUMMARY

The discussed model assists the urologists in decision-making on perioperative AMP and contributes to a responsible use of antibiotics.

Surgical Complications of Urinary Diversion

Urinary diversion (UD) with an intestinal segment has significant risks of short- and long-term complications. With modern reporting criteria, understanding of the true prevalence and spectrum of these complications has improved. Methods to minimize early postoperative complications include enhanced recovery pathways, restricted intraoperative fluid protocols, and referral to high-volume centers. With long-term follow-up after UD, the risk of complications steadily rises. Late surgical complications include ureterointestinal anastomotic strictures, urolithiasis, and stomal issues. Patients with UDs require close surveillance to monitor for anatomic, infectious, and metabolic complications and surgeons who perform UD should be aware of the risk and timing of postoperative complications.

The Continuing Plague of Extended-spectrum β-lactamase-producing Enterobacteriaceae Infections

Antimicrobial resistance is a common iatrogenic complication of modern life and medical care. One of the most demonstrative examples is the exponential increase in the incidence of extended-spectrum β-lactamases (ESBLs) production among Enterobacteriaceae, which is the most common human pathogens outside of the hospital settings. Infections resulting from ESBL-producing bacteria are associated with devastating outcomes, now affecting even previously healthy individuals. This development poses an enormous burden and threat to public health. This paper aims to narrate the evolving epidemiology of ESBL infections, and highlight current challenges in terms of management and prevention of these common infections.

Evaluation of the risk factors associated with the development of post-transurethral resection of the prostate persistent bacteriuria

Objectives

To determine the preoperative, intraoperative and postoperative risk factors that influence the development of persistent post-transurethral resection of the prostate (TURP) urinary tract infection (UTI) defined as pyuria and/or bacteriuria remaining for 3 weeks after surgery.

Patients and methods

This is a prospective study including 100 patients scheduled for TURP. Urine analysis and culture was performed immediately after catheter removal, then at 1 and 3 weeks postoperatively, and the results were correlated to various preoperative, intraoperative and postoperative potential risk factors to detect any significant relation to persistent UTI.

Results

There was a statistically significant relationship between bacteriuria and the following risk factors: old age, past history of diabetes mellitus, large prostatic size, positive preoperative urine analysis and culture, preoperative catheter use, previous urological interventions, large size of sheath, long duration of operation, postoperative catheter events and postoperative manual wash.

Conclusions

Many risk factors have been found to contribute to the development of post-TURP UTI and avoiding these factors can enhance recovery of patients undergoing TURP.

[Prudent use of antimicrobial prophylaxis : Prevention of increasing antibiotic resistance]

BACKGROUND

The use of peri-operative antimicrobial prophylaxis during urological procedures to prevent postoperative complications is very common.

OBJECTIVES

What kind of recommendations for reasonable use of peri-operative antimicrobial prophylaxis during urological procedures to prevent increasing antibiotic resistance and postoperative complications exist?

METHODS

Review of evidence-based recommendations from literature and current Guidelines of the EAU.

RESULTS

For urological procedures there are evidenced-based recommendations for using antimicrobial prophylaxis, although the evidence is not always sufficiently high. For endourological procedures it is recommended to use Cephalosporines group 2 (or 3), Aminopenicillin/Beta-lactamase inhibitor or Cotrimoxazole. For transrectal core biopsy of the prostate, depending on the risk, Fluoroquinolones, Cotrimoxazole or targeted prophylaxis are recommended. For laparoscopic or open procedures, partly optional, Cephalosporines group 2 (or 3), Aminopenicillin/Beta-lactamase inhibitor or Cotrimoxazole and for a cystectomy with opening of the intestinal tract Cephalosporines group 2 or an Aminopenicillin/Beta-lactamase inhibitor, together with Metronidazole are recommended.

