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Lokeshwar SD, Choksi AU, Smani S, Ip KL, Javier-DesLoges JF, Rahman SN, Leapman MS, Martin TV, Hesse DG. Classification and Risk Factors for Surgical Site Infections in Radical Cystectomy: A 16-Year Analysis. Surg Infect (Larchmt) 2024. [PMID: 38959160 DOI: 10.1089/sur.2024.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
Introduction: Surgical site infection (SSI) is a substantial cause of peri-operative morbidity among patients undergoing radical cystectomy (RC). The purpose of this study was to identify the risk factors of SSI after RC and to classify and characterize treatment of SSIs. Methods: We retrospectively analyzed peri-operative characteristics and SSI, for patients undergoing RC from 2007 to 2022. Patients were stratified by SSI versus no SSI and differences were assessed. Uni-variable/multi-variable logistic regression analyses were performed to identify factors associated with SSI. SSIs were categorized by the Centers for Disease Control and Prevention (CDC) type: Superficial incisional, deep incisional, and organ/space confined. Results: Three hundred and ninety-eight patients had RC, 279 open, and 119 robotic; 78 (19.6%) developed SSI. Cohorts were similar demographically. Length of stay (LOS) was longer in the SSI cohort (8.8 d versus 12.4 d, p < 0.001), and body mass index (BMI) was greater in patients with SSI (24.34 vs. 25.39, p = 0.0003). On uni-variable analysis, age, gender, Charlson Comorbidity Index, diabetes mellitus, diversion, odds ratio (OR) time, blood loss, and open versus robotic technique were not substantial SSI predictors. BMI was an independent risk factor for SSI on both uni-variable (OR: 1.07, 95% confidence interval [CI]: 1.018-1.115, p = 0.0061) and multi-variable analysis (OR: 1.06, 95% CI: 1.009-1.109, p = 0.02) for 10 (12.8%) and 24 (30.8%) superficial and deep-incisional SSIs, respectively. Superficial wound SSI was treated conservatively with 60% receiving antibiotic agents and no procedural intervention. Deep SSIs received antibiotic agents and 50% required surgical intervention. There were 44 (56.4%) organ/space SSIs, and the most common treatment was antibiotic agents (100%) and IR drain placement (30, 68.2%). Conclusion: In patients undergoing RC, BMI was an independent risk factor for SSI. Type of the surgical procedure, robotic versus open, was not predictive of SSI. LOS was longer for patients with SSI. SSI was managed differently depending on CDC classification.
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Affiliation(s)
- Soum D Lokeshwar
- Department of Urology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ankur U Choksi
- Department of Urology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shayan Smani
- Department of Urology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kevan L Ip
- Department of Urology, Jefferson School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Syed N Rahman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael S Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Thomas V Martin
- Department of Urology, Yale School of Medicine, New Haven, Connecticut, USA
| | - David G Hesse
- Department of Urology, Yale School of Medicine, New Haven, Connecticut, USA
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Taber C, Lee B, Djang R, Shone E, Perry J, Patel SG. Evaluating the Differences of Wound Related Complications in Robotically Assisted Radical Cystectomy vs Open Radical Cystectomy. Urology 2024:S0090-4295(24)00414-X. [PMID: 38852626 DOI: 10.1016/j.urology.2024.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 04/26/2024] [Accepted: 05/20/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVE To determine whether robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) compared to open radical cystectomy (ORC) or RARC with extracorporeal urinary diversion (ECUD) would result in a decreased rate of surgical site complications. RARC has been shown to be non-inferior to ORC. Both RARC and ORC are complicated by a high rate of perioperative morbidity, including wound-related complications, which may be decreased by a robotic approach with intracorporeal diversion. METHODS A retrospective review of our bladder cancer database for patients undergoing radical cystectomy from 2013-2021. Patients were stratified by surgical technique as RARC with ICUD vs ORC vs RARC with ECUD. Surgical site complications were measured at both 30- and 90-day intervals. RESULTS Of the 269 patients, 127 (47.2%) had RARC with ICUD, 118 (43.7%) had ORC, and 24 (8.9%) had RARC with ECUD (mean ages 71.0, 69.5, and 67.5, respectively). A comparison of the 3 groups demonstrated statistical significance at both the 30-day (P <.001) and 90-day (P <.001) timeframes for total surgical site complications, with RARC with ICUD having the fewest amount of patients experiencing a surgical site complication (0.8%) followed by ORC (25.4%) and RARC with ECUD (29.2%). CONCLUSION Overall, we observed lower surgical site complication rates among patients undergoing RARC with ICUD compared to patients who underwent ORC or RARC with ECUD. This study suggests that decreased surgical site complications may be one benefit of the minimally invasive approach, particularly in patients at high risk for surgical site complications after radical cystectomy.
