antibiotic overprescribing by urologists

Antimicrobial prophylaxis for 3 common urologic procedures: more than half had antibiotics overprescribed, according to the American Urological Association (AUA) guidelines of 2008 (See antibiotic overprescribing by urologists jama2019 in dropbox, or doi:10.1001/jamanetworkopen.2018.6248)

Details:

-- the AUA guidelines recommend antimicrobial prophylaxis for most urologic procedures to be no more than 24 hours post procedure

-- 375 patients from 5 geographically diverse Veterans Health Administration sites from across the United States, from January 2016 to July 2017. These records were manually reviewed for periprocedural or post procedural antimicrobial prescribing

-- 98% male, mean age 64, 77% white

-- additionally, 29,530 records were evaluated by administrative data through the VA system overall for antimicrobial prescribing practices

-- urologic procedures assessed: transurethral resection of bladder tumor (TURBT), transurethral resection of the prostate (TURP), and ureteroscopy (URS)

Results:

-- for the 375 patients whose records were manually assessed:

    --87% had pre-procedure urine cultures, a median of 11 days before the procedure; 33% had bacteriuria or candiduria

        --management of preprocedural urine culture was inappropriate in 28%, mostly because of failure to collect a culture (47%); 43% given preprocedural antibiotics were given them >7days before the procedure

    -- post procedural antimicrobial agents were continued to be prescribed beyond 24 hours in 56% of the patients; 84% of these were guideline discordant [ie, 16% of those on longer-term antibiotics had them appropriately]

        -- median duration of unnecessary antimicrobial therapy: 3 days

-- for the large database analysis of 29,530 patients:

    -- excessive post procedural antimicrobial agents were prescribed in 37%, for median of 3 days of excess therapy

        -- those facilities with higher TURP volume had lower excess antimicrobial prescribing; but there was no relationship for TURBT or URS with volume of procedures

        -- there was significant interfacility variation; however there was a statistically significant correlation between the frequency of post procedural antimicrobial prescribing comparing any two procedures within the same facility. These were highly significant (p<0.001) for any combination of two of the three procedures

Commentary:

-- though urologists comprise only 1% of prescribing providers in 2015, they were the eighth highest prescriber of outpatient antimicrobial agents among all specialties.

-- Antimicrobials are typically prescribed before, during, and after urologic procedures

-- the issue of overprescribing was mainly for post procedure prophylaxis. Pre-procedure is harder to critique, since the AUA guidelines do not specify a time-frame for urine testing. However, if one accepts the 2005 Infectious Diseases Society of America guidelines, where asymptomatic bacteriuria be assessed immediately before the procedure and stopped immediately after, there is some concern since in the above study these tests were done a median of 11 days before the procedure

-- the AUA guidelines do suggest prophylaxis for 24 or fewer hours during the perioperative period, unless there was pre-existing or untreated bacterial colonization. they suggest using cephalosporins, fluroquinolones and aminoglycosides. 

    --the AUA document (again, from 2008) comments that there have been 4 RCTs comparing oral cipro vs IV cephalosporins, involving 345 patients getting endoscopic procedures (including the procedures in the VA study above), finding no difference in the postop bacteriuria. [though the guidelines have had amendments noting the increasing concerns about the use of fluoroquinolones, see auanet.org for their updates, and https://gmodestmedblogs.blogspot.com/2019/01/warning-fluoroquinolones-and-aortic.html for the FDA concerns]

    --the Canadian Urological Association of 2015 recommended choosing an antibiotic for TURP based "in part on the local epidemiology of drug resistance in potential uropathogens", noting that there was no difference in the studies on outcomes after a pretty wide array of antibiotics used but most studies were with IV cephalosporins (see Mrkobrada M. Can Urol Assoc J. 2015; 9(1-2): 13, or doi: 10.5489/cuaj.2382 )

-- As noted above, though there was overall a large variation in antimicrobial prescribing between the different VA institutions, in general there was concordance within the same institution. It would seem to be useful to know what the reasons really were. These may be related to such things as: level of awareness/discussion of the guidelines, whether the institution had students/residents, the opinions and role of the department leadership or perceived educational leader, the role of drug company representatives, the age of the urologists, ...

-- it would be interesting to know what antibiotics were used, and if these varied between the hospitals. in particular, it would be important to know how often fluroquinolones are used, given their increasingly acknowledged immediate adverse effects, the increasing issue of resistance to them, and the significant concern about their effect on the microbiomes (see further references in blog below)

-- one strength of this study is that there was a component of doing rigorous manual evaluation of 375 patient records, as well as the larger data-mining analysis. And both confirmed excessive antibiotic prescribing. a weakness is that there was not lots of racial/ethnic diversity, and that the study's generalizability was limited to veterans seeking care in the VA system

--so, this study, as well as the one yesterday, serve as strong reminders that we need to have rigorous programs to educate providers of the need to minimize antibiotic usage. The surgical prophylactic antibiotic overuse is perhaps the easiest to fix: develop clear check-list protocols for antibiotics (taking into account the local epidemiology/resistance patterns of likely pathogens), with a clear algorithm of when to exceed the baseline antibiotic prophylaxis. This algorithm could be reasonably hard-wired into the order set for patients, with clinicians able to over-ride as indicated (an opt-out strategy). then a pretty straight-forward, on-going quality improvement initiative could track this to assess adherence to the accepted institutional guideline. And, it would be useful to standardize the specific antibiotic regimen, favoring the one which is more patient-tolerable and narrow-spectrum.

see https://gmodestmedblogs.blogspot.com/2019/01/antibiotic-overprescribing-2-more.html from yesterday for reference to prior articles on antibiotic overprescribing in general, effects on the microbiome, and profound concerns about antibiotic resistance

   

geoff

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