Extended antimicrobial prophylaxis raises C. diff risk

Seattle-Whereas best practice policy states that antimicrobial prophylaxis for urologic procedures should be discontinued within 24 hours, extended regimens are common among patients undergoing surgery for urologic cancer and putting them at risk for hospital-acquired Clostridium difficile colitis, say researchers from the University of Washington, Seattle.

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"A recent review indicates that the rate of C. difficile colitis has been increasing worldwide and points to increased antimicrobial use as a major contributing factor," said first author Joshua Calvert, MPH, a medical student at the University of Washington.

“Our study demonstrates that inappropriate antimicrobial prophylaxis is exposing patients undergoing genitourinary cancer surgery to a preventable complication and one that is also a source of increased health care costs. These findings indicate a need for efforts that will improve provider compliance with evidence-based approaches to postoperative care.”

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The authors suggested that surgeon-led quality collaboratives might be a viable approach for successfully changing surgeon behavior in terms of antimicrobial prescribing for patients undergoing urologic cancer surgery.

Dr. Gore“Processes of care that reflect ingrained provider practices respond well to feedback reporting that is a common strategy for quality improvement within existing surgical collaboratives,” noted senior author John Gore, MD, MS, assistant professor of urology at the University of Washington.

In the research, which was presented at the 2014 AUA annual meeting in Orlando, FL, and subsequently published in the Journal of Urology (2014; 192:425-9), practice patterns for antimicrobial prophylaxis during the years 2007 to 2012 and the impact of using an extended regimen on hospital-acquired C. difficile colitis were analyzed using data from the Premier Perspectives Database. Based on searching by ICD-9 codes, the study included 59,184 patients who underwent radical prostatectomy, 27,921 patients who underwent partial or radical nephrectomy, and 5,425 patients who had radical cystectomy.

Mean duration of antimicrobial prophylaxis was 10.3 days for the cystectomy patients, 4.0 days in the nephrectomy group, and 1.9 days for men undergoing prostatectomy. Extended antimicrobial prophylaxis, defined as receipt of the initially prescribed antimicrobial or antimicrobial within the same class beyond 24 hours postoperatively, was identified in 56.3% of the cystectomy cohort, 28.8% of nephrectomy patients, and 17.7% of patients undergoing radical prostatectomy.

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Rates of postoperative C. difficile colitis in the cystectomy, nephrectomy, and prostatectomy groups were 1.7%, 0.23%, and 0.02%, respectively. In multivariate logistic regression analysis adjusting for age, gender, race, marital status, comorbidity, insurance status, and hospital type, extended antimicrobial prophylaxis increased the risk of C. difficile colitis by 3.8-fold among patients who underwent nephrectomy and by 1.6 times in the cystectomy cohort.

Study patients were operated on at more than 400 different hospitals, and the analyses also determined that hospital identity was a major factor in extended antimicrobial use. Variation at the hospital level was greatest within the prostatectomy patient group and least prominent for radical cystectomy.

Calvert acknowledged that since the Premier Perspective Database represents a subset of American hospitals, the study results might not be fully generalizable to the entire nation. Nevertheless, they are expected to be fairly representative of nationwide trends because the database encompasses a large, heterogeneous group of hospitals and includes all patients regardless of payer.

Other limitations of the study include the possibility that C. difficile colitis rates are underreported, as the database does not capture infections that occurred after patient discharge. In addition, while the definition for extended antimicrobial prophylaxis was designed to help exclude patients who might have been receiving prolonged treatment because of a suspected or existing infection, there is not granularity in the data to identify variables that could otherwise explain ongoing antimicrobial treatment or that might have increased patient risk for the hospital-acquired infection.

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