EAU 2017: The use of antibiotic prophylaxis in patients undergoing radical cystectomy for bladder cancer

London, England (UroToday.com) Urinary tract infections after radical cystectomy (RC) and urosepsis remains prevalent and continue to be a significant cause of morbidity in this patient population. While traditional antibiotic prophylaxis has often been dictated by colorectal literature, due to the entrance into the small bowel for urinary reconstruction, there is very little literature regarding antibiotic prophylaxis in RC alone.

The authors aimed to address this issue by retrospectively analyzing the RC database of 3 different clinical centers in the Netherlands. Baseline clinicopathologic variables included age, gender, body mass index (BMI), ASA score, clinical and pathological TNM, type and duration of AB and type of urinary diversion. They also accounted for the presence of urologic devices before RC, neo-adjuvant chemotherapy (NAC), previous radiotherapy and prolonged steroid therapy before surgery. Urine samples and blood samples were obtained for microbiological cultures. Urinary tract infection was diagnosed according to EAU/ESIU clinical definitions. Patients were stratified based on length of perioperative antibiotic therapy administration – short (<72 hours) vs. long (>72 hours). The primary objective of the group was to assess the antibiotic (AB) utilization, the percentage and severity of UTIs after surgery, the bacteria responsible for them and their AB sensitivity, frequency of in-hospital interventions (imaging or procedures) due to UTIs and 30-day readmission rate.

A total of 217 patients were identified between 2009-2015. Median length of hospital stay was 13 days (IQR 11-20.5), of which 9.2% were still in hospital after 30 days. 16.1% of patients discharged prior to 30-days were readmitted within 30 days. Of note, looking at the demographics, only 6.9% of the patients received NAC despite 68% being pT2+. 60% of patients had some urinary tract drainage prior to surgery (urinary catheter, stent, nephrostomy tube) and 95% underwent intestinal preparation.

The most frequently used antibiotic therapy was a combination of metronidazole (98.2%) with a cephalosporin (89.9%), typically cefuroxime. The median of days of AB administration after RC was 7 days (IQR 5-14) but after cessation of the first AB therapy, additional antibiotics were used in 51.6% of the patients.

The overall number of UTIs was 42 (19.4%): 9.7% pyelonephritis, 7.8% urosepsis and 1.8% uroseptic shock. Enterococcus spp. was the most frequently isolated bacteria in urine (25.7%) and in blood (42.9%). In this cohort, the Enterococcus species showed significant resistance to cephalosporins and ciprofloxacin (100%).
- This point was highlighted during discussion; traditionally, E.coli was presumed to be the primary source of UTI in this population. Unfortunately, most prophylaxis regimens don’t usually cover Enterococcus.
- A main take-home point then is that UTI post-RC should be treated with coverage that includes Enterococcus

On final multivariate analysis assessing predictors of UTIs, continent urinary diversion was the only significant predictor. Considering the production of mucus and long-term urinary drainage, this is understandable – another abstract in this same session discussed using sandostain to help reduce mucus production and UTI burden.
They did note that antibiotic prophylaxis duration did not impact UTI risk.

Limitations / Discussion Points:
1. The generalizability regarding antibiotic choice is somewhat limited by the different antibiograms of each region/country. Each hospital often has its own antibiogram detailed bacteria prevalence and antibiotic susceptibility.
2. Practice pattern differences may affect outcomes. Median hospital stay of 13 days is significantly longer than in other regions/countries, and perhaps may skew the results. Additionally, median duration of 7 days is far beyond traditional guidelines for antibiotic prophylaxis. The author mentioned that at the time of the study, 5 days was the typical prophylactic coverage at their hospital.

While an interesting study, unfortunately due to practice pattern differences and differing antibiograms, this is not generalizable. It does confirm the high rate of UTIs. Key take-home points: Antibiotic duration didn’t affect UTI risk (hence shorter course may be preferred) and Enterococcus is the most common cause of post-RC UTI and should be covered with subsequent antibiotic therapy.

Presented by: Maximilian Haider

Co-authors: Mayr R., Fritsche H-M., Ladurner C., Pycha A., Comploj E., Lemire F., Lacombe L., Fradet Y., Lodde M.

Institution(s):
1. Erasmus MC, Dept. of Pathology, Rotterdam, The Netherlands
2. Erasmus MC, Cancer Computational Biology Center (CCBC), Rotterdam, The Netherlands
3. Erasmus MC, Dept. of Urology, Rotterdam, The Netherlands

Written by: Thenappan Chandrasekar , Clinical Fellow, University of Toronto
Twitter: @tchandra_uromd

at the #EAU17 -March 24-28, 2017- London, England
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