Urinary Tract Infections Following Radical Cystectomy with Enhanced Recovery Protocol: A Prospective Study - Beyond the Abstract

Urinary tract infection (UTI) is a common complication following radical cystectomy (RC) with a rate ranging between 9.5% and 39%. It can significantly increase morbidity and readmission rates as well as the financial burden for both patients and the health care system. In the past decade, attempts have been made to improve cystectomy recovery and decrease postoperative morbidity using Enhanced Recovery After Surgery (ERAS®) protocols. These protocols include avoiding bowel preparations, early feeding, and mobilization, perioperative prophylactic antibiotics, as well as postoperative suppressive antibiotics in some institutions. Much of the work to prevent postoperative UTIs has focused on changing the perioperative antibiotic regimen; however, this has not shown a significant reduction in UTI rate.

In this study, we assessed the effect of postoperative suppressive antibiotics on the rate of UTI following RC in the context of an established ERAS® protocol. We retrospectively reviewed 427 patients who underwent RC with ERAS® between May 2012 and January 2017 at our institution. Our ERAS® protocol included 24-hr perioperative prophylactic antibiotics followed by suppressive antibiotics until removal of the catheter/stents. We defined UTI as (i) positive urine culture and documented symptoms, (ii) positive urine culture with treatment per practitioner discretion, or (iii) negative or unavailable urine culture but UTI treatment based on the clinical presumption. Urosepsis was defined if any of UTI episodes were associated with positive blood culture. Based on this definition, the incidence of UTI and urosepsis was 36.1% and 7.13% within 90-days following RC, respectively. Candida (25%) and Escherichia coli (22%) were the most commonly identified pathogens (Figure 1).

Figure 1. Frequency of common pathogens cultured from patients with UTI
pathogens

The high rate of candida-positive urine culture in our study, which is in line with the increasing trend of fungal UTIs in recent years, requires distinct attention. The presence of foreign bodies (i.e. catheter/stents) and patient’s comorbidities, as well as the use of broad-spectrum antibiotics for presumed UTI, can potentially contribute to the development of fungal UTI following RC. The AUA recommendation is to not extend prophylactic antibiotics beyond 24 hours after surgery except for special situations. However, most institutions continue the use of antibiotics as a “suppressive regimen”, based on their own protocols.

In our study, UTI and urosepsis were significantly lower in patients who received suppressive fluoroquinolones compared to other antibiotic regimens. It is worth mentioning that the FDA recently updated its black box warning to include the association between fluoroquinolones and potentially disabling side effects. In RC patients, the risks and benefits of such antibiotic use need to be considered before the prescription. Particular attention should be paid to the patients with an orthotopic neobladder since we showed that the risk of UTI in this group is more than twice that of the patients with an ileal conduit.

In summary, this study showed that UTI is common following RC and urinary diversion with candida and Escherichia coli as the most common pathogens. The use of suppressive fluoroquinolones has been associated with a significant decrease in UTI rate. We recommend multi-institutional prospective studies/trials to confirm the results of our study and demonstrate the optimal antibiotic regimen/intervention to prevent UTI in patients with RC.

Written by: Alireza Ghoreifi, MD and Hooman Djaladat, MD, MS, Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California

References:

  1. Ghoreifi, Alireza, Christine M. Van Horn, Willem Xu, Jie Cai, Gus Miranda, Sumeet Bhanvadia, Anne K. Schuckman, Siamak Daneshmand, and Hooman Djaladat. "Urinary tract infections following radical cystectomy with enhanced recovery protocol: A prospective study." In Urologic Oncology: Seminars and Original Investigations. Elsevier, 2020.
  2. Clifford, Thomas G., Behrod Katebian, Christine M. Van Horn, Soroush T. Bazargani, Jie Cai, Gus Miranda, Siamak Daneshmand, and Hooman Djaladat. "Urinary tract infections following radical cystectomy and urinary diversion: a review of 1133 patients." World journal of urology 36, no. 5 (2018): 775-781.
  3. Djaladat, Hooman, Behrod Katebian, Soroush T. Bazargani, Gus Miranda, Jie Cai, Anne K. Schuckman, and Siamak Daneshmand. "90-Day complication rate in patients undergoing radical cystectomy with enhanced recovery protocol: a prospective cohort study." World journal of urology 35, no. 6 (2017): 907-911.
  4. Daneshmand, Siamak, Hamed Ahmadi, Anne K. Schuckman, Anirban P. Mitra, Jie Cai, Gus Miranda, and Hooman Djaladat. "Enhanced recovery protocol after radical cystectomy for bladder cancer." The Journal of urology 192, no. 1 (2014): 50-56.
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