Background: RC with urinary diversion is associated with significant postoperative infectious complications. There is limited data to guide optimal perioperative antimicrobial selection in patients undergoing RC. National guidelines recommend prophylaxis with a second or third generation cephalosporin as the preferred regimen, based on data extrapolated from colorectal procedures. To determine the optimal prophylaxis regimen, all positive cultures from RC patients over the previous 2 years were reviewed in May 2013. A culture-directed perioperative prophylaxis regimen was instituted following review by antimicrobial stewardship, urology, and infection control. We evaluated the impact of this regimen on reducing post RC infections.
Methods: All adult patients who underwent RC with urinary diversion between 5/1/2011-5/22/2013 and 5/23/2013-5/30/2014 were included in this analysis. Patients with urinary infections immediately before surgery were excluded. Prophylaxis regimen pre-review was cefoxitin or a fluoroquinolone. A new prophylaxis regimen that optimized Enterococcus, Candida, Enterobacteriaceae and anaerobic coverage was instituted for patients in the post-review group: ampicillin/sulbactam + gentamicin + fluconazole or vancomycin + gentamicin + metronidazole + fluconazole.
Results: Figure 1 shows a distribution of clinically significant isolates from blood, urine, tissue and abdominal fluid cultures collected within 30 days after RC from patients in the pre-review group (N = 258). The post-review group included 128 patients. The new culture-directed prophylaxis regimen significantly decreased 30-day postoperative infection rate based on positive cultures (41% versus 30%, p = 0.04). 30-day C. difficile infection rate was similar pre and post-review (7% versus 4%, p = 0.17). Significant reduction in Candida (25% versus 4%, p = 0.02) and anaerobic (9% versus 3%, p < 0.01) infections were observed.
Conclusion: Interdisciplinary collaboration and implementation of a culture-directed perioperative prophylaxis regimen reduced postoperative infections after RC.
B. Anderson, None
S. Pearce, None
G. Steinberg, None
N. Smith, None
E. Landon, None
N. Pettit, None
J. Pisano, None