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Roger PM, Bastian S, Breurec S, Saliège M, Blanchet P, Brureau L. Simplified antibiotic guidelines in urology are associated with decreased multidrug-resistant Enterobacterales. Infect Dis Now 2023; 53:104763. [PMID: 37467843 DOI: 10.1016/j.idnow.2023.104763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE A simplified therapeutic guideline (STG) was established in our urology ward in 2019 for urinary infections. Our aim was to describe the level of physician adherence to STG and the impact of a limited number of antibiotic compounds on the rate of multidrug-resistant (MDR) bacteria. As guidelines should improve patient care, unfavorable outcomes were also reported. METHODS The STG for community-acquired and nosocomial urinary infections, including six antibiotics, was established in November 2019 and has been officially applied since January 2020. Treatment duration has to be ≤14 days. We conducted a before-after study to measure physician adherence to the STG for bacteremia treatment between January 2017 and December 2022. Adherence was defined as exclusive use of STG antibiotics. All isolated bacteria from blood cultures were recorded, including MDR Enterobacterales, defined as AmpC β-lactamase- or ESBL-producing strains. Unfavorable outcomes were defined as uncontrolled infection, a second surgical procedure, ICU requirement, and/or death. RESULTS Seventy-six cases of bacteremia occurred between January 2017 and December 2019, and ninety between January 2020 and December 2022. The main comorbid condition was urological cancer (46%). The main reason for surgery was ureteral stent (32%). Antibiotic management in accordance with STG increased from 18% to 52%, p < 0.001, and treatments > 14 days decreased from 53% to 28%, p < 0.001. MDR Enterobacterales bacteremia was reduced from 52% to 35%, p = 0.027. The rate of unfavorable outcomes was unchanged. CONCLUSION STG adherence in urology was satisfactory and associated with reduced MDR Enterobacterales bacteremia.
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Affiliation(s)
- Pierre-Marie Roger
- Infectiologie, Centre Hospitalier Universitaire de Guadeloupe, France; Faculté de Médecine, Université des Antilles, Pointe-à-Pitre, Guadeloupe, France.
| | - Sylvaine Bastian
- Service de Microbiologie, Centre Hospitalier Universitaire de Guadeloupe, France
| | - Sébastien Breurec
- Faculté de Médecine, Université des Antilles, Pointe-à-Pitre, Guadeloupe, France; Service de Microbiologie, Centre Hospitalier Universitaire de Guadeloupe, France; Laboratoire Interaction des Ecosystèmes Microbiens, Institut Pasteur de Guadeloupe, France; Centre d'Investigation Clinique 1424, INSERM, France
| | - Marion Saliège
- Pharmacie, Centre Hospitalier Universitaire de Guadeloupe, France
| | - Pascal Blanchet
- Faculté de Médecine, Université des Antilles, Pointe-à-Pitre, Guadeloupe, France; Urologie, Centre Hospitalier Universitaire de Guadeloupe, France; Institut de Recherche en Santé, Environnement et Travail, Université de Rennes, Inserm, EHESP, UMR-S 1085, F-97110 Pointe-à-Pitre, France
| | - Laurent Brureau
- Faculté de Médecine, Université des Antilles, Pointe-à-Pitre, Guadeloupe, France; Urologie, Centre Hospitalier Universitaire de Guadeloupe, France; Institut de Recherche en Santé, Environnement et Travail, Université de Rennes, Inserm, EHESP, UMR-S 1085, F-97110 Pointe-à-Pitre, France
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Chua KJ, Patel HV, Srivastava A, Doppalapudi SK, Lichtbroun B, Patel N, Elsamra SE, Singer EA, Jang TL, Ghodoussipour SB. Annual trends of cystectomy complications: A contemporary analysis of the NSQIP database. Urol Oncol 2023; 41:390.e19-390.e26. [PMID: 37246134 DOI: 10.1016/j.urolonc.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/19/2023] [Accepted: 03/24/2023] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Despite significant morbidity, radical cystectomy (RC) is standard of care for muscle invasive bladder cancer, certain high-risk nonmuscle invasive tumors and after failure of intravesical or trimodal therapy. Modern efforts have hastened the recovery after this surgery without impact on overall complication rates. Our primary aim was to examine changes in complication rates of RC over time. METHODS The National Surgical Quality Improvement Program database included 11,351 RC from 2006 to 2018 for nondisseminated bladder cancer. Baseline characteristics and complication rates were studied across time periods: 2006 to 2011, 2012 to 