Optimizing practices to prevent urinary tract infection after cystoscopy and urodynamics in women: A quality improvement study

OBJECTIVE

The objective of this study was to reduce the incidence of urinary tract infection (UTI) in women undergoing outpatient cystoscopy and/or urodynamic studies (UDS) at our centre by identifying and then altering modifiable risk factors through an analysis of incidence variability among physicians.

METHODS

This was a quality improvement study involving adult women undergoing outpatient cystoscopy and/or UDS at an academic tertiary urogynecology practice. Prophylactic practices for cystoscopy/UDS were surveyed and division and physician-specific UTI rates following cystoscopy/UDS were established. In consultation with key stakeholders, this delineated change concepts based on associations between prophylactic practices and UTI incidence, which were then implemented while monitoring counterbalance measures.

RESULTS

Two "Plan-Do-Study-Act-Cycles" were conducted whereby 212 and 210 women were recruited, respectively. Change concepts developed and implemented were: (1) to perform routine urine cultures at the time of these outpatient procedures, and (2) to withhold routine prophylactic antibiotics for outpatient cystoscopy/UDS, except in patients with signs of cystitis. There was no change in the incidence of early presenting UTI (9.0% vs. 9.2%, p = 0.680), but there were significantly fewer antibiotic-related adverse events reported (8.5% vs. 1.5%, p = 0.001). There was no significant change in the total incidence of UTI rates between cycles (7.8% vs. 5.6%, p = 0.649).

CONCLUSIONS

No specific strategies to decrease the incidence of UTI following outpatient cystoscopy/UDS were identified, however, risk factor-specific antibiotic prophylaxis, as opposed to universal antibiotic prophylaxis, did not increase UTI incidence.

Antibiotic prophylaxis in urologic interventions: Who, when, where?

BACKGROUND

Periprocedural prophylaxis in medicine encompasses the set of measures (physical, chemical, and pharmacological) used to reduce the risk of infection. Antibiotic prophylaxis (AP) refers to the administration of a short-term regimen of antibiotics shortly before a medical procedure to reduce the risk of infectious complications that can result from diagnostic and therapeutic interventions. The outspreading growth of multidrug-resistant bacterial species and changes in the bacterial local ecosystem have impeded the development of a unique scheme of AP in urology.

OBJECTIVES

To review the literature and current guidelines regarding AP for urological diagnostic and therapeutic procedures, and to define agents, timing, and occasions when administering pharmacological prophylaxis. Secondly, according to current literature, to open new scenarios where AP can be useful or useless.

RESULTS

Major gaps in evidence still exist in this field. AP appears useful in many invasive procedures and some sub-populations at risk of infectious complications. AP is not routinely recommended for urodynamic exams, diagnostic cystoscopy, and extracorporeal shock-wave lithotripsy. The available data regarding the use of AP during the transperineal prostate biopsy are still unclear; conversely, in the case of the transrectal approach AP is mandatory. AP is still considered the gold standard for the prevention of postoperative infective complications in the case of ureteroscopy, percutaneous nephrolithotomy, endoscopic resection of bladder tumor, endoscopic resection of the prostate, and prosthetic or major surgery.

CONCLUSION

The review highlights the complexity of determining the appropriate candidates for AP, emphasizing the importance of considering patient-specific factors such as comorbidities, immunocompetence, and the nature of the urologic intervention. The evidence suggests that a one-size-fits-all approach may not be suitable, and a tailored strategy based on the specific procedure and patient characteristics is essential.

Evaluating the Safety of Performing Flexible Cystoscopy When Urinalysis Suggests Presence of "Infection": Results of a Prospective Clinical Study in 2350 patients

Background

There is significant underutilisation of allocated health service resources when a scheduled flexible cystoscopy (FC) is cancelled because a pre-cystoscopy urinalysis (PCU) suggests “infection”, despite patients being asymptomatic for urinary tract infection (UTI).

Objective

To evaluate the risk of UTI or urinary sepsis when FC is performed in asymptomatic patients with a PCU positive for leucocyte esterase and/or nitrites.