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Affiliation(s)
- Carson Taber
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
| | - Brennan Lee
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Robin Djang
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Erin Shone
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Julie Perry
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Sanjay G Patel
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Boutefnouchet C, Aouras H, Khennouchi NCEH, Berredjem H, Rolain JM, Hadjadj L. Algerian postcaesarean surgical site infections: A cross-sectional investigation of the epidemiology, bacteriology, and antibiotic resistance profile. Am J Infect Control 2024; 52:456-462. [PMID: 37805027 DOI: 10.1016/j.ajic.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) are one of the most common health care-associated infections in low and middle-income countries. The aims of this cross-sectional descriptive study were to estimate the frequency of postcaesarean infection with associated clinical characteristics and the antibiotic resistance profile of bacterial isolates. METHODS Patients who underwent a cesarean section at the obstetrics and gynecology department of the hospital in Annaba, Algeria were included. Each woman was followed postoperatively for 30 days and sociodemographic data were collected. Culture-based microbiological methods were used to identify the causative bacteria and determine their antibiotic resistance phenotype and molecular characterization. RESULTS Among 1,810 patients, we recorded 36 (1.9%) SSIs. Most patients had undergone an emergency delivery (75%) and low educational level (72.2%). The most frequent maternal pathologies were Body Mass Index ≥ 30 (63.9%), scarred uteri (58.3%), anemia (55.6%), and an American Society of Anaesthesiologists score between II and III (33.3%). Of the 43 bacteria isolated, Enterobacteriaceae were the most frequent (62.8%), predominated by Escherichia coli strains (43.5%), a majority of which were extended-spectrum β-lactamases carriers (62.9%). Although gram-positive cocci were less frequent (37.2%), a majority of Enterococcus faecalis (56.2%) were observed and 2 strains of vancomycin-resistant Enterococcus faecium harboring the vanA gene were identified. CONCLUSIONS Extensive surveillance of at-risk populations should be integrated to prevent the occurrence of SSIs.
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Affiliation(s)
- Chahinez Boutefnouchet
- Laboratoire de Biochimie et Microbiologie Appliquée, Département de Biochimie, Faculté des Sciences, Université Badji Mokhtar-Annaba, Algeria; Aix Marseille University, IRD, APHM, MEPHI, Faculté de Médecine et de Pharmacie, Marseille Cedex 05, France; IHU Méditerranée Infection, France
| | - Hayet Aouras
- Etablissement Hospitalier de Santé Abdallah Nouaouria "'El Bouni"' Annaba, Algeria
| | - Nour Chems El Houda Khennouchi
- Laboratoire de Biotechnologie des substances naturelles et applications, Université L'arbi Ben M'hidi, Oum El Bouaghi, Algeria
| | - Hajira Berredjem
- Laboratoire de Biochimie et Microbiologie Appliquée, Département de Biochimie, Faculté des Sciences, Université Badji Mokhtar-Annaba, Algeria
| | - Jean-Marc Rolain
- Aix Marseille University, IRD, APHM, MEPHI, Faculté de Médecine et de Pharmacie, Marseille Cedex 05, France; IHU Méditerranée Infection, France
| | - Linda Hadjadj
- Aix Marseille University, IRD, APHM, MEPHI, Faculté de Médecine et de Pharmacie, Marseille Cedex 05, France; IHU Méditerranée Infection, France.