2014, and 2015 to 2018. Thirty-day complications, readmissions, and mortality were identified. RESULTS Overall complication rates decreased over time (56.5%, 57.4%, 50.6%, P < 0.01). Infectious complications were stable, including UTIs (10.1%, 8.8%, 8.3% respectively, P = 0.11) and sepsis (10.4%, 8.8%, 8.7% respectively, P = 0.20). On multivariable analysis, ASA≥3 (OR 1.399, 95% CI 1.279-1.530) was associated with increased complications, while procedures in 2015 to 2018 (OR 0.825, 95% CI 0.722-0.942), laparoscopic/robotic approach (OR 0.555, 95%CI 0.494-0.622), and ileal conduit (OR 0.796, 95% CI 0.719-0.882) were associated with decreased complication rates. Other outcomes of interest included mean length of stay (LOS), which decreased over time (10.5, 9.8, 8.6 days, respectively, P < 0.01) and readmission (20.0%, 21.3%, 21.0%, respectively, P = 0.84) and mortality rates were stable (2.7%, 1.7%, 2.0%, respectively, P = 0.13). CONCLUSION Decreased early complications and LOS after RC over time may reflect beneficial effects of recent advances in bladder cancer treatment such as enhanced recovery after surgery protocols and minimally invasive techniques. Further opportunities to improve long term outcomes, readmissions and infection rates are needed.
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Affiliation(s)
- Kevin J Chua
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Hiren V Patel
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Arnav Srivastava
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | | | - Benjamin Lichtbroun
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Nikhil Patel
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Sammy E Elsamra
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Eric A Singer
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Division of Urologic Oncology, The Ohio State Comprehensive Cancer Center, Columbus, OH
| | - Thomas L Jang
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Saum B Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ.
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Houenstein HA, Jing Z, Elsayed AS, Ramahi YO, Stöckle M, Wijburg C, Hosseini A, Wiklund P, Kim E, Kaouk J, Dasgupta P, Khan MS, Wagner AA, Syed JR, Peabody JO, Badani K, Richstone L, Mottrie A, Maatman TJ, Balbay D, Redorta JP, Rha KH, Gaboardi F, Rouprêt M, Aboumohamed A, Hussein AA, Guru KA. Analysis of Complications After Robot-Assisted Radical Cystectomy Between 2002-2021. Urology 2023; 171:133-139. [PMID: 36241062 DOI: 10.1016/j.urology.2022.08.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/17/2022] [Accepted: 08/21/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To identify trends in complications following robot-assisted radical cystectomy (RARC) using a multi-institutional database, the International Robotic Cystectomy Consortium (IRCC). METHODS A retrospective review of the IRCC database was performed (2976 patients, 26 institutions from 11 countries). Postoperative complications were categorized as overall or high grade (≥ Clavien Dindo III) and were further categorized based on type/organ site. Descriptive statistics was used to summarize the data. Multivariate analysis (MVA) was used to identify variables associated with overall and high-grade complications. Cochran-Armitage trend test was used to describe the trend of complications over time. RESULTS 1777 (60%) patients developed postoperative complications following RARC, 51% of complications occurred within 30 days of RARC, 19% between 30-90 days, and 30% after 90 days. 835 patients (28%) experienced high-grade complications. Infectious complications (25%) were the most prevalent, while bleeding (1%) was the least. The incidence of complications was stable between 2002-2021. Gastrointestinal and neurologic postoperative complications increased significantly (P < .01, for both) between 2005 and 2020 while thromboembolic (P = .03) and wound complications (P < .01) decreased. On MVA, BMI (OR 1.03, 95%CI 1.01-1.05, P < .01), prior abdominal surgery (OR 1.26, 95%CI 1.03-1.56, P = .03), receipt of neobladder (OR 1.52, 95%CI 1.17-1.99, P < .01), positive nodal disease (OR 1.33, 95%CI 1.05-1.70, P = .02), length of inpatient stay (OR 1.04, 95%CI 1.02-1.05, P < .01) and ICU admission (OR 1.67, 95%CI 1.36-2.06, P < .01) were associated with high-grade complications. CONCLUSION Overall and high-grade complications after RARC remained stable between 2002-2021. GI and neurologic complications increased, while thromboembolic and wound complications decreased.
