Compliance of clinical practice with guidelines on prophylactic antibiotic use in urologic cancer surgery

In the era of rising microbial resistance to antibiotic treatment, it is of outmost importance to rationalize the exposure to antibiotics, especially in the context of prophylaxis. Related to the use of antibiotics for peri-operative prophylaxis in urologic cancer surgery, several guidelines exist, including the Guidelines of the European (EAU) and American Association of Urology (AUA), and of the American Society of Health-System Pharmacists (ASHP). In the EAU Guideline, although possible choices of antimicrobial prophylaxis are listed (favoring use of cephalosporin’s generation 2/3 and aminopenicillins/beta lactamase inhibitor), it is emphasized that specific antimicrobial should be chosen based on pathogen prevalence, antibiotic susceptibility and virulence. Stringent regulatory conditions regarding the use of fluoroquinolones are implemented by the European Commission, resulting in the suspension of the indication for peri-operative antibiotic prophylaxis. AUA/ASHP guidelines are more permissive to fluoroquinolones, depending on the resistance of the setting. All guidelines are univocal in limiting antibiotic exposure to ≤ 24 h, unless indications of infection exist.
In this paper, preliminary data on the compliance of clinical practice in urologic cancer surgery with these guidelines at the PHI University Clinic of Urology in Skopje are presented. From the official database for evidence of patients (Venicom software), 31 patients who underwent urological cancer surgery were identified, including radical prostectomy, transurethral resection of the prostate, radical cystectomy, partial/radical nephrectomy, partial/complete penile amputation. Antimicrobial administration, class and duration for peri-procedural prophylaxis were extracted.
Most used antibiotics were 3rd generation cephalosporins, followed by fluoroquinolones (in around 70.97% and 19.35% of patients, respectively), as single-therapy regimens. In 9.68% of patient, a combination of 3rd generation cephalosporin and nitroimidazole was used for prophylaxis in radical nephrectomy and cystectomy. Therefore, antimicrobial use consistent with EAU-recommendations included the appropriate class in around 71% of patients and in around 90% of patients with AUA/ASHP Best Practices. In around 71% of patients (mostly treated with 3rd generation cephalosporin, ⁓ 68%) no indications of infection were observed. In these patients, an average prophylaxis duration ranged from 2 days (for radical prostatectomy and transurethral resection of prostate treated with 3rd generation cephalosporin and fluoroquinolone, respectively) to 7 days (for radical nephrectomy treated with 3rd generation cephalosporin).
The results obtained are in line with a reported real-world (non-)adherence, pointing that in interpreting the compliance with the guidelines, other factors have to be considered as well. In this line, clinical pharmacists hold a pivotal role in implementation of the current guidelines in (urological) surgery by optimizing antibiotic treatment, dose adjustment, prevention of polypharmacy-related interactions, but also promoting evidence-based prophylaxis and rationale use of antibiotics.