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Blachman-Braun R, Gurayah AA, Mason MM, Hougen HY, Gonzalgo ML, Nahar B, Punnen S, Parekh DJ, Ritch CR. Incidence and predictors of deep incisional and organ/space surgical site infection following radical cystectomy. Urol Oncol 2023; 41:455.e17-455.e24. [PMID: 37524577 DOI: 10.1016/j.urolonc.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE To investigate clinical risk factors associated with postoperative deep incisional or organ/space surgical site infections (SSI) following radical cystectomy (RC) in a well characterized and large contemporary cohort. METHODS We used the American College of Surgeons National Surgical Quality Improvement Program database to identify adult patients who underwent RC for bladder cancer between 2015 and 2020 (n = 13,081). We conducted multivariable-adjusted logistic regression and Cox adjusted proportional hazards regression analysis to identify clinical predictors of deep incisional or organ/space SSI in the 30-day postoperative-period following RC. RESULTS Deep incisional or organ/space SSI risk increased with continent urinary diversion (HR = 1.61, 95% CI: 1.38-1.88; P < 0.001), obesity (HR = 1.60, 95% CI: 1.35-1.90; P < 0.001), diabetes mellitus (HR = 1.30, 95% CI: 1.13-1.51; P < 0.001), and being functionally dependent before surgery (HR = 2.09, 95% CI: 1.44-3.03; P < 0.001). CONCLUSIONS Postoperative deep incisional or organ/space SSIs following RC occur more frequently in patients who were obese, diabetic, functionally dependent before surgery, and those who underwent continent urinary diversion. These findings may assist urologists in preoperative counseling, medical optimization, and choice of urinary diversion approach, as well as improved patient monitoring and identification of candidates for intervention postoperatively.
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Affiliation(s)
- Ruben Blachman-Braun
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL.
| | | | | | - Helen Y Hougen
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Mark L Gonzalgo
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - Bruno Nahar
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - Sanoj Punnen
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - Dipen J Parekh
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - Chad R Ritch
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
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Rich JM, Garden EB, Arroyave JS, Elkun Y, Ranti D, Pfail JL, Klahr R, Omidele OO, Adams-Sommer V, Patel G, Schaefer SH, Brown C, Badani K, Lavallee E, Mehrazin R, Attalla K, Waingankar N, Wiklund P, Sfakianos JP. Infections After Adoption of Antibiogram-directed Prophylaxis and Intracorporeal Urinary Diversion for Robot-assisted Radical Cystectomy. Eur Urol Focus 2023:S2405-4569(23)00212-2. [PMID: 37838593 DOI: 10.1016/j.euf.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/01/2023] [Accepted: 09/19/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has significantly decreased the morbidity associated with radical cystectomy. However, infectious complications including sepsis, urinary tract (UTIs), wound (WIs), and intra-abdominal (AIs) infections remain common. OBJECTIVE To assess whether intracorporeal urinary diversion (ICUD) and antibiogram-directed antimicrobial prophylaxis would decrease infections after robotic-assisted radical cystectomy (RARC). DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis was performed of a prospectively maintained database of patients undergoing RARC between 2014 and 2022 at a tertiary care institution, identifying two groups based on adherence to a prospectively implemented modified ERAS protocol for RARC: modified-ERAS-ICUD and antibiogram-directed ampicillin-sulbactam, gentamicin, and fluconazole prophylaxis were utilized (from January 2019 to present time), and unmodified-ERAS-extracorporeal urinary diversion (UD) and guideline-recommended cephalosporin-based prophylaxis regimen were utilized (from November 2014 to June 2018). Patients receiving other prophylaxis regimens were excluded. INTERVENTION ICUD and antibiogram-directed infectious prophylaxis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was UTIs within 30 and 90 d postoperatively. The secondary outcomes were WIs, AIs, and sepsis within 30 and 90 d postoperatively, and Clostridioides difficile infection (CDI) within 90 d postoperatively. RESULTS AND LIMITATIONS A total of 396 patients were studied (modified-ERAS: 258 [65.2%], unmodified-ERAS: 138 [34.8%]). UD via a neobladder was more common in the modified-ERAS cohort; all other intercohort