Design, setting, and participants

A prospective cohort study was conducted in a high-volume UK centre recruiting all patients undergoing outpatient FC.

Intervention

A protocol was developed to guide response to PCU performed prior to FC, which was performed regardless of the result, unless patients were symptomatic for UTI. All patients completed a questionnaire to identify risk factors and were followed up via a telephone survey and a review of electronic clinical records.

Outcome measurements and statistical analysis

Post-FC UTI was defined as hospital admission with UTI/urinary sepsis or if patients were symptomatic for UTI with receipt of antibiotics or with positive urine culture and sensitivity. An analysis of the association was performed.

Results and limitations

An initial pilot study confirmed the safety and feasibility of our protocol. Of 1996 patients, 136 (6.8%) developed a UTI by our definition, with 51 (2.6%) having a culture-proven infection. The risk was higher in patients with a positive PCU (odds ratio [OR] 1.61, 95% confidence interval [CI] = 1.07–2.40, p = 0.02), history of UTI (OR 1.72, 95% CI = 1.09–2.73, p = 0.02), or a bladder tumour on FC (OR 2.22, 95% CI = 1.27–3.90, p = 0.005). No patient with a positive PCU developed urinary sepsis. The main limitation of this study was the lack of pre-protocol control.

Conclusions

We observed a clinically low and acceptable risk of UTI, with no incidence of sepsis, when FC was performed in asymptomatic patients with a PCU suggesting “infection”. Routine cancellation of these patients is unnecessary and may worsen the burden on health service resources.

Patient summary

We evaluated the safety of performing flexible cystoscopy when the urine dipstick on the day suggested presence of an “infection” but the patient had no symptoms of urinary tract infection (UTI). Our study in over 2000 patients demonstrated a low incidence of UTI, and none of these patients developed sepsis. We therefore recommend that flexible cystoscopy should not be cancelled automatically on the basis of the dipstick result alone, as it might delay a time-sensitive crucial diagnosis.

A Randomized Controlled Trial to Study the Rationale of Antibiotic Prophylaxis in Diagnostic Rigid Cystoscopy: A Relook in The Era of Antibiotic Stewardship

Background

In the era of widespread antibiotic (AB) resistance, the role of prophylaxis in diagnostic cystoscopy is controversial.

Aim

This study aimed to compare the incidence of postcystoscopy positive urinary culture (PC-PUC) and urinary tract infection (UTI) in patients undergoing diagnostic rigid cystoscopy with and without prophylaxis with preprocedural single-dose intravenous AB.

Materials and Methods

This prospective study was done in patients with preprocedural sterile urine undergoing elective diagnostic rigid cystoscopy. Patients were randomized into two groups, with one group receiving preprocedure single dose of intravenous cefuroxime sodium as prophylaxis half to 1 h before the procedure (Group AB prophylaxis) and the other group receiving no antibiotic prophylaxis (Group NAB). All patients were followed up till 1-month postprocedure, for any symptoms of urinary infection, mandatory urine microscopy and culture at 24-48 h, 1 week and 4 weeks post procedure, and addition sample in case of any urinary symptoms or fever.

Results

A total of 225 patients were studied, with 110 in AB prophylaxis and 115 in NAB groups. The use of prophylaxis did not decrease the incidence of PC-PUC (8.7%-3.6%; P = 0.167) or UTI (6.1%-1.8%; P = 0.102). Females and diabetics had significantly higher risk of PC-PUC, on univariate and multivariate analysis, not affected by prophylaxis.

Conclusion

Preprocedural AB prophylaxis does not decrease the incidence of postcystoscopy bacteriuria significantly. Females and diabetics have significantly increased risk, but prophylaxis has no role in them either.

