Impact of Pathogen Colonization on Infection of the Urinary Tract after Radical Cystectomy
Jacqueline M. Speed, MD; Elodi J. Dielubanza, MD; H. Abraham Chiang, MD; Adam S. Kibel, MD; Preston A. Mark, MD; MPH; Matthew Mossanen, MD
Brigham and Women's, Boston, MA
BACKGROUND: Urinary tract infection (UTI) is a common complication after radical cystectomy (RC) that can lead to readmission. The consequences of microbial colonization in RC patients is not well described. We explored the prevalence of colonization through surveillance cultures in a RC cohort and examined its impact on the risk of post-operative UTI. We hypothesized that colonized RC patients would have higher rates of UTI. METHODS: We queried an IRB-approved, institutional database of 134 RC patients managed with our Enhanced Recovery After Surgery (ERAS) protocol from 2015-2017. Inclusion criteria for study was receipt of surveillance urine culture prior to hospital discharge. Patients who received antimicrobials for infection prior to admission for RC were excluded. Perioperative antimicrobial prophylaxis included ceftriaxone and metronidazole for 24 hours and single-dose ciprofloxacin for stent removal. Patient demographics and pertinent clinical data were collected. Colonization was defined as isolation of yeast or bacteria on urine culture in an asymptomatic patient. UTI was defined as fever or localizing urinary symptoms with positive urine culture. Statistical analysis was performed using student's T-test, Mann-Whitney U and Fisher's exact test, as appropriate. RESULTS: Fifty-nine patients received surveillance cultures, of which 29% (n=17) had robotic RC and 76% (n=45) had an ileal conduit. Median age was 68 and 57% (n=33) of patients were male. Colonization was present in 49% of patients (n=29) and was not associated with age, diabetes, surgical approach or diversion type. Candida, enterococcus, and coagulase (-) staphylococcus were the most common isolates in 11, 7, and 5 patients, respectively. 17% of patients (n=10) developed a UTI within 90 days and 30% (n=18) developed a UTI within the follow-up period (median follow-up 7.4 months). Of the patients who developed UTI within 90 days, 4 of 10 were associated with stent removal, all were in patients who were not colonized, and all required readmission. Enterococcus, klebsiella, and pseudomonas were the most common pathogens in UTI. There was no statistically significant difference in the rate of UTI among those with negative surveillance cultures and colonized patients (36.7% vs 24.1%, p=0.40). Only 2 of 7 patients with colonization on surveillance culture and UTI had a UTI caused by the same organism. CONCLUSIONS: Microbial colonization and UTI are common after radical cystectomy. However, colonization did not predict UTI in our cohort. Pre- hospital discharge surveillance cultures may have limited utility in predicting and preventing post-operative UTI in this population.
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