demographic differences were not statistically different. Comparing cohorts, modified-ERAS had significantly reduced rates of 30-d (7.8% vs 15.9%, p = 0.027) and 90-d UTIs (11.2% vs 25.4%, p = 0.001), and 30-d WIs (1.2% vs. 8.7%, p < 0.001); neither group had a WI after 30 d. Rates of AIs, sepsis, and CDI did not differ between groups. On multivariate regression, the modified-ERAS protocol correlated with a reduced risk of UTIs and WIs (all p < 0.01). The primary limitation is the retrospective study design. CONCLUSIONS Utilization of ICUD and antibiogram-based prophylaxis correlates with significantly decreased UTIs and WIs after RARC. PATIENT SUMMARY In this study of infections after robotic radical cystectomy for bladder cancer, we found that intracorporeal (performed entirely inside the body) urinary diversion and an institution-specific antibiogram-directed antibiotic prophylaxis regimen led to fewer urinary tract infections and wound infections at our institution.
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Affiliation(s)
- Jordan M Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Evan B Garden
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Yuval Elkun
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Ranti
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John L Pfail
- Department of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Rebecca Klahr
- Department of Medicine, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Olamide O Omidele
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Gopi Patel
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah Hall Schaefer
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Conner Brown
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ketan Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Etienne Lavallee
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kyrollis Attalla
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nikhil Waingankar
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Antonelli L, Sebro K, Lahmar A, Black PC, Ghodoussipour S, Hamilton-Reeves JM, Shah J, Bente Thoft J, Lerner SP, Llorente C, Lucca I, Preston MA, Psutka SP, Sfakianos JP, Vahr Lauridsen S, Williams SB, Catto J, Djaladat H, Kassouf W, Loftus K, Daneshmand S, Fankhauser CD. Association Between Antibiotic Prophylaxis Before Cystectomy or Stent Removal and Infection Complications: A Systematic Review. Eur Urol Focus 2023:S2405-4569(23)00028-7. [PMID: 36710211 DOI: 10.1016/j.euf.2023.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/24/2022] [Accepted: 01/17/2023] [Indexed: 01/29/2023]
Abstract
CONTEXT Patients undergoing radical cystectomy frequently suffer from infectious complications, including urinary tract infections (UTIs) and surgical site infections (SSIs) leading to emergency department visits, hospital readmission, and added cost. OBJECTIVE To summarize the literature regarding perioperative antibiotic prophylaxis, ureteric stent usage, and prevalence of infectious complications after cystectomy. EVIDENCE ACQUISITION A systematic review of PubMed/Medline, EMBASE, Cochrane Library, and reference lists was conducted. EVIDENCE SYNTHESIS We identified 20 reports including a total of 55 306 patients. The median rates of any infection, UTIs, SSIs, and bacteremia were 40%, 20%, 11%, and 6%, respectively. Perioperative antibiotic prophylaxis differed substantially between reports. Perioperative antibiotics were used only during surgery in one study but were continued over several days after surgery in all other studies. Empirical use of antibiotics for 1-3 d after surgery was described in 12 studies, 3-10 d in two studies, and >10 d in four studies. Time to stent removal ranged from 4 to 25 d after cystectomy. Prophylactic antibiotics were used before stent removal in nine of 20 studies; two of these studies used targeted antibiotics based on urine cultures from the ureteric stents, and the other seven studies used a single shot or 2 d of empirical antibiotics. Studies with any prophylactic antibiotic before stent removal found a lower median percentage of positive blood cultures after stent removal than studies without prophylactic antibiotics before stent removal (2% vs 9%). CONCLUSIONS We confirmed a high proportion of infectious complications after cystectomy, and a heterogeneous pattern of choice and duration of antibiotics during and after surgery or stent removal. These findings highlight a need for further studies and support quality prospective trials. PATIENT SUMMARY In this review, we observed wide variability in the use of antibiotics before or after surgical removal of the bladder.