Flexible cystoscopy for ureteral stent removal without antimicrobial prophylaxis. A prospective observational study

OBJECTIVE

Flexible cystoscopy for ureteral stent removal after ureteroscopy is widely performed. In this scenario, the real need for antimicrobial prophylaxis is still uncertain. Aim of this study is to determine the urinary tract infections rate after 4 weeks from outpatient flexible cystoscopies for ureteral stent removal without antimicrobial prophylaxis.

PATIENTS AND METHODS

A prospective observational study was performed between November 2017 and August 2018 in a single, high-volume Institution.Risk factors for UTIs were recorded. Immediately before cystoscopy, each patient submitted a voided urine specimen. Antibiotics were not given before or after cystoscopy. About 7 and 28 days after cystoscopy all the patients underwent abdomen US, urine analysis and culture, and clinical evaluation to assess possible symptoms of UTI.

RESULTS

A total of 192 patients were enrolled in the study, 76 patients (39.2%) were female. Median age was 55 years [IQR 47- 68]. Median BMI was 24.2 [22.9-26.7]. Eighteen patients (9.4%) had asymptomatic bacteriuria before cystoscopy and 39 (20.3%) had positive culture at 7 days. About 21 patients (10.9%) were diagnosed with febrile UTI in the 28 days FU period. The 28.6 % of the Febrile patients had asymptomatic bacteriuria before the stent removal (p < 0.001), this group was slightly older (p = 0.085) and with higher BMI (p = 0.036).Forty-eight patients had positive urine culture at 7 days, of whom 27 (14.1%) were asymptomatic and were classified as asymptomatic bacteriuria. Multivariate analysis shows that only high BMI and bacteriuria before the procedure were significantly associated with developing a febrile UTI, none of the other risk factors was significant.

CONCLUSION

Our data show a high rate of UTI after flexible cystoscopies for ureteral stent removal without antimicrobial prophylaxis especially in patients with asymptomatic bacteriuria, in those with high BMI and in the elderly; in these subgroups, antimicrobial prophylaxis should be recommended.

Antibiotics are not necessary during routine cystoscopic stent removal: A randomized controlled trial at UC San Diego

Introduction:

Current American Urological Association (AUA) Best Practice Statement recommends antibiotic prophylaxis for cystoscopy with manipulation, including stent removal; although no Level 1b trials explicitly address prophylaxis for stent removal. We sought to determine the efficacy of prophylactic antibiotics to prevent infectious complications after stent removal.

Materials and Methods:

Following institutional review board approval, patients undergoing removal of ureteral stent placed during stone surgery were recruited from July 2016 to March 2019. Patients were recruited at the time of stent removal and randomized to treatment (single dose 500 mg oral ciprofloxacin) or control group (no antibiotics). Telephone contact was attempted within 14 days of stent removal to assess for urinary tract infection (UTI) symptoms, antibiotic prescriptions, or Emergency Department visits. Primary outcome was UTI within 1 month of stent removal – defined by irritative voiding symptoms, fever or abdominal pain associated with positive urine culture (Ucx) (>100k colony-forming units/mL).

Results:

Seventy-seven patients were enrolled, with 58 meeting final inclusion criteria for the analysis (33 treatment, 25 controls). No differences were seen with clinical and demographic variables, except a higher body mass index in the treatment group (P = 0.007). Positive Ucx rate before stone surgery (16.7% vs. 11.8%, P = 0.819) and at the time of stent removal (16.0% vs. 11.1%, P = 0.648) was not significantly different in treatment versus control groups, respectively. Primary outcome: No patients in either cohort developed symptomatic culture-diagnosed UTI within 1 month of stent removal. Of patients with documented phone follow-up (treatment n = 29, control n = 22), only one patient (control) reported any positive response on phone survey.

Conclusions:

We found a low infectious complication rate regardless of antibiotic prophylaxis use during cystoscopic stent removal. The necessity of antibiotics during routine cystoscopic stent removal warrants possible reevaluation of the AUA best practice statement.

[Is it necessary to perform urine culture systematically prior to double J ureteral stent removal?]

OBJECTIVE

To assess the value of systematic urine culture before ureteric double j removal.