CONCLUSIONS

Using prudent peri-operative antimicrobial prophylaxis patient surgical risk factors as well as the expected spectrum of pathogens and the local resistance profile should be considered. Perioperative antibiotic prophylaxis on the one hand aims at preventing postoperative infections, and on the other hand plays an important role in the total antibiotic consumption. It is therefore a pivotal aspect of "Antimicrobial Stewardship" strategies in the health-care system.

Antibiotic Prophylaxis in Radical Prostatectomy: Comparison of 2-Day and More than 2-Day Prophylaxis

The efficacy of antibiotic prophylaxis in radical prostatectomy (RP) remains to be established. We retrospectively compared the occurrence of perioperative infections after RP between the 2 different antibiotic protocols. This study involved 428 cases of laparoscopic radical prostatectomy (LRP). After excluding patients who had no perioperative urine culture data, 313 consecutive patients who underwent LRP for prostate carcinoma were classified into 2 groups according to the duration of antimicrobial prophylaxis. To group 1 (153 patients), a second-generation cephalosporin was administered for less than 2 days, whilst the remaining 160 patients in group 2 were administered the drug for more than 2 days. The overall incidence of postoperative bacteriuria was 50.8%, being significantly higher in group 1 (56.9%) than in group 2 (45%). The incidence of surgical site infection (SSI) was significantly higher in group 1 (5.2%) than in group 2 (0.6%). Multivariate analysis revealed that old age, duration of antibiotics for more than 2 days, and duration of Foley catheter placement were independently associated with postoperative infectious complications (all, P < 0.05). Multivariate analysis revealed that duration of antibiotics for more than 2 days, duration of Foley catheter placement, and duration of surgical drain placement were independently associated with postoperative SSI (all, P < 0.05). The incidence of postoperative bacteriuria and SSI were higher in patients who received antibiotics for a short duration. Based on our results, we demonstrated that the outcome of postoperative infectious complications is dependent on old age, short antibiotic administration duration, and prolonged Foley catheterization. Prolonged drain placement is associated with SSI, whilst a longer duration of antibiotics use and prolonged Foley catheterization are associated with a decrease in the incidence of SSI.

Nursing Diagnosis Risk for Delayed Surgical Recovery (00246): Concept Clarification and Definition of Empirical Referents

PURPOSE

To clarify the concept of risk for delayed surgical recovery (00246) and to define the empirical referents for identification of predictive factors of delay in recovery.

METHOD

A concept analysis was developed based on the eight steps proposed by Walker and Avant.

RESULTS

Defining attributes were determined and antecedents and consequents identified. Cases were proposed cases and empirical referents established.

CONCLUSION

The results provided evidences and instrumentalize empirical referents, which may support an accurate nursing diagnosis.

IMPLICATIONS FOR NURSING PRACTICE

This clarification may contribute to the return to daily activities in a shortest time and promote surgical safety of the patient.

OBJETIVOS

Clarificar o conceito de risco de recuperação cirúrgica retardada (00246) e definir as referências empíricas para a identificação dos fatores preditores de atraso na recuperação. MÉTODO: Foi desenvolvida a análise de conceito desse fenômeno, com base nas oito etapas propostas por Walker e Avant.

RESULTADOS

Foram determinados os atributos definidores e identificados seus antecedentes e consequentes. Foram propostos casos e estabelecidas as referências empíricas. CONCLUSÕES: Os resultados proporcionaram evidências e instrumentalização das referências empíricas, o que pode auxiliar na acurácia do diagnóstico de enfermagem. IMPLICAÇÕES PARA A PRÁTICA DE ENFERMAGEM: Esta clarificação poderá contribuir para o retorno do paciente às atividades diárias em um tempo mais curto e promoção da segurança cirúrgica.

[Community acquired urinary tract infections - association with risk factors : Changes in causative organisms and resistance over time]

BACKGROUND

Published studies on community-acquired urinary tract infections (UTI) often do not link microbiological findings with clinical risk factors and patient data.

