Adherence to Antibiotic Prophylaxis Guidelines Among Patients Undergoing Radical Cystectomy With Ileal Conduit for Bladder Cancer - Megan Prunty

March 21, 2023

Megan Prunty joins Ruchika Talwar to discuss a Journal of Urology publication that explores prophylactic antibiotic use in the setting of radical cystectomy. The study used the Premier Healthcare Database to evaluate the use of antibiotics for radical cystectomy from 2015 to 2020 and focused on the subset of patients that get ileal conduits. The study found that only 28% of patients who get cystectomies in the US actually have guidelines-based or guidelines-driven antibiotics. The vast majority of deviation from AUA guidelines is extended duration antibiotic use, and the patients who got guidelines-driven antibiotics had fewer infectious complications. The study suggests that if adherence to the AUA guidelines is encouraged, it could decrease some of the infectious complications seen in patients, specifically UTI, pyelonephritis, and C. diff infections.


Megan Prunty, MD, Urology Resident, University Hospitals, Case Western Reserve University, Cleveland, OH

Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN

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Ruchika Talwar: Hi everyone, my name's Ruchika Talwar. I'm a current Urologic Oncology Fellow at Vanderbilt University Medical Center and I'm the AUA's Legislative Fellow for this year. I'm really excited to kick off UroToday's Health Policy Center of Excellence and we'll be highlighting a series of notable articles that delve into the world of urologic health policy. And I am super excited that our first speaker is here with us today, Dr. Megan Prunty from Case Western, and she'll be discussing her recent article published in JU that explores prophylactic antibiotic use in the setting of radical cystectomy. Thanks Dr. Prunty, for making time to chat.

Megan Prunty: Yeah, thank you so much for having me.

Ruchika Talwar: So let's jump right in. Tell me about your article.

Megan Prunty: Sure. So we use the Premier Healthcare Database, which uses charge codes to get very granular data on inpatient admissions and hospital charges. And it is so large that it encompasses about 25% of all hospital stays in the US. So the AUA guidelines had previously been based on data from Premier that was published using data that went up to 2013, and we realized that's a decade out of date. So we decided to use very similar methodologies and try and update our information and our data on cystectomy and antibiotic use. So we queried the database from 2015 to 2020 and evaluated the use of antibiotics for radical cystectomy, specifically for the subset of patients that get ileal conduits. And then we went ahead and categorized them as guidelines based or not guidelines based, and then evaluated infectious outcomes based on that categorization.

Ruchika Talwar: Great. And what did you find?

Megan Prunty: So not surprising, only 28% of all patients who get cystectomies in the US actually have guidelines-based or guidelines-driven antibiotics, and that's better than it was in 2013. And 2013, I think they found 13% of all patients got AUA guidelines-driven antibiotics. So we're improving, but still 28% is far below the mark of what we would hope to see for our patients getting cystectomies. So the vast majority of the, I don't want to call it an error, but deviation from AUA guidelines is extended duration antibiotic use, and we define that as more than 24 hours of antibiotics. And I'll give you the caveat of how to think about this. So the current AUA guidelines as they stand as of 2020, recommend a single dose of antibiotics for a cystectomy. But for the 2015 to 2020 period, less than 24 hours was acceptable, so that's what we used for this paper. And so 37% of patients got extended duration antibiotics beyond 24 hours. And then the other deviances were combination antibiotic therapies when they weren't necessarily indicated.

Ruchika Talwar: So what do your results mean for our patients?

Megan Prunty: So in terms of our patients, I think what we noticed is that patients who got guidelines driven antibiotics had fewer infectious complications, and that's all retrospective. So there's a number of things that factor into their outcomes. But if we encourage adherence to the AUA guidelines, then I'm hopeful that we could decrease some of the infectious complications that we see in our patients, specifically UTI, pyelonephritis, C. diff infections, all the things that go along with antibiotic use.

Ruchika Talwar: Yeah. And often these patients, especially those who undergo a major surgery like a radical cystectomy, have prolonged hospital stays, so they're getting exposed to all sorts of nasty multi-drug resistant bugs. And then obviously their new plumbing, so to speak, does predispose them to more severe infections. So I think you're right. I think hopefully adhering to a better protocol for prophylactic antibiotics will help improve outcomes.

Megan Prunty: Yeah.

Ruchika Talwar: There's been a lot of focus on guideline adherence lately, and that's the big reason I brought you here in our health policy discussion for UroToday.

Megan Prunty: Yeah.

Ruchika Talwar: As our healthcare system tries to shift towards value-based care, they're looking for measures of quality and one of those big measures of quality is guideline adherence, for all the reasons that you mentioned. I think being good stewards of antimicrobials is important for resistance to avoid complications, all of those things. But thank you for this work that you're doing because I think that hopefully we can improve the quality of care that we provide by making sure clinician teams do follow guidelines and provide evidence-based care.

Megan Prunty: Absolutely. Absolutely.

Ruchika Talwar: A question that I had regarding the use of local antibiograms, for lack of a better term, obviously resistance does vary from area to area. I'm not sure if that's something that you were able to look at with your Premier Database, but even just sort of spit-balling here, I can't think of a situation in which extended duration of antibiotics would be beneficial with different types of antibiotic user dosing. But is that something that you think could have contributed to this 20 or so percent adherence rate?

Megan Prunty: I'll come around back to your question, but ultimately for this study, we did not have access to patient preoperative cultures. So there is undoubtedly a subset of patients in this study who had a positive urine culture preoperatively, were diagnosed with a UTI clinically, and then received appropriate extended duration antibiotics based on that antibiogram. But I don't have local antibiotics unfortunately for our study. But one thing I think is interesting, it's not necessarily a local antibiogram, but it's just an understanding of the GI flora is that one of the most common deviations from the AUA guidelines was adding Flagyl or metronidazole to the antibiotic regimen. And as long as you're not in the large bowel, that shouldn't be relevant or necessary. So by definition, ileal conduit should be small bowel and you shouldn't need Flagyl. And so maybe that sort of understanding of the microbiome of the small bowel versus large bowel could be relevant clinically, especially in this picture.

Ruchika Talwar: Yeah, I think that makes a lot of sense. Well, thank you again for taking the time to chat. Congratulations on your study. I think it's important work, and a lot of people say, "Well, we have these guidelines out there, there's no need to be exploring this any further," but I think your results really underscore the fact that we do need to be measuring the quality of care we deliver. Because 28%, that's far deviating from anything that could be accounted for when we talk about resistance patterns or certain pre-op cultures, it's hard for me to believe that 75-plus percent of patients had some kind of pre-op culture.

Megan Prunty: Yeah. Right, right.

Ruchika Talwar: Yeah. But congratulations again on your study. It's great. And thanks for chatting.

Megan Prunty: I appreciate that. Yeah, thank you so much for having me.

Ruchika Talwar: And we are excited to continue to highlight more articles in this Health Policy Center of Excellence, so please do tune in and thanks for watching UroToday.