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Published on: May 19, 2022
The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious
Joseph J Pariser1, Blake B Anderson1, Shane M Pearce1
1Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL.
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 3g, gentamicin 4mg/kg, and fluconazole 400mg 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 (P = 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.
Insights
A new antimicrobial regimen for radical cystectomy (RC) significantly reduced postoperative infections by 11%. This broader, culture-directed approach, including antifungal coverage, also shortened hospital stays and lowered infection risks.
Area of Science:
- Urology
- Infectious Diseases
- Surgical Oncology
Background:
- Radical cystectomy (RC) with urinary diversion carries a high risk of infectious complications.
- Current antimicrobial prophylaxis may not adequately address the spectrum of potential pathogens.
Purpose of the Study:
- To evaluate the impact of a broader, culture-based preoperative antimicrobial regimen, including antifungal coverage, on infectious complications following radical cystectomy.
- To identify risk factors for postoperative infections after RC.
Main Methods:
- A retrospective study compared infectious complications in 386 patients undergoing RC before (May 2011-May 2013) and after (May 2013-May 2014) a change in antimicrobial prophylaxis.
- The new regimen included ampicillin-sulbactam, gentamicin, and fluconazole, replacing cefoxitin.
- Multivariate logistic regression identified independent risk factors for infection.
Main Results:
- The overall infection rate decreased from 41% to 30% (P=0.043) with the new regimen.
- Specific improvements were noted in wound infections (14% to 6%, P=0.025) and fungal infections (10% to 3%, P=0.021).
- Median length of stay decreased from 8 to 7 days (P=0.008), and the new regimen was associated with a reduced risk of infection (OR=0.58, P=0.044).
Conclusions:
- A broader, culture-directed antimicrobial prophylaxis including antifungal coverage effectively decreased postoperative infectious complications after radical cystectomy.
- Obesity, longer operating room time, smoking, and total parenteral nutrition are significant risk factors for infection post-RC.
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