MATERIALS AND METHODS

We retrospectively correlated clinical findings of all patients with UTI of a urological outpatient clinic with the respective microbiological analysis of their urine samples over 2 periods of time: (A: 2005-2006 and B: 2011-2012). Patients were stratified to the following risk groups: uncomplicated cystitis, diabetes mellitus type 2, nursing home resident, prostatitis/epidydimitis, permanent catheter.

RESULTS

The incidence of Escherichia coli (p < 0.001) and proteus (p < 0.001) significantly decreased from period A to B, while enterococci (p = 0.003) and staphylococci (p < 0.001) significantly increased. Antibiotic sensitivity to fosfomycin (p < 0.001), doxycycline (p < 0.001), nitrofurantoin (p < 0.001), and nitroxoline increased (p < 0. 001) and sensitivity to amoxicillin (p < 0.001) and gentamicin decreased (p < 0.001). Patients with a permanent catheter had significantly poorer sensitivity rates (50% and less) for almost all antibiotics tested compared to the overall group. The risk of a UTI with 3MRGN or MRSA bacteria was significantly higher for catheter carriers and nursing home residents.

CONCLUSIONS

Empiric antibiotic first-line therapy with nitrofurantoin and fosfomycin for uncomplicated community acquired UTIs are well indicated in conformity with guidelines. The accumulation of multiresistant pathogens in patients with a permanent bladder catheter requires restrictive use of any permanent catheter drainage.

How to Use Antimicrobial Prophylaxis in Urological Procedures

A revision of clinical practice in terms of antimicrobial prophylaxis is urgently needed starting from: (1) obtaining information about local pathogen profiles and antimicrobial resistance, (2) evaluating all patient-related risk factors for the development of infectious complications, (3) and prescribing antimicrobials according to the principles of the European Association of Urology guidelines.

Antibiotic prophylaxis may not be necessary in patients with asymptomatic bacteriuria undergoing intradetrusor onabotulinumtoxinA injections for neurogenic detrusor overactivity

Many of the patients undergoing intradetrusor onabotulinumtoxinA injections for refractory neurogenic detrusor overactivity (NDO) present with chronic bacteriuria. In these patients, antibiotic prophylaxis has been widely recommended since bacteriuria might impair treatment efficacy and cause urinary tract infections (UTI) but the evidence is limited. The aim of this study was to evaluate if an antibiotic prophylaxis is needed in patients with asymptomatic bacteriuria undergoing intradetrusor onabotulinumtoxinA injections. Between 06/2012 and 12/2014, a consecutive series of 154 patients undergoing a total of 273 treatment cycles were prospectively evaluated. Before treatment urine samples were collected, patients with no clinical signs for UTI underwent onabotulinumtoxinA injections, no antibiotic prophylaxis was given. Asymptomatic bacteriuria was found in 73% (200/273 treatments). Following treatment, UTI occurred in 5% (9/200) and 7% (5/73) of patients with and without bacteriuria, respectively. Intradetrusor onabotulinumtoxinA injections were clinically and urodynamically successful in 70% (192/273). There was no association between bacteriuria and treatment-related adverse events (odds ratio 0.64, 95% CI 0.23–1.81, p = 0.4) nor between bacteriuria and therapy failure (odds ratio 0.78, 95% CI 0.43–1.43, p = 0.4). Thus, we conclude that antibiotic prophylaxis needs to be critically reconsidered in patients undergoing intradetrusor onabotulinumtoxinA injections, especially taking into account the alarming antibiotic resistance worldwide.

A case of acute onset postoperative gas gangrene caused by Clostridium perfringens

Background

Gas gangrene is a necrotic infection of soft tissue associated with high mortality rates. We report a case of postoperative gas gangrene with very acute onset and rapid progression of symptoms. To our knowledge, this case is the most acute onset of postoperative gas gangrene ever reported.