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Affiliation(s)
- Luca Antonelli
- Department of Urology, Luzerner Kantonsspital, University of Lucerne, Lucerne, Switzerland; Department of Urology, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Kirby Sebro
- Department of Urology, Western General Hospital, Edinburgh, UK
| | - Abdelilah Lahmar
- Medicine, Faculty of Medicine and Pharmacy, Mohammed VI University Hospital, Oujda, Morocco
| | - Peter C Black
- Vancouver Prostate Centre and Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Jay Shah
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Seth Paul Lerner
- Scott Department of Urology, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Carlos Llorente
- Department of Urology and Research Unit, Hospital Universitario Fundación Alcorcon, Alcorcón, Madrid, Spain
| | - Ilaria Lucca
- Department of Urology, CHUV, Lausanne, Switzerland
| | - Mark A Preston
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Susanne Vahr Lauridsen
- Department of Urology, Copenhagen University Hospital, Copenhagen, Denmark; WHO-CC, Parker Institute Bispebjerg & Frederiksberg University Hospital, Copenhagen, Denmark
| | - Stephen B Williams
- Division of Urology, Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Hooman Djaladat
- Institute of Urology, Kenneth Norris Jr. Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Wassim Kassouf
- Department of Surgery (Urology), Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Katherine Loftus
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn school of Medicine at Mount Sinai, New York, NY, USA
| | - Siamak Daneshmand
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Christian D Fankhauser
- Department of Urology, Luzerner Kantonsspital, University of Lucerne, Lucerne, Switzerland.
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Schneidewind L, Torabi L, Dräger DL, Hakenberg OW. Reduction of Perioperative Antibiotic Prophylaxis in Open Radical Cystectomy with Ileal Conduit Is Feasible: Results of a Prospective Clinical Trial. Urol Int 2021; 106:825-831. [PMID: 34903704 PMCID: PMC9533434 DOI: 10.1159/000520564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/13/2021] [Indexed: 11/19/2022]
Abstract
Introduction The aim of this study is to perform a prospective clinical trial in antibiotic prophylaxis, infectious complication, and colonization of ileal conduit (IC) following radical cystectomy (RC) since urinary tract infections (UTIs) and surgical site infections (SSIs) contribute significantly to the morbidity associated with RC and IC. Moreover, an optimal regimen of antibiotic prophylaxis has not been established, yet. Material and Methods After a positive vote of ethical review committee and the registration at the German Clinical Trials Register (DKRS 00020406), we started a prospective clinical unicentric not interventional study. The urine samples were collected by sterile catheterization of the IC. All patients received an antibiotic prophylaxis with 3 × 500 mg metronidazole and 3 × 1.5 g cefuroxime intravenously for 3 days starting on the day before RC. Ureteral stents got removed on days 9 and 10 after surgery without prior antibiotic administration. The student t test and the χ2 test or the Fisher exact test were used. For risk factor assessment, the univariate Cox regression method was applied. Results Nineteen male (63.3%) and 11 female patients (36.7%) with a median age of 70.5 years were included. Three patients developed complicated UTI (10%) on day 12 after RC with E. faecium and needed antibiotic treatment with meropenem (Clavien-Dindo II). Two patients (6.7%) developed SSI with E. faecium and needed surgery (Clavien-Dindo IIIb). Palliative RC (p < 0.0001), prior radiation therapy (p < 0.0001), and timeframe >3 months from diagnosis to RC (p = 0.036) are significantly associated with the development of complicated UTI. Interestingly, the IC got colonized with Staph. haemolyticus at day 12 after RC (n = 12; 40.0%). We must assume that our data have some limitations like a unicentric study population. Conclusion Further evaluation of reduction to single-shot antibiotic prophylaxis in nonpalliative RC with IC could be feasible.
