Proposal and clinical validation of a perioperative algorithm enhancing antimicrobial stewardship in substitution urethroplasty

doi:10.1016/j.ajur.2024.01.003

Asian Journal of Urology, 2024, 11 (4): 604-610 doi: 10.1016/j.ajur.2024.01.003

Original Articles

Proposal and clinical validation of a perioperative algorithm enhancing antimicrobial stewardship in substitution urethroplasty

Phillip Marks^a,Benedikt Kranzbühler^a,b,Luis A. Kluth^c,Christian P. Meyer^d,Clemens M. Rosenbaum^e,Tim A. Ludwig^a,Liucheng Ding^a,f,Lennart Kühnke^a,Frederik König^a,Roland Dahlem^a,Margit Fisch^a,Malte W. Vetterlein^a,*(

),on behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology Young Academic Urologists

^aDepartment of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
^bDepartment of Urology, University Hospital Zürich, Zürich, Switzerland
^cDepartment of Urology, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
^dDepartment of Urology, Ruhr-University Bochum, Campus OWL, Herford, Germany
^eDepartment of Urology, Asklepios Hospital Barmbek, Hamburg, Germany
^fDepartment of Urology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China

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Abstract

Objective: To evaluate the impact of a standardized antibiotic stewardship protocol on three subsequent endpoints in patients undergoing urethroplasty.

Methods: Men undergoing bulbar substitution urethroplasty between January 2009 and December 2016 were stratified by urine culture (UCx) at the time of surgery (sterile vs. non-sterile) and were subjected to a standardized algorithm for urinalysis and antimicrobial therapy. We performed quantitative and qualitative exploration of UCx results and the microbial spectrum. The ability of the algorithm to improve antibiotic stewardship was tested by three endpoints: (a) immediate (UCx 2 days postoperatively), (b) short-term (21-day infectious complications), and (c) long-term (retreatment-free survival [RFS]). Statistical analyses included bivariate comparisons. The Kaplan-Meier estimators were used to compare RFS between the groups. The multivariable Cox regression was used to evaluate the independent effect of UCx status at the time of surgery on RFS.

Results: Of 374 men, 235 (63%) had a sterile and 139 (37%) a non-sterile culture at the time of surgery. The proportion of sterile cultures at the time of surgery (63%) was significantly improved to 82% 2 days postoperatively (p<0.001). There were 16 (4.3%) patients with infectious complications with no difference between patients with sterile versus non-sterile culture (p=0.6). At median follow-up of 29 months, there was no difference in RFS (84%) between patients with sterile versus non-sterile culture (p=0.3). Positive UCx was not a predictor of recurrence after multivariable adjustment (p=0.5).

Conclusion: A standardized protocol such as the one introduced improves antibiotic stewardship through frequent testing and culture-specific treatment. This is crucial in avoiding unnecessary antimicrobial treatment, and reducing infectious events and adverse effects of a positive UCx on long-term stricture recurrence.

Key words： Antibiotic prophylaxis Oral mucosa Urethroplasty Urethral stricture

Received: 15 September 2023 Available online: 20 October 2024

Corresponding Authors: *E-mail address: m.vetterlein@uke.de (M.W. Vetterlein).

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	Phillip Marks
	Benedikt Kranzbühler
	Luis A. Kluth
	Christian P. Meyer
	Clemens M. Rosenbaum
	Tim A. Ludwig
	Liucheng Ding
	Lennart Kühnke
	Frederik König
	Roland Dahlem
	Margit Fisch
	Malte W. Vetterlein
	on behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology Young Academic Urologists

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Cite this article:

Phillip Marks,Benedikt Kranzbühler,Luis A. Kluth, et al. Proposal and clinical validation of a perioperative algorithm enhancing antimicrobial stewardship in substitution urethroplasty[J]. Asian Journal of Urology, 2024, 11(4): 604-610.

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http://www.ajurology.com/EN/10.1016/j.ajur.2024.01.003 OR http://www.ajurology.com/EN/Y2024/V11/I4/604

The flowchart of a standardized perioperative algorithm regarding frequent urinalysis and culture-specific targeted treatment, which is applied to patients undergoing urethral reconstruction at the Department of Urology at the University Medical Center Hamburg-Eppendorf. The day indications in the diagram refer to the days before (i.e., -1 day means 1 day prior to surgery) and after the surgery, with “Day 0” representing the day of the surgery. POD, postoperative Day; UA, urinalysis; UCx, urine culture; LEUK⁺⁺⁺, leukocytes significantly positive; Tx, therapy; Preop, preoperative. ? Each UCx with a positive finding implicates targeted culture-specific antimicrobial therapy for ±5 days.

Baseline and intraoperative characteristics in 374 men undergoing one-stage buccal mucosal graft urethroplasty stratified according to preoperative UCx (the UCx-2) results.

Graphic representation of patients presenting with a non-sterile urine culture at the time of surgery and the microbial spectrum in such patients; UCx, urine culture.

Bivariate analyses of preoperative UCx (the UCx-2) findings with immediate and short-term outcomes in 374 men undergoing one-stage bulbar buccal mucosal graft urethroplasty.

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