Culture-Directed Prophylaxis Linked with Reduced Post-Cystectomy Infection Rates

SAN DIEGO—Culture-directed perioperative prophylaxis may reduce the incidence of post-operative infections after radical cystectomy (RC), according to data presented at IDWeek 2015.

Zhe Han, PharmD, and colleagues at the University of Chicago studied adult patients who underwent RC with urinary diversion before and after implementation of a new perioperative prophylaxis regimen that optimized Enterococcus, Candida, Enterobacteriaceae, and anaerobic bacteria coverage. 

This regimen, which was developed by an antimicrobial stewardship team and the urology, infectious diseases and infection control departments, consisted of either ampicillin/sulbactam plus gentamicin plus fluconazole or a combination of vancomycin plus gentamicin plus metronidazole plus fluconazole. Prior to this, prophylaxis consisted of cefoxitin or a fluoroquinolone.

The new prophylaxis regimen was implemented after a multidisciplinary review of all positive cultures from RC patients in May 2013. For the study, the researchers looked at two periods: May 1, 2011 to May 22, 2013 (pre-review, 258 patients) and May 23, 2013 to May 30, 2014 (post-review, 128 patients).

Implementation of the culture-directed prophylaxis regimen was associated with a significant decrease in the 30-day post-operative infection rate (based on positive cultures) from 41.5% in the pre-review group to 30.5% in the post-review group. The 30-day post-operative rate of Clostridium difficile infection did not change significantly between the pre- and post-review periods (6.6% vs. 3.9%).

“A multidisciplinary approach is needed to design optimal perioperative prophylaxis regimen in this complicated patient population,” Dr Han told Infectious Disease Advisor. “It is important to consider the patient population, surgical approach, and technique and local epidemiologic data to tailor perioperative antibiotic regimens and make the largest impact on postoperative infections.”

Dr. Han noted that patients undergoing RC often have significant co-morbidities and antibiotic exposure prior to procedures. This puts them at risk for post-operative infections due to a broader range of pathogens than the currently recommended antibiotic prophylaxis would cover, including potential resistant bacteria and yeast, she said.

Speaking on behalf of the Infectious Diseases Society of America, a co-sponsor of ID Week, Aaron E. Glatt, MD, a hospital epidemiologist at South Nassau Communities Hospital in Oceanside, N.Y., said the investigation by Dr Han’s group was a decent-sized study that provides useful information supporting the use of culture-directed prophylaxis. 

He said he believes this approach makes sense, but it does present some challenges. For example, he noted that patients have to be available to provide a urine specimen, and this specimen must be obtained properly. If not, “you may end up getting garbage sometimes in the culture,” said Dr Glatt, adding that this could result in prescribing antibiotics for the wrong pathogens.

Reference

1. Han Z, Pariser J, Anderson B, et al. Poster Abstract 374. Culture-Directed Perioperative Prophylaxis Regimen Reduces Infections After Radical Cystectomy (RC).  Presented at: IDWeek 2015. Oct. 7-11, 2015. San Diego.