Perioperative infectious risk in urology: Management of preoperative polymicrobial urine culture. A systematic review. By the infectious disease Committee of the French Association of urology

Preoperative and Intraoperative Urine Cultures and Its Association With Postoperative Infection After Ureteroneocystostomy

OBJECTIVE

To unveil this association, we hypothesize that preoperative and intraoperative urinary tract infection (UTI) will be correlated with postoperative UTI and sepsis occurrence.

PATIENTS AND METHODS

The 2020 National Surgical Quality Improvement Program Pediatric (NSQIP-P) data was analyzed for patients undergoing ureteroneocystostomy (UNC) for vesicoureteral reflux (VUR). Patients that underwent UNC for treatment of VUR with urine culture obtained within 2weeks preoperatively or on the day of surgery were identified. The patients were divided into 3 groups: no bacterial growth, bacterial growth with UTI, and bacterial growth polymicrobial growth. Patient demographics and preoperative variables were evaluated.

RESULTS

The postoperative urinary tract infection rate of the three groups were 2.0%, 9.2%, and 9.9% for group A, B, C, respectively (P < .001). Postoperative sepsis was noted to be 0.5%, 1.3%, and 3.6% for group A, B, C (P < .01). Additionally, there was a difference between mean operative time (P < .001), mean length of stay (P = .03), and mean days from operation to discharge (P < .01). On adjusted analysis, both groups B and C had higher rates of UTI compared to group A. Group C was also seen to have greater rates of sepsis on adjusted analysis.

CONCLUSION

The association found between preoperative UTI with less than 2 species of microorganisms (group B) and postoperative UTI indicates that UTI treatment and antibiotic prophylaxis should be considered when undergoing UNC for VUR. The results of this study may lead to more careful consideration of the use of preoperative and intraoperative urine culture as well as treatment of UTI in pediatric patients with VUR undergoing UNC.

Development and validation of a parsimonious prediction model for positive urine cultures in outpatient visits

Urine culture is often considered the gold standard for detecting the presence of bacteria in the urine. Since culture is expensive and often requires 24-48 hours, clinicians often rely on urine dipstick test, which is considerably cheaper than culture and provides instant results. Despite its ease of use, urine dipstick test may lack sensitivity and specificity. In this paper, we use a real-world dataset consisting of 17,572 outpatient encounters who underwent urine cultures, collected between 2015 and 2021 at a large multi-specialty hospital in Abu Dhabi, United Arab Emirates. We develop and evaluate a simple parsimonious prediction model for positive urine cultures based on a minimal input set of ten features selected from the patient's presenting vital signs, history, and dipstick results. In a test set of 5,339 encounters, the parsimonious model achieves an area under the receiver operating characteristic curve (AUROC) of 0.828 (95% CI: 0.810-0.844) for predicting a bacterial count ≥ 105 CFU/ml, outperforming a model that uses dipstick features only that achieves an AUROC of 0.786 (95% CI: 0.769-0.806). Our proposed model can be easily deployed at point-of-care, highlighting its value in improving the efficiency of clinical workflows, especially in low-resource settings.

Single-dose fosfomycin could prevent infectious complications after retrograde intrarenal surgery: A prospective study

BACKGROUND

In this study, we aimed to show the protective effect of a single-dose Fosfomycin from infective complications against the standard usage of cephalosporine before retrograde intrarenal surgery.

MATERIAL

A total of 186 patients who underwent retrograde intrarenal surgery between 2020 and 2021, included the study. Patients were divided into two groups: group 1(n=49), patients who received an oral dose of 3g Fosfomycin tromethamine powder administered 4-6h before the operation; and group 2 (n=137): patients who received Cephalosporin 30min before surgery and an additional dose 6h after surgery.

RESULTS

The median age and stone size were significantly higher in the cephalosporin group (P=0.006 and P=0.008, respectively). There was no statistically significant difference between the groups in terms of postoperative fever and postoperative UTI (P=0.408 and P=0.438). Additionally, no patient developed sepsis. and no adverse event was seen in either group. Preoperative urinary tract infection (UTI) and previous Extracorporeal Shock Wave lithotripsy (ESWL) were independent risk factors and increased postoperative infectious complications (O.R. 2.929 95% C.I. 0.723, P<0.001, and O.R. 2.860 95% C.I. 0.985, P=0.004, respectively).

CONCLUSION

Infectious is still one of the important complications after RIRS, and preoperative UTI is an independent risk factors for infections. Fosfomycin monotherapy could be sufficient and is also effective in patients with preoperative culture positive.

Preoperative ureteral stenting in women with deep posterior endometriosis and ureteral involvement: Is it useful?

OBJECTIVE

Systematic placement of a ureteral stent before surgery for posterior deep infiltrating endometriosis (DIE) was previously recommended, but it could increase perioperative complications. We evaluate the role of preoperative ureteral stent in women requiring surgery for ureteral involvement (UI) with large posterior DIE nodules and/or grade I-II hydronephrosis.

METHODS

Women undergoing minimally invasive surgery for DIE with UI having posterior nodules >3 cm and/or grade I-II hydronephrosis from 2014 to 2019 were retrospectively included. We progressively changed our strategy from a systematic pre-operative stent insertion (S-PS, up to 2016) to a non-systematic one (NS-PS, from 2016).

RESULTS

Eighty-eight women in the S-PS group and 96 in the NS-PS were included. Low urinary tract infections (UTI) were higher in the S-PS group (13.6% vs 2.1%, P = 0.003). Hospital stay was longer in women with S-PS (9.8 ± 5.3 days vs 6.7 ± 2.5 days, P < 0.001). Logistic regression analysis confirmed a significant association between NS-PS and low UTI (adjusted OR 0.20, 95% CI 0.05-0.81, P = 0.024).

