Adherence to the AUA Penile Prosthesis Antibiotic Prophylaxis Guidelines in Diabetic Patients is Associated with Significantly Higher Risks of Device Infection
Maxwell M. Towe, MD1, Lael Reinstatler, MD MPH2, Mohamad M. Osman, MD1, Linda M. Huynh, MD1, Farouk M. El-Khatib, MD1, Gregory Broderick, MD3, Arthur L. Burnett, MD4, Martin S. Gross, MD5, Georgios Hatzichristodoulou, MD6, Jonathan Clavell-Hernandez, MD7, Gerard D. Henry, MD8, Tung-Chin Hsieh, MD9, Lawrence C. Jenkins, MD10, Aaron C. Lentz, MD11, Ricardo M. Munarriz, MD12, Daniar Osmonov, MD13, Sung Hun Park, MD14, Jay Simhan, MD15, Run Wang, MD7, Faisal A. Yafi, MD1
1University of California Irvine, Orange, CA, 2Dartmouth-Hitchcock Medical Center, Lebanon, NH, 3Mayo Clinic-Jacksonville, Jacksonville, FL, 4Johns Hopkins University, Baltimore, MD, 5Dartmouth-Hitchcock Medical Center/Dartmouth-Hitchcock Keene, Keene, NH, 6Julius-Maximilians-University of Würzburg, Würzburg, Germany, 7University of Texas Medical School at Houston, Houston, TX, 8Ark-La-Tex Urology, Shreveport, LA, 9University of California San Diego, San Diego, CA, 10Ohio State University, Columbus, OH, 11Duke University, Raleigh, NC, 12Boston University, Boston, MA, 13University Medical Center Schleswig-Holstein, Kiel, Germany, 14Sewum Urology Center of Excellence, Seoul, Korea, Republic of, 15Einstein Healthcare Network, Philadelphia, PA
BACKGROUND: The most devastating complication following penile prosthesis (PP) implantation is an infection requiring device explantation. Current AUA guidelines recommend antibiotic prophylaxis before PPI with an aminoglycoside and either a 1st/2nd generation cephalosporin or vancomycin. We conducted a multi-institutional study to examine infection rates in diabetic patients undergoing PP implantation with different prophylactic antibiotic regimens, and compared outcomes based on adherence to AUA guidelines.
METHODS: Between April 2003 and May 2018, data was collected from 15 different institutions, and charts of 710 patients with diabetes receiving primary PP implantation were reviewed. Demographic data including age, race, Body Mass Index (BMI), and type of diabetes were collected for each patient. Pre-operative antibiotic regimen was recorded for each patient and primary outcomes were post-operative infection, explantation, and revision rates. Patients had a median follow up time of 7 months (range: 0 - 157). Patients were included in the analysis only if they had complete information regarding perioperative antibiotics and outcomes. Univariate comparisons of proportions were completed for rates of infection, explantation, and revision between different antibiotic regimens.
RESULTS: Overall, 603 patients had complete records and were included in this study. The total number of infections, explantations, and revisions for all patients included were 23 (3.8%), 29 (4.8%), and 33 (5.5%), respectively. The AUA prophylaxis guidelines were followed in 282 patients, 220 (36.5%) received Gentamicin + Vancomycin as prophylaxis and 62 (10.3%) received Gentamicin + Cephalosporin (Cefazolin), while 321 (53.2%) received prophylaxis that differed from guidelines. The number of infections in the AUA guidelines group was 17 (6.0%) vs. 6 (1.9%) for the non-AUA guidelines group, p = 0.008. The number of explantations in the AUA guidelines group was 23 (8.2%) vs. 6 (1.9%) in the non-AUA guidelines group, p < 0.001. There was no significant difference in revision rates between the two groups (p = 0.360). On further analysis, the infection rate for patients treated with Gentamicin + Vancomycin (7.73%) dropped significantly when a Quinolone (1.04%) was added to the regimen, p=0.001. Similar reductions were seen with explantation (9.6% to 1.0%, p < 0.001) and revision (8.2% to 3.1%, p = 0.028) rates. Out of the 23 recorded infections, 14 (60.9%) of them grew a positive culture with at least one isolated organism and 6 (42.9%) of them grew multiple species. Overall, 9 (64.3%), 6 (42.9%), 4 (28.6%), and 3 (21.4%) of the cultures grew gram-positive, gram-negative, anaerobic bacteria, and fungi, respectively.
CONCLUSIONS: Adherence to the AUA penile prosthesis antibiotic prophylaxis guidelines confers a higher rate of device infection in diabetic patients. The high rate of infection was noted in patients receiving the most commonly prescribed antibiotic regimen of Gentamicin + Vancomycin. The AUA guidelines should be amended to reflect findings of this and other device infection related studies.
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