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New England Section of the American Urological Association

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Antibiotic Prophylaxis Prior to Outpatient Urologic Procedures: Outcomes From a Department-Wide Quality Improvement Project
Matthew B. Buck, BS, Justin Nguyen, MD, Alejandro Abello, MD, Michael S. Leapman, MD, Jaime A. Cavallo, MD, MPHS, Patrick A. Kenney, MD.
Yale University School of Medicine, New Haven, CT, USA.

Background:Urinary tract infections (UTI) are a common complication following office-based lower urinary tract procedures. While the American Urological Association Best Practice Statement provides guidelines on antibiotic prophylaxis in this setting, significant variability remains in practice. We assessed the effects of operationalizing a standardized approach to antibiotic use for outpatient lower tract procedures through a nursing-driven algorithm. Methods: In February 2019, we implemented a clinical decision-support algorithm based on the Best Practice Statement within a regional healthcare network including five practice sites across two states. Covered procedures were outpatient cystourethroscopies with or without manipulation and urodynamic testing. Antibiotic selection was based on an algorithm consisting of established patient risk factors. Nursing staff assessed risk factors and administered single dose 3g oral fosfomycin for eligible patients. We evaluated the impact of our protocol in reducing site-level variation in antibiotic use, abnormal urinalysis, and rates of UTI. Results: 12,909 patients were seen from January 2018 to December 2020, with 7,711 falling under the antibiotic protocol. We observed a reduction in the variation of antibiotic administration post-protocol (difference in SD = -10.55, p < 0.001), accompanied by an overall decrease in antibiotic use rate (- 9.4%, p < 0.001). Changes varied by site, with the pre-intervention highest utilizer experiencing a decrease (absolute percent change 30.70%, relative percent change - 60.99%) and the lowest utilizer experiencing an increase (absolute percentage change +14.92%, relative percentage change +46.83). Antibiotic use rate changes were not accompanied by a change in abnormal urinalysis (+2.69%, p = 0.437) or urinary tract infection ( +0.04%, p = 0.652). Conclusions: Operationalizing a standardized nurse-driven antibiotic prophylaxis pathway for office based cystoscopy reduced practice-level variation in antibiotic administration across a regional healthcare system. Changes in antibiotic practices were not associated with measurable changes in overall rates of UTI.


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