Antibiotic prophylaxis prior to office-based urologic procedures: outcomes from a department-wide quality improvement project

Abstract

Introduction: Urinary tract infections (UTI) are a common complication following office-based lower urinary tract procedures. While the American Urological Association (AUA) provides guidelines on antibiotic prophylaxis in this setting, significant practice variability remains. We implemented a standardized approach to antibiotic prophylaxis for office-based lower tract procedures through a nursing-driven algorithm. We hypothesized that a risk-adapted approach would reduce prophylactic antibiotic utilization and practice variability without increasing febrile UTI rates.

Methods: We conducted a pre-post study to examine the protocol's effects on antibiotic usage, abnormal urinalysis, and UTI rates. In February 2019 we implemented a clinical decision-support algorithm based on the AUA guidelines within our regional healthcare network. For office-based cystoscopy or urodynamics, nurses employed a standardized protocol to assess patient and procedural risk factors and administer single-dose 3 g oral fosfomycin to eligible patients.

Results: 12,909 patients had office-based procedures from March 2017 to December 2020, of whom 7,711 were treated after implementation of the nursing pathway. While overall antibiotic prophylaxis usage declined after implementation (-9.4%, p < 0.001), changes varied by site of practice. Frequency of prophylaxis decreased at the site with the highest baseline use (absolute change: -30.7% from pre to post-intervention, relative change: -61.0%) and increased at the site with the lowest baseline (absolute change: +14.9%, relative change: +46.8%). Following implementation, no changes in the occurrence of UTI were observed (+ 0.04%, p = 0.65).

Conclusions: Operationalizing a standardized antibiotic prophylaxis pathway for office-based cystourethroscopy and urodynamics reduced practice-level variation in antibiotic administration across a regional healthcare system. Despite an overall reduction in the use of antibiotic prophylaxis, there was no increase post-procedural febrile UTI rates.

Keywords: Antimicrobial prophylaxis; Evidence-based practice; Office-based procedures; Procedural antibiotics; Quality improvement.