MATERIAL AND METHODS

This prospective audit was performed to assess the validity of our current clinical practice. A cohort of informed patients without clinical signs of urinary tract infection and without predefined risk factors were programmed for ureteral double j stent removal in an outpatient setting. Urine was sampled for culture immediately before the procedure. Patients had to complete a self-questionnaire 15 days following stent removal, inquiring about tolerance and complications which were to be analyzed according to the culture results. The primary endpoint was the occurrence of febrile urinary tract infection.

RESULTS

Among the 56 participants, immediate preoperative urine culture revealed colonization in 9 patients (16.1%) and contamination in 6 patients (10.7%). A significant association was found between bacteriuria and double j placement following surgery with urinary tract injury (P<0.02) and diabetes (P<0.009). Two patients had fever including a man with sterile urine and a woman with Staphylococcus Aureus infection. No hospitalization was necessary. Twelve patients reported functional signs with lumbar pain being the most common. There was no significant association between functional signs and patients' clinical characteristics.

CONCLUSION

This evaluation was not in favor of modifying our protocol of care i.e. the lack of performing neither antibiotic prophylaxis nor systematic urine culture before JJ ureteral stent removal in a selected population.

LEVEL OF EVIDENCE

4.

Antimicrobial agents for preventing urinary tract infections in adults undergoing cystoscopy

BACKGROUND

Cystoscopy is commonly performed for diagnostic purposes to inspect the interior lining of the bladder. One disadvantage of cystoscopy is the risk of symptomatic urinary tract infection (UTI) due to pre-existing colonization or by introduction of bacteria at the time of the procedure. However, the incidence of symptomatic UTI following cystoscopy is low. Currently, there is no consensus on whether antimicrobial agents should be used to prevent symptomatic UTI for cystoscopy.

OBJECTIVES

To assess the effects of antimicrobial agents compared with placebo or no treatment for prevention of UTI in adults undergoing cystoscopy.

SEARCH METHODS

We comprehensively searched electronic databases of the Cochrane Library, PubMed, Embase, LILACS, and CINAHL. We searched the WHO ICTRP and ClinicalTrials.gov for ongoing trials. We used no language or date restrictions in the electronic searches. We searched the reference lists of identified articles and contacted authors for related information. The last search of the electronic databases was 4 February 2019.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) or quasi-RCTs that compared any prophylactic antibiotic versus placebo, no treatment, or other non-antibiotic prophylaxis in adults undergoing cystoscopy. There was no restriction on the dose, frequency, formulation, duration, or mode of administration of the antibiotics.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were systemic UTI, symptomatic UTI (composite of systemic and/or localized UTI), and serious adverse events. Secondary outcomes were minor adverse events, localized UTI, asymptomatic bacteriuria, and bacterial resistance. We assessed the quality of evidence using GRADE.