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Affiliation(s)
- Laila Schneidewind
- Department of Urology, University Medical Center Rostock, Rostock, Germany
| | - Laura Torabi
- Department of Urology, University Medical Center Rostock, Rostock, Germany
| | - Desiree L Dräger
- Department of Urology, University Medical Center Rostock, Rostock, Germany
| | - Oliver W Hakenberg
- Department of Urology, University Medical Center Rostock, Rostock, Germany
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Goldman L, McAlister SA, Keith A, Bone N, McSwain JM, Klineline DN, Hagedorn Wonder A. Collecting Site-Level Data on Organisms Causing Surgical Site Infections to Guide Quality Improvement. AORN J 2021; 113:389-396. [PMID: 33788227 DOI: 10.1002/aorn.13356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/26/2020] [Accepted: 09/28/2020] [Indexed: 11/07/2022]
Abstract
Surgical site infections (SSIs) negatively affect patients and health care organizations. We conducted a descriptive, correlational study at two hospitals that provide care to rural patients in one Midwestern state. The study purposes were to describe: types of organisms causing reportable organ/space SSIs that occurred within 30 days of an open or a laparoscopic abdominal surgery (N = 20), and commonalities in patient- and care-related factors to provide baseline information for site-level prevention efforts for quality improvement. We identified Escherichia coli in almost half of the SSI cases (n = 9, 45%). Common patient-related factors included ethnicity, smoking, and dirty or contaminated wounds. Common care-related factors included longer surgery times (> 60 minutes), unplanned surgeries, and procedures that involved the colon or small bowel. Personnel can use site-level data to monitor prevalent types of organisms causing SSIs, enabling an evidence-based, interdisciplinary approach to develop and test methods to enhance prevention.
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Haywood S, Donahue TF, Bochner BH. Management of Common Complications After Radical Cystectomy, Lymph Node Dissection, and Urinary Diversion. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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The impact of preoperative nutritional status on post-surgical complication and mortality rates in patients undergoing radical cystectomy for bladder cancer: a systematic review of the literature. World J Urol 2020; 39:1045-1081. [PMID: 32519225 DOI: 10.1007/s00345-020-03291-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/29/2020] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To investigate the impact of preoperative nutritional factors [body mass index (BMI)], hypoalbuminemia (< 3.5 g/dL, sarcopenia) on complication and mortality rates after radical cystectomy (RC) for bladder cancer. METHODS The PubMed database was systematically searched for studies investigating the effect of nutritional status on postoperative outcomes after RC. English-language articles published between March 2010 and March 2020 were reviewed. For statistical analyses odds ratios (ORs) and hazard ratios (HRs) weighted mean was applied. RESULTS Overall, 81 studies were included. Twenty-nine studies were enrolled in the final analyses. Patients with a 25-29.9 kg/m2 BMI (OR 1.55, 95% confidence interval [CI] 1.14-2.07) and those with a BMI ≥ 30 kg/m2 (OR 1.73, 95% CI 1.29-2.40) had a significantly increased risk of 30 day complications after RC. Preoperative hypoalbuminemia increased the risk of 30 day complications (OR 1.56, 95% CI 1.07-2.35); it was a predictor of worse 3 year overall survival (OS) (HR 1.86, 95% CI 1.32-2.66). Sarcopenic patients had a higher risk of 90 day complications than non-sarcopenic ones (OR 2.49, 95% CI 1.22-5.04). Sarcopenia was significantly associated with unfavorable 5 year cancer-specific survival (CSS) (HR 1.73, 95% CI 1.07-2.80), and OS (HR 1.60, 95% CI 1.13-2.25). CONCLUSION High BMI, hypoalbuminemia, and sarcopenia significantly increased the complication rate after RC. Hypoalbuminemia predicted worse 3 year OS and sarcopenia predicted unfavorable 5 year CSS and OS. Preoperative assessment of RC patients' nutritional status is a useful tool to predict perioperative and survival outcomes.
