Antibiotic over-use for urological procedures

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A US study suggests that antibiotics are being overused in up to 60% of patients undergoing common urological procedures. The study, led by Dr Daniel Livorsi, University of Iowa assistant professor of internal medicine, shows that the high rates of overuse were mostly due to extended use of antibiotics following the procedure.

It is common for patients undergoing a urological or any other surgical procedure to be given antibiotics as a precaution to prevent a surgery-related infection. But overuse of antibiotics can promote antibiotic resistance, which the US Centres for Disease Control and Prevention has defined as a major health concern. Moreover, unnecessary use of antibiotics exposes patients to potential harm, such as an increased risk of infection by C. difficile bacteria.

Based on evidence that a longer course of antibiotics does not add any benefit to patient outcomes and may in fact increase risks to patient health, the American Urological Association (AUA) recommends that antibiotics should be given for no more than 24 hours following most urological procedures.

Livorsi and his colleagues took two approaches to investigate whether urologists are following the AUA guidelines for antibiotic prescribing. They manually reviewed the medical records of 375 patients who had one of three common urological procedures. These procedures all use endoscopic devices inserted into the urethra to examine and manipulate portions of the urinary tract. The patients were treated between January 2016 and July 2017 at five Veterans Health Administration hospitals located in different parts of the US.

The team also reviewed administrative data from 29,530 patient records from the entire Veterans Health Administration system.

Overall, the study found that 217 of the 375 patients (58%) were prescribed antibiotics in a way that did not follow the AUA guidelines. The most common deviation from the guidelines involved antibiotic-prescribing after the procedure: 211 patients (56%) were given antibiotics for longer than 24 hours following a procedure. In fact, patients were often given antibiotics for three to five days following a procedure instead of the 24 hours or less that the guidelines recommend.

The national administrative data also showed high rates of excess antibiotic prescribing; nearly 40% of records showed a median of three extra days of antibiotic therapy.

Overall, there was good agreement between the results from the manual chart reviews and the administrative data among the cases evaluated by both data sources. “This study shows that antibiotics are often continued for several days after common urologic procedures, even when there is no clear indication for antibiotics. This seemingly unnecessary use of antibiotics is exposing patients to potential harm,” says Livorsi, who also is a physician with University of Iowa Health Care and the Iowa City VA Health Care System. “Reducing unnecessary antibiotic use in this setting is just one example of how physicians can be better stewards of antibiotics.”

The team chose to look at patients within the VA system because it is the largest integrated health care system in the US, which makes it easier to do this type of study. However, Livorsi does not think the findings are unique to the VA. He notes other studies in non-VA settings have found similar results.

The study did not investigate why urologists are prescribing antibiotics for longer than recommended after a procedure. Given that the AUA provides clear recommendations for antibiotic therapy during these procedures, Livorsi believes it would be helpful to understand if urologists are not aware of the guidelines and the evidence behind them, or if there are other reasons why urologists are not adhering to the recommendations.

Nonetheless, the researchers believe the study identifies the post-procedure period as a good opportunity to improve antibiotic prescribing in a way that could decrease antibiotic resistance and reduce health care costs without harming patient outcomes.

“If a patient undergoing surgery is given antibiotics for more than 24 hours, he or she should ask the provider to explain why more antibiotics are necessary,” Livorsi says.

Abstract
Importance: The American Urological Association guidelines recommend 24 or fewer hours of antimicrobial prophylaxis for most urologic procedures. Continuing antimicrobial therapy beyond 24 hours may carry more risks than advantages.
Objectives: To assess guideline discordance of antimicrobial prophylaxis for common urologic endoscopic procedures, and to identify opportunities for improving antimicrobial prescribing through future stewardship interventions.
Design, Setting, and Participants: This multicenter cohort study conducted manual audits of medical records of 375 patients who underwent 1 of 3 urologic procedures (transurethral resection of bladder tumor [TURBT], transurethral resection of the prostate [TURP], and ureteroscopy [URS]) at 5 Veterans Health Administration facilities from January 1, 2016, to June 30, 2017. Antimicrobial prescribing practices across the national Veterans Health Administration system were assessed using the administrative data for 29 530 records.
Main Outcomes and Measures: Guideline discordance was assessed in the medical record review. Excessive postprocedural antimicrobial use was measured in the national administrative data analysis.
Results: The medical records of a total of 375 patients were manually reviewed. Among the 375 patients, 366 (97.6%) were male and 9 (2.4%) were female, with a mean (SD) age of 64.2 (10.9) years and a predominantly white race/ethnicity (289 [77.1%]). In addition, 29 530 patient records in the national administrative database were assessed. Among the patient records, 28 938 (98.0%) were male and 592 (2.0%) were female with a mean (SD) age of 69.1 (10.2) years and a predominantly white race/ethnicity (23 297 [78.9%]). Among the manually reviewed medical records, periprocedural or postprocedural antimicrobial prescribing was guideline discordant in 217 patients (57.9%). Postprocedural antimicrobial agents were continued beyond 24 hours in 211 patients (56.3%) and were guideline discordant in 177 patients (83.9%), with a median (interquartile range) duration of 3 (3-5) days of unnecessary antimicrobial therapy. In the analysis of national administrative data, excessive postprocedural antimicrobial agents were prescribed in 10 988 of 29 350 patient records (37.2%), with a median (interquartile range) of 3 (2-6) excess days. For any given facility, a statistically significant correlation was observed in the frequency of postprocedural antimicrobial prescribing between any 2 procedures, indicating that facilities with higher rates of excessive use for 1 procedure also had higher rates for another procedure: TURP and TURBT (ρ = 0.719; 95% CI, 0.603-0.803; P < .001), TURP and URS (ρ = 0.629; 95% CI, 0.476-0.741; P < .001), and TURBT and URS (ρ = 0.813; 95% CI, 0.724-0.873; P < .001).
Conclusions and Relevance: In this study of patients who underwent common urologic procedures, the rate of guideline-discordant antimicrobial use was high mostly because of overprescribing of postprocedural antimicrobial agents; future antimicrobial stewardship interventions should target the postprocedural period.

Authors
Chelsea Khaw, Anthony D Oberle, Brian C Lund, Jason Egge, Brett H Heintz, Bradley A Erickson, Daniel J Livorsi

University of Iowa Healthcare material
JAMA Network Open abstract


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