MAIN RESULTS

We included 20 RCTs and two quasi-RCTs with 7711 participants, all of which compared antibiotic prophylaxis with placebo or no treatment control. We found no studies comparing antibiotic prophylaxis with non-antibiotic prophylaxis.Primary outcomesSystemic UTI: antibiotic prophylaxis may have little or no effect on the risk of systemic UTI compared with placebo or no treatment (risk ratio (RR) 1.12, 95% confidence interval (CI) 0.38 to 3.32; 5 RCTs; 504 participants; low-quality evidence); this corresponds to two more people (95% CI 12 fewer to 46 more) per 1000 people developing a systemic UTI. We downgraded the quality of the evidence for study limitations and imprecision.Symptomatic UTI: antibiotic prophylaxis may reduce the risk of symptomatic UTI (RR 0.49, 95% CI 0.28 to 0.86; 11 RCTs; 5441 participants; low-quality evidence); this corresponds to 30 fewer people (95% CI 42 fewer to 8 fewer) per 1000 people developing a symptomatic UTI when provided with antibiotic prophylaxis. We downgraded the quality of the evidence for study limitations and potential publication bias.Serious adverse events: the studies reported no serious adverse events in either the intervention group or control group and no effect size could be calculated. Antibiotic prophylaxis may have little or no effect on serious adverse events (4 RCTs, 630 participants; very low-quality evidence), but we are very uncertain of this finding. We downgraded the quality of the evidence for study limitations and very serious imprecision.Secondary outcomesMinor adverse events: prophylactic antibiotics may have little or no effect on minor adverse events when compared with placebo or no treatment (RR 2.82, 95% CI 0.54 to 14.80; 4 RCTs; 630 participants; low-quality evidence). We downgraded the quality of the evidence for study limitations and imprecision.Localized UTI: prophylactic antibiotics may have little or no effect on the risk of localized UTI (RR 1.0, 95% CI 0.06 to 15.77; 1 RCT; 200 participants; very low-quality evidence), but we were very uncertain of this finding. We downgraded the quality of the evidence for study limitations and very serious imprecision.Bacterial resistance: prophylactic antibiotics may increase bacterial resistance (RR 1.73, 95% CI 1.04 to 2.87; 38 participants; 2 RCTs; very low-quality evidence), but we were uncertain of this finding. We downgraded the quality of the evidence for study limitations, indirectness, and imprecision.We were able to perform few secondary analyses; these did not suggest any subgroup effects.

AUTHORS' CONCLUSIONS

Antibiotic prophylaxis may reduce the risk of symptomatic UTI but not systemic UTIs. Serious and minor adverse events may not be increased with the use of antibiotic prophylaxis. The findings are informed by low- and very low-quality evidence ratings for all outcomes.

Safety and effectiveness of zero antimicrobial prophylaxis protocol for outpatient cystourethroscopy

OBJECTIVES

To examine compliance and clinical outcomes after implementation of a zero antimicrobial prophylaxis protocol for outpatient cystoscopy in an academic centre.

PATIENTS AND METHODS

Medical records of all patients who underwent diagnostic cystoscopy in the year preceding and year following protocol implementation were evaluated for urinary tract infection (UTI) diagnosis within 30 days of cystoscopy. Variables compared between groups included age, sex, smoking history, benign prostatic hyperplasia (BPH) diagnosis, diabetes mellitus, immunosuppression, catheter use (indwelling, suprapubic, or intermittent), and previous lower urinary tract reconstruction (augmentation cystoplasty or neobladder). UTI was defined using the National Surgical Quality Improvement Program definition. Rates were compared between groups, and statistical analyses were performed using chi-squared and Fisher's exact tests and multivariable logistic regression, with significance defined as α < 0.05.

RESULTS

In total, 941 patients were included in the analysis (72% men), 513 before protocol initiation, and 427 after. Groups were similar with regard to demographic variables and potential risk factors for infection. After protocol implementation, there was a significant reduction in patients receiving procedural antimicrobial prophylaxis (30% vs 15%; P < 0.001). The incidence of UTI after cystoscopy was slightly higher in the post-protocol group (2.9-3.7%), but the difference was not statistically significant (chi-squared = 0.56, P = 0.45). The incidence of UTI did not significantly differ with procedural antibiotic prophylaxis or with other antibiotic use at time of cystoscopy. Five out of a total of 31 UTIs (16%) over the study period resulted in fever, and four (13%) resulted in urosepsis. The probability of neither complication differed significantly between pre- and post-protocol groups. The only significant patient-level predictor of post-cystoscopy UTI was catheter use (odds ratio 1.48, 95% confidence interval 1.06-2.06).

CONCLUSION

Protocol implementation led to a significant decrease in procedural antimicrobial prophylaxis, indicating protocols may be effective tools in promoting antibiotic stewardship. UTI incidence did not change significantly under the protocol, and antibiotic prophylaxis did not decrease infection rate. Our results support catheter use as a risk factor for post-cystoscopy infection, but other patient variables, including those present in the American Urological Association Best Practice statement, were not predictive. In total, this analysis suggests that decreasing antibiotic prophylaxis for cystourethroscopy is safe and can be effective in the outpatient setting.