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Affiliation(s)
| | - Zhe Jing
- Roswell Park Comprehensive Cancer Center
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ketan Badani
- Icahn School of Medicine at Mount Sinai Hospital
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Current Bladder Dysfunction Reports: Antibiotic Overuse in Office-Based Lower Urinary Tract Procedures. CURRENT BLADDER DYSFUNCTION REPORTS 2022. [DOI: 10.1007/s11884-022-00672-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lu X, Jiang H, Wang D, Wang Y, Chen Q, Chen S, Chen M. Early Warning Models to Predict the 90-Day Urinary Tract Infection Risk After Radical Cystectomy and Urinary Diversion for Patients With Bladder Cancer. Front Surg 2022; 8:782029. [PMID: 35127802 PMCID: PMC8814316 DOI: 10.3389/fsurg.2021.782029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/08/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose To develop and validate a nomogram of the 90-day urinary tract infection (UTI) risk for patients with bladder cancer undergoing radical cystectomy (RC) and urinary diversion. Patients and Methods The predictive nomogram was based on a retrospective study on the consecutive patients who underwent RC and urinary diversion for bladder cancer between January 2014 and March 2021. The incidence and microbiology of UTI were reported. The univariate and multivariate logistic analyses were conducted to determine independent risk factors associated with UTI. The predictive accuracy and discriminatory ability of the established nomogram were evaluated by the concordance index (C-index) and decision curve analysis (DCA). The performance of the model was validated internally. Results A total of 220 patients were included and the incidence of UTI within 90 days was 27.3%. The most commonly identified pathogens were Enterococcus (42.0%), Escherichia coli (21.70%), and Candida (13.0%). Urinary diversion type, Charlson comorbidities index (CCI), stricture, and prognostic nutritional index (PNI) were included in the nomogram. The C-index of the nomogram for predicting UTI was 0.858 (95% CI: 0.593–0.953). In the validation cohort, the nomogram also showed high-predictive accuracy. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) index indicated that PNI led to improvement in predictive ability. Conclusion The proposed early warning model shows great accuracy in predicting the incidence of 90-day UTI after RC and urinary diversion in patients with bladder cancer.
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Affiliation(s)
- Xun Lu
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
| | - Hua Jiang
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
| | - Dong Wang
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
| | - Yiduo Wang
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
| | - Qi Chen
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
- Department of Interventional Radiology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Shuqiu Chen
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
- Shuqiu Chen
| | - Ming Chen
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
- *Correspondence: Ming Chen
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Schneidewind L, Torabi L, Dräger DL, Hakenberg OW. Reduction of Perioperative Antibiotic Prophylaxis in Open Radical Cystectomy with Ileal Conduit Is Feasible: Results of a Prospective Clinical Trial. Urol Int 2021; 106:825-831. [PMID: 34903704 PMCID: PMC9533434 DOI: 10.1159/000520564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/13/2021] [Indexed: 11/19/2022]
Abstract
Introduction The aim of this study is to perform a prospective clinical trial in antibiotic prophylaxis, infectious complication, and colonization of ileal conduit (IC) following radical cystectomy (RC) since urinary tract infections (UTIs) and surgical site infections (SSIs) contribute significantly to the morbidity associated with RC and IC. Moreover, an optimal regimen of antibiotic prophylaxis has not been established, yet. Material and Methods After a positive vote of ethical review committee and the registration at the German Clinical Trials Register (DKRS 00020406), we started a prospective clinical unicentric not interventional study. The urine samples were collected by sterile catheterization of the IC. All patients received an antibiotic prophylaxis with 3 × 500 mg metronidazole and 3 × 1.5 g cefuroxime intravenously for 3 days starting on the day before RC. Ureteral stents got removed on days 9 and 10 after surgery without prior antibiotic administration. The student t test and the χ2 test or the Fisher exact test were used. For risk factor assessment, the univariate Cox regression method was applied. Results Nineteen male (63.3%) and 11 female patients (36.7%) with a median age of 70.5 years were included. Three patients developed complicated UTI (10%) on day 12 after RC with E. faecium and needed antibiotic treatment with meropenem (Clavien-Dindo II). Two patients (6.7%) developed SSI with E. faecium and needed surgery (Clavien-Dindo IIIb). Palliative RC (p < 0.0001), prior radiation therapy (p < 0.0001), and timeframe >3 months from diagnosis to RC (p = 0.036) are significantly associated with the development of complicated UTI. Interestingly, the IC got colonized with Staph. haemolyticus at day 12 after RC (n = 12; 40.0%). We must assume that our data have some limitations like a unicentric study population. Conclusion Further evaluation of reduction to single-shot antibiotic prophylaxis in nonpalliative RC with IC could be feasible.