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Mahmoudi L, Ghouchani M, Mahi-Birjand M, Bananzadeh A, Akbari A. Optimizing compliance with surgical antimicrobial prophylaxis guidelines in patients undergoing gastrointestinal surgery at a referral teaching hospital in southern Iran: clinical and economic impact. Infect Drug Resist 2019; 12:2437-2444. [PMID: 31496756 PMCID: PMC6689569 DOI: 10.2147/idr.s212728] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/09/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Antibiotic prophylaxis is one of the major approaches to prevent surgical site infection. Despite the availability of international guidelines on it, the practice of antibiotic prophylaxis is still far from optimal. This study aimed to assess the impact of guideline implementation on the rational use of prophylactic antibiotics and its cost-saving effect in gastrointestinal surgery by clinical pharmacist intervention. METHODS A pre and post intervention study was carried out between October 2017 and June 2018 on patients who underwent gastrointestinal surgery in a major referral teaching hospital in Shiraz, southern Iran. The intervention phase consisted of revising the institutional guidelines for surgical antimicrobial prophylaxis, assigning a clinical pharmacist to the surgical department, and arranging several meetings with the surgical department regarding the appropriate utilization of antibiotics. Differences in antibiotic utilization in patients before and after the intervention phase were compared. Exposures were surgical antimicrobial prophylaxis timing and agents, and main outcomes were incidence of surgical site infection and length of hospital stay. RESULTS A total of 430 patients were included in the post intervention phase, while 445 patients were included in the baseline evaluation. Promoting appropriate antibiotic use in the post intervention group had the potential to decrease medication costs by reducing unnecessary prescriptions and duration of antibiotic usage (P<0.001). In the pre intervention group, the mean cost of antibiotic prescriptions was 11.5 times that of the post intervention group. Mean hospitalization in the pre intervention group was greater than the post intervention group (P<0.001). Furthermore, our data revealed that the rate of postsurgery infection in the post intervention group was 3.03%, while this rate was 6.76% in the preintervention group (P=0.01). CONCLUSION This study provides evidence that adherence to surgical antimicrobial prophylaxis guidelines increased the rational use of prophylactic antibiotics, with substantial cost savings in patients who underwent surgery.
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Affiliation(s)
- Laleh Mahmoudi
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrdad Ghouchani
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Motahareh Mahi-Birjand
- Infectious Disease Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | | | - Ali Akbari
- Department of Anesthesiology, Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
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Kolwijck E, Seegers AEM, Tops SCM, van der Heijden AG, Sedelaar JPM, Ten Oever J. Incidence and microbiology of post-operative infections after radical cystectomy and ureteral stent removal; a retrospective cohort study. BMC Infect Dis 2019; 19:303. [PMID: 30943902 PMCID: PMC6448312 DOI: 10.1186/s12879-019-3932-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-operative infections are frequent after radical cystectomy with urinary diversion surgery (UDS). Reduction of post-operative infections necessitates appropriate peri-operative antimicrobial prophylaxis targeting causative bacteria. We assessed the incidence and microbiology of infections in the 30-day post-operative period after UDS and investigated effectiveness of the currently used peri-operative antibacterial prophylaxis. METHODS Retrospective cohort study of all patients undergoing UDS in a tertiary university medical center from January 2014 until September 2016. Antibiotic prophylaxis consisted of cefazolin plus metronidazol according to the Dutch national guideline. Primary outcome was the incidence of post-operative infections within 30 days. Risk factors for post-operative infections and antimicrobial susceptibility profiles of cultured bacteria were also assessed. RESULTS 147 patients were included. 69 patients (46.9%) had 82 post-operative infections, 27 of which were patients with bacteremia (18.4%). Highest incidence of infections was on day 4-5 and on day 8-10 postoperatively. The second peak was associated with ureteral stent removal. 