Case presentation

A 65-year-old Japanese female patient developed a shock state 16 h after radical cystectomy with ileal conduit reconstruction. Two days after the operation, she was transferred to the intensive care unit because of deterioration in her respiratory and circulatory condition. Soon after moving her to the ICU, a subcutaneous hemorrhage-like skin rash appeared and extended rapidly over her left side. Blood tests performed on admission to the ICU indicated severe metabolic acidosis, liver and renal dysfunction, and signs of disseminated intravascular coagulation. Suspecting necrotizing fasciitis or gas gangrene, we performed emergency fasciotomy. Subsequently, multidisciplinary treatment, including empirical therapy using multiple antibiotics, mechanical ventilation, hyperbaric oxygen therapy, polymyxin B-immobilized fiber column direct hemoperfusion, and continuous hemodiafiltration, was commenced. Culture of the debris from a wound abscess removed by emergency fasciotomy detected the presence of Clostridium perfringens. We hypothesized that the source of infection in this case may have been the ileum used for bladder reconstruction. Although the initial treatment prevented further clinical deterioration, she developed secondary infection from the 3rd week onward, due to infection with multiple pathogenic bacteria. Despite prompt diagnosis and intensive therapy, the patient died 38 days after the operation.

Conclusion

Although the patient did not have any specific risk factors for postsurgical infection, she developed a shock state only 16 h after surgery due to gas gangrene. Our experience highlights the fact that physicians should be aware that any patient could possibly develop gas gangrene postoperatively.

Preoperative risk assessment in children undergoing major urologic surgery

BACKGROUND

Preoperative risk assessment is standard in adult surgery, but often these risk assessments cannot be applied to children. Previous studies emphasize the differences between pediatric and adult populations and variability by surgical procedure types.

OBJECTIVE

We investigated preoperative risk factors for several outcomes in children undergoing major urologic surgery using the National Surgical Quality Improvement Program (NSQIP) Pediatric.

STUDY DESIGN

A cohort of 2-18-year-old children who underwent major urologic surgery was identified by Current Procedure Terminology (CPT) codes in the 2012-2013 NSQIP-Pediatric. The NSQIP-Pediatric prospectively collects standardized and validated data from 61 sites on preoperative, operative, and 30-day postoperative variables. Urologic surgeries involving dissection of the peritoneal or extraperitoneal space were included. Patients undergoing pure genitourinary surgery were analyzed separately from those with bowel involvement to improve homogeneity. Postoperative outcomes including hospital length of stay and 30-day infective complications, non-infective complications, unplanned reoperation and readmissions were evaluated by fitting multivariable logistic regression models.

RESULTS

A total of 2601 patients were identified, of whom 399 (15.3%) underwent bowel-involved surgery and 2202 (84.7%) underwent pure genitourinary surgery. Patients in the bowel-involved group were significantly older with more comorbidity. Postoperative complications, unplanned return to operating room, hospital length of stay and readmission rates were all significantly worse in the bowel-involved group. In the pure genitourinary group, older age and white race improved some outcomes, while American Society of Anesthesia (ASA) class ≥ 3, total operation time, obesity, pulmonary risk factors, preoperative renal disease, developmental delay, structural central nervous system abnormality, and supplemental nutrition independently predicted at least one negative outcome (Table).

DISCUSSION

Consistent with previous research on reconstructive surgery, we identified a significant difference in patient age, surgery details, comorbidity, and increased complications for patients undergoing urologic surgery with bowel involvement compared with pure genitourinary surgery. Focusing solely on pure genitourinary surgery, we identified predictors of outcomes. Identification of these factors in pediatric urology is novel and only recently possible with the availability of the NSQIP-Pediatric.

CONCLUSION

Using the NSQIP-Pediatric, we confirmed differences in complication rates for major urologic surgeries, with and without bowel involvement in a national sample. Preoperative risk characteristics were also identified for patients undergoing pure genitourinary surgery. Further investigation into these relationships is necessary to better elucidate their clinical significance with the goal of improving surgical planning, postoperative care, and family counseling.