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Affiliation(s)
- Laila Schneidewind
- Department of Urology, University Medical Center Rostock, Rostock, Germany
| | - Laura Torabi
- Department of Urology, University Medical Center Rostock, Rostock, Germany
| | - Desiree L Dräger
- Department of Urology, University Medical Center Rostock, Rostock, Germany
| | - Oliver W Hakenberg
- Department of Urology, University Medical Center Rostock, Rostock, Germany
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Lee CU, Lee JH, Lee DH, Song W. Feasibility and Safety of Stentless Uretero-Intestinal Anastomosis in Radical Cystectomy with Ileal Orthotopic Neobladder. J Clin Med 2021; 10:jcm10225372. [PMID: 34830652 PMCID: PMC8624446 DOI: 10.3390/jcm10225372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/25/2021] [Accepted: 11/17/2021] [Indexed: 11/16/2022] Open
Abstract
Background: We evaluated the feasibility and safety of stentless uretero-intestinal anastomosis (UIA) during radical cystectomy (RC) with an ileal orthotopic neobladder. Methods: We retrospectively reviewed 403 patients who underwent RC for bladder cancer between August 2014 and December 2018. The primary objective was to study the effect of stentless UIA on uretero-intestinal anastomosis stricture (UIAS), and the secondary objective was to evaluate the association between stentless UIA and other complications, including paralytic ileus, febrile urinary tract infection (UTI), and urine leakage. Kaplan–Meier survival analysis was used to estimate UIAS-free survival, and Cox proportional hazard models were applied to identify factors associated with the risk of UIAS. Results: Among 403 patients with 790 renal units, UIAS was identified in 39 (9.7%) patients and 53 (6.7%) renal units. Forty-four (83.0%) patients with UIAS were diagnosed within 6 months. The 1- and 2-year overall UIAS-free rates were 93.9% and 92.7%, respectively. Paralytic ileus was identified in 105 (26.1%) patients and resolved with supportive treatment. Febrile UTI occurred in 57 patients (14.1%). However, there was no leak of the UIA. Conclusions: Stentless UIA during RC with an ileal orthotopic neobladder is a feasible and safe surgical option. Further prospective randomized trials are required to determine the clinical usefulness of stentless UIA during RC.
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Affiliation(s)
- Chung Un Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (C.U.L.); (J.H.L.)
| | - Jong Hoon Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (C.U.L.); (J.H.L.)
| | - Dong Hyeon Lee
- Department of Urology, Ewha Womans University Medical Center, Ewha Womans University School of Medicine, Seoul 07985, Korea;
| | - Wan Song
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (C.U.L.); (J.H.L.)
- Correspondence: ; Tel.: +82-2-3410-3559
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Maibom SL, Joensen UN, Poulsen AM, Kehlet H, Brasso K, Røder MA. Short-term morbidity and mortality following radical cystectomy: a systematic review. BMJ Open 2021; 11:e043266. [PMID: 33853799 PMCID: PMC8054090 DOI: 10.1136/bmjopen-2020-043266] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To study short-term (<90 days) morbidity and mortality following radical cystectomy (RC) for bladder cancer and identify modifiable risk factors associated with these. DESIGN Systematic review. METHODS The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE were searched for relevant papers on 11 June 2019 and rerun on 27 May 2020. Studies reporting complications, reoperations, length of stay and mortality within 90 days were included. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine and the quality of evidence was assessed using the Newcastle-Ottawa Scale. RESULTS The search retrieved 1957 articles. Sixty-six articles were included. The quality of evidence was poor to good. Most studies were retrospective, and no randomised clinical trials were identified. Of included studies a median of 6 Martin criteria for reporting complications after surgery were fulfilled. The Clavien-Dindo classification for grading complications was most frequently used. The weighted overall complication rate after RC was 34.9% (range 28.8-68.8) for in-house complications, 39.0% (range 27.3-80.0) for 30-day complications and 58.5% (range 36.1-80.5) for 90-day complications. The most common types of complications reported were gastrointestinal (29.0%) and infectious (26.4%). The weighted mortality rate was 2.4% (range 0.9-4.7) for in-house mortality, 2.1% (0.0-3.7) for 30-day mortality and 4.7% (range 0.0-7.0) for 90-day mortality. Age and comorbidity were identified as the best predictors for complications following RC. CONCLUSION Short-term morbidity and mortality are high following RC. Reporting of complications is heterogeneous and the quality of evidence is generally low. There is a continuous need for randomised studies to address any intervention that can reduce morbidity and mortality following RC. PROSPERO REGISTRATION NUMBER 104937.