4.8% of 147 study patients developed bacteremia 24 h after stent removal, which counted for 25.9% of all bacteremia episodes found in this study. Enterobacteriaceae were cultured in 67.9% of blood cultures and were only highly susceptible to ciprofloxacine, piperacillin-tazobactam (90%), meropenem and gentamicin (100%). Multivariate logistic regression analysis showed orthotopic Hautmann neobladder to be associated with increased infections complications: odds ratio 4.1 (95% confidence interval 1.6-10.5), p = 0.03. CONCLUSIONS The incidence of infections after radical cystectomy is high and particularly ureteral stent removal was associated with both bacteremia and complicated urinary tract infections. Based on the results of this study, antibiotic prophylaxis might need to be broadened for patients undergoing radical cystectomy. Further research is required to investigate whether current guidelines need to be altered concerning administration of antibiotic prophylaxis just before stent removal.
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Affiliation(s)
- E Kolwijck
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands. .,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - A E M Seegers
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - S C M Tops
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - A G van der Heijden
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J P M Sedelaar
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J Ten Oever
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
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Kolwijck E, Seegers AEM, Tops SCM, van der Heijden AG, Sedelaar JPM, Ten Oever J. Incidence and microbiology of post-operative infections after radical cystectomy and ureteral stent removal; a retrospective cohort study. BMC Infect Dis 2019. [PMID: 30943902 DOI: 10.1186/s12879.019-3932-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-operative infections are frequent after radical cystectomy with urinary diversion surgery (UDS). Reduction of post-operative infections necessitates appropriate peri-operative antimicrobial prophylaxis targeting causative bacteria. We assessed the incidence and microbiology of infections in the 30-day post-operative period after UDS and investigated effectiveness of the currently used peri-operative antibacterial prophylaxis. METHODS Retrospective cohort study of all patients undergoing UDS in a tertiary university medical center from January 2014 until September 2016. Antibiotic prophylaxis consisted of cefazolin plus metronidazol according to the Dutch national guideline. Primary outcome was the incidence of post-operative infections within 30 days. Risk factors for post-operative infections and antimicrobial susceptibility profiles of cultured bacteria were also assessed. RESULTS 147 patients were included. 69 patients (46.9%) had 82 post-operative infections, 27 of which were patients with bacteremia (18.4%). Highest incidence of infections was on day 4-5 and on day 8-10 postoperatively. The second peak was associated with ureteral stent removal. 4.8% of 147 study patients developed bacteremia 24 h after stent removal, which counted for 25.9% of all bacteremia episodes found in this study. Enterobacteriaceae were cultured in 67.9% of blood cultures and were only highly susceptible to ciprofloxacine, piperacillin-tazobactam (90%), meropenem and gentamicin (100%). Multivariate logistic regression analysis showed orthotopic Hautmann neobladder to be associated with increased infections complications: odds ratio 4.1 (95% confidence interval 1.6-10.5), p = 0.03. CONCLUSIONS The incidence of infections after radical cystectomy is high and particularly ureteral stent removal was associated with both bacteremia and complicated urinary tract infections. Based on the results of this study, antibiotic prophylaxis might need to be broadened for patients undergoing radical cystectomy. Further research is required to investigate whether current guidelines need to be altered concerning administration of antibiotic prophylaxis just before stent removal.
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Affiliation(s)
- E Kolwijck
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands. .,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - A E M Seegers
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - S C M Tops
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - A G van der Heijden
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J P M Sedelaar
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J Ten Oever
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
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