CONCLUSION

Systematic placement of a ureteral stent before surgery in women requiring surgery does not reduce overall perioperative complication rate, but it is associated with a longer duration of hospitalization and a higher low UTI rate.

Preoperative polymicrobial urine culture: An analysis of the risk of perioperative urinary tract infection

PURPOSE

To report our management of preoperative polymicrobial urine culture and to determine its correlation with the risk of postoperative urinary tract infection (UTI).

PATIENTS AND METHODS

We retrospectively identified all patients with preoperative polymicrobial urine culture in our center between January 2017 and October 2019. Preoperative urine cultures were collected 5 to 8 days before the surgery. No antibiotic prophylaxis was administered preoperatively in the absence of pyuria. Patients with pyuria (≥10 leukocytes/mm³) were treated preoperatively with Ceftriaxone. In case of beta-lactam allergy, the choice between other antibiotic therapies was left to the surgeon's discretion. A second urine culture was collected the day before surgery. The primary endpoint was the occurrence of UTI within 15 days following surgery.

RESULTS

In all, 690 patients were included in the study. In line with our protocol, patients had Ceftriaxone, Fluoroquinolones, another antibiotic or no antibiotic prophylaxis in 492 cases (71.3%), 22 cases (3.2%), 31 cases (4.5%), and 145 cases (21%), respectively. The overall sterilization rate of 40.4% was similar between each treatment arm (P=0.54). Postoperative UTI occurred in 68 cases (10.5%). In multivariate analysis, a sterile urine culture the day before surgery was the only factor decreasing the risk of postoperative UTI (OR 0.39, 95%CI, 0.17-0.84; P=0.022).

CONCLUSIONS

Our findings suggest that empirical antibiotic therapy for the treatment of preoperative polymicrobial urine culture is no longer adequate. Further evaluation of organisms isolated may provide the necessary antibiograms for initiation of susceptibility based antibiotic therapy that could decrease postoperative UTI rates.

LEVEL OF EVIDENCE

3.

[Infectious emergencies in urology]

OBJECTIVE

To report the nature, diagnosis and therapeutic strategy of infectious emergencies in urology.

MATERIAL AND METHODS

Bibliographic research from Pubmed, Embase, and Google scholar in July 2021. A synthesis of the guidelines of national infectious diseases societies.

RESULTS

Urosepsis and complicated urinary tract infection have a standardized definition. Diagnosis and therapeutic strategy are presented for upper tract urinary infection, male urinary infection, healthcare associated urinary infection, symptomatic canduria and urinary infections of the elderly. Appropriate antibiotherapy should be tailored to the degree of severity, bacterial ecosystem, patient characteristics et localization of the infection.

CONCLUSION

Urinary infections can be critical and require immediate care. Knowledge of the guidelines and of appropriate diagnosis and therapeutics strategy improve care which should be rapidly applied, and collegial.

Epidemiology and risk factors for ureteral stent-associated urinary tract infections in non-transplanted renal patients: a systematic review of the literature

PURPOSE

Pathophysiology and risk factors for Ureteral Stent-Associated Urinary Tract Infection (USAUTI) have been poorly investigated. This situation results in highly diverse practices regarding USAUTI prevention, diagnosis and treatment. The aim of the present study was to describe the epidemiology and risk factors for USAUTI in non-transplanted patients.

METHODS

We conducted a systematic literature review based on a comprehensive PubMed® bibliographic strategy, between October 1998 and March 2020. The methodological quality of the studies included was analyzed according to dedicated grids. The main endpoints were the correlation between different potential risk factors and infection ureteral stent-associated urinary tract infection or colonization rate. Conclusions and their level of evidence were reported on the basis of a critical analysis of the best available scientific evidence. This work has been submitted to a national review, which enabled the potentially divergent opinions of experts to be collected, thereby ensuring adequate quality of data.

RESULTS AND CONCLUSION

Twenty-six studies out of the 505 articles identified, were included in the final analysis. Staphylococcus spp, E. coli, Klebsiella spp, Pseudomona aeruginosa, Enterococcus spp. and Candida spp. were the microorganisms most often responsible for asymptomatic bacteriuria (ABU) or USAUTI. Longer indwelling time, diabetes mellitus, female gender, chronic renal failure, diabetic nephropathy and cancer were identified as risk factors for ABU and ureteral stent colonization. No specific risk factor for UTI was identified in the literature studied. A causal relationship between ureteral stent colonization and USAUTI or urosepsis remains to be demonstrated.

[Evaluation of French practices in 2019 regarding prevention and treatment of urinary tract infections related to ureteral stent]

INTRODUCTION

Urological recommendations never focused on prevention and treatment of urinary tract infections related to endo-ureteral material.

METHODS

We conducted an evaluation of French professional practices in May 2019 in the aim of highlighting the important heterogeneity of practices using a Survey Monkey inquiry.

RESULTS

One-hundred-and-seventy-five urologists answered the inquiry, as to say 13% of French urologists. Questions regarding the management of pre-surgical polymicrobial urine sample, medical and surgical management of pyelonephritis on endo-ureteral material and regarding the need to diagnose and treat asymptomatic bacteriuria before endo-ureteral stent removal are the main points a majority of French urologists felt uncomfortable with.

CONCLUSION

This study evaluated French practices in 2019. The diversity of the answers highlights the need for new recommendations on these subjects of daily practice. Future recommendations should allow their homogenization based on the existing evidence-based data.