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Affiliation(s)
- Sophia Liff Maibom
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Ulla Nordström Joensen
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Alicia Martin Poulsen
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
- Section for Surgical Pathophysiology, The Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Klaus Brasso
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Martin Andreas Røder
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
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García-Rojo E, Medina-Polo J, Miranda-Utrera N, Abad-López P, Gonzalez-Padilla D, González-Díaz A, Arrébola-Pajares A, Guerrero-Ramos F, Tejido-Sánchez Á, Rodríguez-Antolín A. Evaluation of health care-associated infections following radical cystectomy. Actas Urol Esp 2021; 45:124-131. [PMID: 32948346 DOI: 10.1016/j.acuro.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/27/2020] [Accepted: 06/13/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND OBJECTIVE Radical cystectomy is a complex surgery with a high rate of complications including infections, which lead to increased morbidity and mortality, longer hospital stay and higher costs. The aim of this work is to evaluate health care-associated infections (HAIs) in these patients, as well as associated microorganisms, antibiotic resistance profiles and risk factors. MATERIAL AND METHODS Prospective study from 2012 to 2017. Epidemiologic variables, comorbidities and surgical variables are collected. The microorganisms involved and antibiotic susceptibility patterns are analyzed. RESULTS 122 patients. Mean age 67 (SD:18,42). Mean hospital stay 23.5 days (18.42). HAIs rate of 45%, with predominant urinary tract infections (43%) and surgical wound infections (31%). Positive cultures in 78.6% of cases. Increased isolation of Enterococcus (18%) and Escherichia coli (13%). Forty-three percent of microorganisms were resistant to amoxicillin/ampicillin, 23% to beta-lactamases and 36% to quinolones. Empirical treatment was adequate in 87.5%. Hospital stay is increased (17 days, p< 0.05) due to HAIs. Lower rate of infectious complications in the laparoscopic vs. open approach (p< 0.001) and in orthotopic vs. ileal conduit diversion (p = 0.04) CONCLUSIONS: We found a high rate of HAIs in our radical cystectomy series, with predominant urinary tract and surgical wound infections. E.coli and Enterococcus spp. are the most frequently isolated microorganisms, with high rates of resistance to some commonly used antibiotics.
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Antimicrobial Resistance in Enterobacterales Bacilli Isolated from Bloodstream Infection in Surgical Patients of Polish Hospitals. Int J Microbiol 2021; 2021:6687148. [PMID: 33510792 PMCID: PMC7826220 DOI: 10.1155/2021/6687148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/12/2020] [Accepted: 01/05/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Aims Bloodstream infections (BSIs) are one of the most frequently observed hospital-acquired infections (HAIs). We sought to describe the epidemiology and drug resistance secondary Enterobacterales BSIs in surgical patients and check for any correlation with the type of hospital ward. Materials and Methods This multicenter (13 hospitals in southern Poland) laboratory-based retrospective study evaluated adults diagnosed with BSI secondary to surgical site infection (SSI) hospitalized in 2015-2018; 121 Enterobacterales strains were collected. The drug resistance was tested according to the EUCAST recommendations. Tests confirming the presence of extended-spectrum β-lactamases (ESBLs) and bla resistance genes were carried out. The occurrence of possible clonal epidemics among K. pneumoniae strains was examined. Results The prevalence of Enterobacterales in secondary BSI was 12.1%; the most common strains were E. coli (n = 74, 61.2%) and Klebsiella spp. (n = 33, 27.2%). High resistance involved ampicillin and ampicillin/sulbactam (92, 8-100%), fluoroquinolones (48-73%), and most cephalosporins (29-50%). Carbapenems were the antimicrobials with the susceptibility at 98%. The prevalence of ESBL strains was 37.2% (n = 45). All the ESBL strains had bla CTX-M gene, 26.7% had the bla SHV gene, and 24.4% had bla TEM gene. The diversity of Klebsiella strains was relatively high. Only 4 strains belonged to one clone. Conclusions What is particularly worrying is the high prevalence of Enterobacterales in BSI, as well as the high resistance to antimicrobial agents often used in the empirical therapy. To improve the effectiveness of empirical treatment in surgical departments, we need to know the epidemiology of both surgical site infection and BSI, secondary to SSI. We were surprised to note high heterogeneity among K. pneumoniae strains, which was different from our previous experience.