Osteoblast integration of dental implant materials after challenge by sub-gingival pathogens: a co-culture study in vitro

Sub-gingival anaerobic pathogens can colonize an implant surface to compromise osseointegration of dental implants once the soft tissue seal around the neck of an implant is broken. In vitro evaluations of implant materials are usually done in monoculture studies involving either tissue integration or bacterial colonization. Co-culture models, in which tissue cells and bacteria battle simultaneously for estate on an implant surface, have been demonstrated to provide a better in vitro mimic of the clinical situation. Here we aim to compare the surface coverage by U2OS osteoblasts cells prior to and after challenge by two anaerobic sub-gingival pathogens in a co-culture model on differently modified titanium (Ti), titanium-zirconium (TiZr) alloys and zirconia surfaces. Monoculture studies with either U2OS osteoblasts or bacteria were also carried out and indicated significant differences in biofilm formation between the implant materials, but interactions with U2OS osteoblasts were favourable on all materials. Adhering U2OS osteoblasts cells, however, were significantly more displaced from differently modified Ti surfaces by challenging sub-gingival pathogens than from TiZr alloys and zirconia variants. Combined with previous work employing a co-culture model consisting of human gingival fibroblasts and supra-gingival oral bacteria, results point to a different material selection to stimulate the formation of a soft tissue seal as compared to preservation of osseointegration under the unsterile conditions of the oral cavity.

The complex epidemiology of extended-spectrum β-lactamase-producing Enterobacteriaceae

ABSTRACT 

Antimicrobial resistance is a growing worldwide iatrogenic complication of modern medical care. Extended-spectrum β-lactamases have emerged as one of the most successful resistance mechanisms, limiting our therapeutic options to treat various human infections. The dissemination of these enzymes to the community probably signifies an irreversible step. This paper will review the evolution of human infections associated with extended-spectrum β-lactamase-producing organisms in the past 20 years, and will present and discuss the current challenges, controversies, debates and knowledge gaps in this research field.

[Perioperative antibiotic prophylaxis for major urological interventions]

BACKGROUND

With the emergence of multidrug resistant bacteria reaching alarming levels and the year-long developmental void of new antimicrobial drugs, the rational and appropriate use of antibiotics is of paramount importance. The number of surgical interventions is still increasing so that surgical site infections represent the most frequent form of nosocomial infection.

METHOD

Fundamental hygiene measures as well as aseptic and tissue-preserving surgical techniques are supported by perioperative antibiotic prophylaxis to prevent surgical site infections. This is accomplished by a single short-term antibiotic administration at the beginning of or at the latest during the operative intervention. Due to its contribution to the total consumption of antibiotics and when misused to the development of multidrug resistance, an appropriate and controlled perioperative antibiotic prophylaxis is mandatory.

INDICATION

The indications for perioperative antibiotic prophylaxis depend on the type of surgical procedure, the classification of operative wounds as well as individual patient and operation-related risk factors.

A prospective Korean multicenter study for infectious complications in patients undergoing prostate surgery: risk factors and efficacy of antibiotic prophylaxis

This multicenter study was undertaken to determine the efficacy of antibiotic prophylaxis and identify the risk factors for infectious complications after prostate surgery in Korean patients. A total of 424 patients who underwent surgery of the prostate were reviewed. All patients underwent urinalysis and urine culture preoperatively and postoperatively. Efficacy of antibiotic prophylaxis and risk factors for infectious complications were investigated. Infectious complications were observed in 34.9% of all patients. Factors independently associated with infectious complications were diabetes mellitus (adjusted OR, 1.99; 95% CI, 1.09-3.65, P=0.025) and operation time (adjusted OR, 1.08; 95% CI, 1.03-1.13, P=0.004). Clinicians should be aware of the high risk of infectious complications in patients with diabetes and those who undergo a prolonged operation time. Neither the type nor duration of prophylactic antibiotics resulted in differences in infectious complications.