The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious complications after radical cystectomy

Joseph J Pariser, Blake B. Anderson, Shane M. Pearce, Zhe Han, Joseph A. Rodriguez, Emily Landon, Jennifer C. Pisano, Norm D. Smith, Gary D. Steinberg

Research output: Contribution to journalArticle

23 Citations (Scopus)

Abstract

Objectives: Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort to decrease the rate of infectious complications, we instituted a broader, culture-based preoperative antimicrobial regimen, including fungal coverage, and studied its effect on infectious complications after RC. Materials and methods: In May 2013, antimicrobial prophylaxis for RC was changed at our institution after review of previous positive cultures. Ampicillin-sulbactam 3 g, gentamicin 4 mg/kg, and fluconazole 400 mg replaced cefoxitin. Patients undergoing RC from May 2011 to May 2014 were included. Before and after implementation of the new regimen, 30-day infectious complications (positive blood culture, urinary tract infection, wound infection, abscess, and pneumonia) and adverse events (Clostridium difficile, readmission, and mortality) were compared. Multivariate logistic regression was used to identify independent risk factors for infection while controlling for covariates. Results: In total, 386 patients were studied (258 before the change and 128 after). The overall infection rate decreased with the new regimen (41% vs. 30%, P = 0.043) with improvements in wound (14% vs. 6%, P = 0.025) and fungal (10% vs. 3%, P = 0.021) infections. Median length of stay decreased from 8 (interquartile range [IQR]: 7-12) to 7 (IQR: 7-10) days (= 0.008). On multivariate analysis, the new regimen decreased the risk of infections (odds ratio [OR] = 0.58, 95% CI [0.35-0.99], P = 0.044) whereas body mass index, operating room time, smoking, and total parenteral nutrition increased the risk (all P< 0.05). Conclusions: Risk factors for infection after RC include body mass index, operating room time, smoking, and total parenteral nutrition use. Changing from cefoxitin to broader, culture-directed antimicrobial prophylaxis, based on institutional data to include antifungal coverage, decreased postoperative infections.

Original languageEnglish (US)
Pages (from-to)121.e9-121.e14
JournalUrologic Oncology: Seminars and Original Investigations
Volume34
Issue number3
DOIs
StatePublished - Mar 1 2016
Externally publishedYes

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Cystectomy
Infection
Cefoxitin
Total Parenteral Nutrition
Operating Rooms
Body Mass Index
Smoking
Urinary Diversion
Clostridium difficile
Fluconazole
Wound Infection
Gentamicins
Urinary Tract Infections
Abscess
Length of Stay
Pneumonia
Multivariate Analysis
Logistic Models
Odds Ratio
Mortality

Keywords

  • Antibacterial Agents
  • Antibiotic Prophylaxis
  • Antifungal Agents
  • Cystectomy
  • Infection

Cite this

The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious complications after radical cystectomy. / Pariser, Joseph J; Anderson, Blake B.; Pearce, Shane M.; Han, Zhe; Rodriguez, Joseph A.; Landon, Emily; Pisano, Jennifer C.; Smith, Norm D.; Steinberg, Gary D.

In: Urologic Oncology: Seminars and Original Investigations, Vol. 34, No. 3, 01.03.2016, p. 121.e9-121.e14.

Research output: Contribution to journalArticle

Pariser, Joseph J ; Anderson, Blake B. ; Pearce, Shane M. ; Han, Zhe ; Rodriguez, Joseph A. ; Landon, Emily ; Pisano, Jennifer C. ; Smith, Norm D. ; Steinberg, Gary D. / The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious complications after radical cystectomy. In: Urologic Oncology: Seminars and Original Investigations. 2016 ; Vol. 34, No. 3. pp. 121.e9-121.e14.
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abstract = "Objectives: Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort to decrease the rate of infectious complications, we instituted a broader, culture-based preoperative antimicrobial regimen, including fungal coverage, and studied its effect on infectious complications after RC. Materials and methods: In May 2013, antimicrobial prophylaxis for RC was changed at our institution after review of previous positive cultures. Ampicillin-sulbactam 3 g, gentamicin 4 mg/kg, and fluconazole 400 mg replaced cefoxitin. Patients undergoing RC from May 2011 to May 2014 were included. Before and after implementation of the new regimen, 30-day infectious complications (positive blood culture, urinary tract infection, wound infection, abscess, and pneumonia) and adverse events (Clostridium difficile, readmission, and mortality) were compared. Multivariate logistic regression was used to identify independent risk factors for infection while controlling for covariates. Results: In total, 386 patients were studied (258 before the change and 128 after). The overall infection rate decreased with the new regimen (41{\%} vs. 30{\%}, P = 0.043) with improvements in wound (14{\%} vs. 6{\%}, P = 0.025) and fungal (10{\%} vs. 3{\%}, P = 0.021) infections. Median length of stay decreased from 8 (interquartile range [IQR]: 7-12) to 7 (IQR: 7-10) days (= 0.008). On multivariate analysis, the new regimen decreased the risk of infections (odds ratio [OR] = 0.58, 95{\%} CI [0.35-0.99], P = 0.044) whereas body mass index, operating room time, smoking, and total parenteral nutrition increased the risk (all P< 0.05). Conclusions: Risk factors for infection after RC include body mass index, operating room time, smoking, and total parenteral nutrition use. Changing from cefoxitin to broader, culture-directed antimicrobial prophylaxis, based on institutional data to include antifungal coverage, decreased postoperative infections.",
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AU - Rodriguez, Joseph A.

AU - Landon, Emily

AU - Pisano, Jennifer C.

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AU - Steinberg, Gary D.

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N2 - Objectives: Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort to decrease the rate of infectious complications, we instituted a broader, culture-based preoperative antimicrobial regimen, including fungal coverage, and studied its effect on infectious complications after RC. Materials and methods: In May 2013, antimicrobial prophylaxis for RC was changed at our institution after review of previous positive cultures. Ampicillin-sulbactam 3 g, gentamicin 4 mg/kg, and fluconazole 400 mg replaced cefoxitin. Patients undergoing RC from May 2011 to May 2014 were included. Before and after implementation of the new regimen, 30-day infectious complications (positive blood culture, urinary tract infection, wound infection, abscess, and pneumonia) and adverse events (Clostridium difficile, readmission, and mortality) were compared. Multivariate logistic regression was used to identify independent risk factors for infection while controlling for covariates. Results: In total, 386 patients were studied (258 before the change and 128 after). The overall infection rate decreased with the new regimen (41% vs. 30%, P = 0.043) with improvements in wound (14% vs. 6%, P = 0.025) and fungal (10% vs. 3%, P = 0.021) infections. Median length of stay decreased from 8 (interquartile range [IQR]: 7-12) to 7 (IQR: 7-10) days (= 0.008). On multivariate analysis, the new regimen decreased the risk of infections (odds ratio [OR] = 0.58, 95% CI [0.35-0.99], P = 0.044) whereas body mass index, operating room time, smoking, and total parenteral nutrition increased the risk (all P< 0.05). Conclusions: Risk factors for infection after RC include body mass index, operating room time, smoking, and total parenteral nutrition use. Changing from cefoxitin to broader, culture-directed antimicrobial prophylaxis, based on institutional data to include antifungal coverage, decreased postoperative infections.

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