Urinary Tract Infection Following Radical Cystectomy with an Enhanced Recovery Protocol
Radical cystectomy with urinary diversion (RC) is a complex surgery associated with morbid complications, such as urinary tract infection (UTI). Enhanced Recovery After Surgery (ERAS) protocols are improving perioperative care, though the literature has limited data on preventive regimens for UTI. We assessed the effect of an ERAS protocol on UTI rates after RC.
We reviewed 279 patients who received RC for bladder cancer with ERAS (2013-2017). The protocol uses perioperative antibiotics, suppressive antibiotics until stent removal, and single-dose aminoglycoside at the time of stent removal by practitioner discretion. UTI was defined as: positive urine culture with symptoms; positive urine culture without documented symptoms but antibiotic treatment by practitioner discretion; or negative/unavailable urine culture with reported symptoms and clinically presumed UTI. UTI within 90 days, patient characteristics, and protocol-related antibiotic use were assessed. Chi-square, Fisher&[prime]s exact test, time to event, and multivariable Cox regression were used.
107 patients (38.4%) had ≥1 UTI within 90 days of RC. Patient characteristics are depicted in Table 1. Median time to UTI was 13 days. 41.1% of first UTI had negative cultures, 18.7% gram-positive bacteria, 22.4% gram-negative bacteria, and 16.8% fungi. 19 first events (17.8%) were before discharge, 52 (48.6%) from discharge to stent removal, and 30 (28.0%) afterward (Table 2). 7 events (6.5%) were urosepsis. On multivariate analysis, postoperative fluoroquinolones reduced UTI risk (HR 0.57, 95%CI 0.352-0.922, p=0.022); and increased UTI-free probability (0.67 vs 0.51 on other regimens, p=0.021). UTI risk increased with each additional hospital stay day (HR 1.07, 95%CI 1.042-1.103, p<0.0001) and orthotopic diversion (HR 1.70, 95%CI 1.102-2.605, p=0.016). </p>
Longer hospital stay and orthotopic diversion were associated with higher UTI risk following radical cystectomy. Suppressive postoperative fluoroquinolone was associated with reduced 90-day UTI risk.