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11
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Numao N, Fujiwara R, Uehara S, Yasuoka S, Fujiwara M, Komai Y, Yuasa T, Yamamoto S, Fukui I, Yonese J. Intraoperative Only versus Extended Duration Use of Antimicrobial Prophylaxis for Infectious Complications in Radical Cystectomy with Intestinal Urinary Diversion. Urol Int 2020; 104:954-959. [PMID: 32814326 DOI: 10.1159/000509881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 07/02/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In spite of the high incidence of infectious complications (ICs), appropriate duration of antimicrobial prophylaxis (AMP) for radical cystectomy (RC) with intestinal urinary diversion (IUD) has not been established. We compared the incidence of ICs after RC with IUD in patients using only intraoperative AMP or extended duration AMP. Risk factors for ICs were also investigated. PATIENTS AND METHODS One hundred twenty-three consecutive patients who underwent RC with IUD were divided into 2 groups based on the AMP duration (intraoperative only vs. extended duration for a median of 3 days). Between the groups, the incidence of ICs was compared. Risk factors for ICs were investigated in multivariate analysis. RESULTS The IC rate was 44%. No significant difference was found in the rate of ICs between the groups. The IC rate was significantly higher in patients with lower estimated glomerular filtration rate (eGFR). Rates of ICs were 60 and 38% in patients with eGFR of less than 60 and equal or more than 60 mL/min/1.73 m2, respectively. CONCLUSIONS Our result indicates that AMP that is administered more than intraoperatively may be excessive in RC with IUD. Patients with a lower eGFR should be particularly cared for postoperative ICs.
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Affiliation(s)
- Noboru Numao
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan,
| | - Ryo Fujiwara
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Sho Uehara
- Department of Urology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shotaro Yasuoka
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Motohiro Fujiwara
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshinobu Komai
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Yuasa
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinya Yamamoto
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Iwao Fukui
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junji Yonese
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Intraoperative Ureteral Stent Use at Radical Cystectomy is Associated with Higher 30-Day Complication Rates. J Urol 2020; 205:483-490. [PMID: 33238829 DOI: 10.1097/ju.0000000000001329] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Radical cystectomy/urinary diversion is a high risk procedure. Intraoperative stents are commonly utilized to decrease ureteroenteric anastomosis related complications. Institutionally some surgeons routinely use intraoperative stents while others do not, providing an opportunity to compare complication differences. MATERIALS AND METHODS We queried a prospective database of 283 patients enrolled in a randomized controlled trial evaluating 30-day perioperative complications with goal directed fluid therapy following open radical cystectomy/urinary diversion between 2014 and 2018. Ureteroenteric anastomosis specific complications (ureteral obstruction, urinary leak, urinary infections/sepsis and intra-abdominal abscess) were compared between groups (intraoperative stent vs nonintraoperative stent group) using Fisher exact test and quantified using logistic regression. RESULTS The nonintraoperative stent group (77 of 283 patients, 27%) was older (median 72 vs 69 years) and was more likely to receive neoadjuvant chemotherapy (53% vs 40%), have baseline renal insufficiency (43% vs 30%) and undergo an ileal conduit (92% vs 53%). However, despite higher comorbidity, the nonintraoperative stent group had a significantly lower rate of ureteroenteric anastomosis complications (14% vs 32%, p=0.004). Since continent diversions may be associated with higher complications, the nonintraoperative stent group with ileal conduit was also compared to intraoperative stent cohorts with ileal conduit, and ureteroenteric anastomosis complications remained lower in the nonintraoperative stent group (14% vs 28%, p=0.043). Multivariable logistic regression showed significantly increased odds of urinary complications with intraoperative stent use (OR 3.55, 95% CI 2.93-4.31; p <0.0001). Importantly there was no obstruction and only 1 leak (1.3%) in the nonintraoperative stent group. CONCLUSIONS Contrary to conventional belief, we found intraoperative stent use in radical cystectomy/urinary diversion was associated with significantly higher infectious complications and urgent care visits, and significantly increased the odds of 30-day ureteroenteric anastomosis associated complications.
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