Sepsis post ureteroscopy: does pre-operative urine screening help?
Pre-operative urine screening and prophylactic antibiotic use in ureteroscopy
BAUS ePoster online library. Henry M.
Jun 26, 2018; 217788
Ms. Mei-Ling Henry
Ms. Mei-Ling Henry
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INTRODUCTION: European guidelines for urology recommend that a urine sample is obtained prior to treatment in patients undergoing an endourological procedure for stone removal and that peri-operative antibiotic prophylaxis is offered (Bonkat et al, 2015). However, the guidance does not give recommendations on specific antibiotic agents or timing of administration. Ureteroscopy is recommended as primary treatment for symptomatic ureteric stone disease or early elective treatment where primary treatment of the stone is not immediately possible. It may also be used for diagnostic purposes (Tsiotras et al, 2018).
Public Health England recommends that local guidelines should be relevant to the local healthcare setting and take local antibiotic resistance patterns into account (Public Health England, 2015). Current local guidelines recommend suitable prophylaxis based on stone position and pre-operative urine culture results. In June 2015 the laboratory method for culturing urine samples in this local NHS trust changed significantly with the introduction of a semi-automated commercial technology. Consequently the number of antibiotics that could be tested became limited and gentamicin susceptibility was no longer routinely performed. This led to the concern that some gentamicin resistant strains may be missed and gentamicin used inappropriately which could contribute to an increased risk of post-procedural sepsis. Furthermore, in August 2016 the pre-operative assessment process for urology patients was moved from within the Urology department to a general pre-operative assessment unit. After the change, routine urine cultures for these patients did not reliably happen for several months. During this time there were multiple cases of severe post-procedural sepsis in patients where there was no urine culture available to guide appropriate prophylaxis, and at least one patient received inappropriate antibiotics which may have contributed to the development of sepsis.
The current process for acting on positive culture results is a letter to the patient's general practitioner (GP) asking them to review the patient and prescribe antibiotics ifsymptomatic.
Adherence to the current local guideline has never been audited; therefore a baseline audit was required to investigate current practice before considering changes to guidance.
AIMS: This audit aimed to ascertain current practice at a single centre for urology, regarding the use of pre-operative urine cultures and the appropriateness of antibiotic prophylaxis given. This audit also aimed to identify problems with the content or implementation of the local guideline in the context of current laboratory testing.
METHODS: Criteria and Standards
The criteria were set based on local guidelines, which reflect European guidance (Table 1) (Bonkat et al, Nicolle et al).
Criterion 1: Patients undergoing pre-operative assessment for ureteroscopic stone removal should have a urine sample sent to the laboratory for culture (standard: 100%).
Criterion 2: Patients with a positive urine culture should be assessed with regards to symptoms of active urinary tract infection (UTI) and if present, prescribed antibiotics prior to date of surgery (standard: 100%).
Criterion 3: Patients undergoing ureteroscopic stone removal (upper 2/3 of ureter) should receive appropriate antibiotic prophylaxis, defined in the local guideline as:
a) gentamicin 2mg/kg, if pre-operative urine culture had no growth and there were no previously reported gentamicin resistant strains;
b) an antibiotic that correlates to the sensitivities on culture report if pre-operative urine culture had positive growth;
c) gentamicin 2mg/kg, if no culture result available and there were no previously reported gentamicin resistant strains (standard: 100%).
Criterion 4: Antibiotic prophylaxis should be administered within 60 minutes (standard: 100%).
Case Identification
The cases were identified from Bluespier Theatre Manager, an electronic system used locally for booking and recording operative procedures, using the inclusion of ureteroscopy in the primary procedure title recorded (includes flexible ureteroscopy and rigid ureteroscopy, Common code M30.9). Sixty consecutive cases of elective ureteroscopy performed at one single centre for urology were identified from 21/08/17 to 30/11/17.
Patients and data sources
This audit used retrospective data collected from digital health records (DHR Unity Viewer), the local laboratory results reporting system (NOTIS) and the electronic theatre manager system (Bluespier Theatre Manager), and cross-referenced between systems by name, date of birth and local hospital number. Pre-hospital prescription data was collected from NHS Summary Care Records, cross-referenced by name, date of birth and NHS number.
Outcome Definitions
Sepsis was defined by evidence of meeting High Risk Red Flag Sepsis criteria (NICE, 2017) as documented in the medical notes accessed on the digital health record.
Statistical Analysis
All data was analysed using Microsoft excel 2010.
RESULTS: Demographics
The mean age of patients operated with ureteroscopy was 60.4 years (range 26.9-79.9) and 51.6% of patients were male. The mean BMI of patients was 29.6kg/m2 (range 17.8-52.9) and 36.7% of patients were obese (defined as BMI >30) (22/60). The median length of stay post-operatively was 1 day (range 0-18).
Criterion 1: Pre-operative urine culture
66.6% of patients had a urine sample sent from pre-operative assessment (40/60). Urine culture results were available 30 days before surgery in 51.6% of patients (31/60) and 90 days before surgery in 78.3% of patients (47/60). The median length of time between pre-operative assessment and surgery was 18 days (range 0-226).
Criterion 2: Pre-operative antibiotic prescription
14.9% of patients had a positive pre-operative urine culture (7/47). Of these patients, one had antibiotics prescribed by their general practitioner (GP), five did not have antibiotics prescribed by their GP, and one had no data on GP prescriptions available.
Criterion 3: Intra-operative antibiotic prophylaxis
The correct antibiotic choice according to guidance was administered in 46.7% of patients (28/60). Where gentamicin was administered, the correct dose of gentamicin was calculated in 67.3% of patients (35/52).
Criterion 4: Timing of administration
88.1% of patients had antibiotic prophylaxis administered less than 60 minutes before the operation start time (52/59). One patient had missing data for timing of administration.
High risk red sepsis was identified in 6.7% of patients (4/60). 
DISCUSSION: Audit findings
Overall compliance with the local guideline was below the standard set in each criterion. Approximately a third of patients did not have a urine sample cultured pre-operatively and approximately half of patients did not have a result reported in the 30 days prior to surgery. This may be related to the varied range of time from pre-operative assessment to surgery (range 0 to 226 days).
There was also poor compliance with correct antibiotic prophylaxis (30% compliance, 18/60). This appears mostly due to antibiotic choice and dose, as the majority of patients received their antibiotic prophylaxis within an appropriate timeframe (88.1%, 52/59). It was noted in particular that there was high use of co-amoxiclav although this antibiotic was not included in the guideline and susceptibility results not routinely reported.
Strengths and limitations
In this audit, retrospective data was collected and therefore reliability of the data relies on the quality of documentation of data recorded for clinical rather than audit purposes. However, this allowed us to include pre-operative and post-operative data for patients attending over several months and record episodes of post-operative sepsis. Use of community data allowed us to see when antibiotics were prescribed but did not provide data on whether a GP letter was received or if the patient was reviewed and found to be asymptomatic, therefore no reliable conclusions can be drawn regarding GP involvement.
Other literature
Chew et al (2016) reported a higher rate of post-operative infection in patients given pre-operative antibiotics than the present study (9.9% vs 6.7%) and Martov et al (2015) reported lower rates (<2.2% vs 6.7%). This discrepancy may be due to subtle differences in outcome definition as we defined infection based on the UK national sepsis guideline, updated in 2017 (NICE, 2017). Pubmed searches revealed no other recent literature with rates of infection reported in relation to ureteroscopy and antibiotic prophylaxis. This suggests a need for further research into the merit of antibiotic prophylaxis.
CONCLUSIONS: This audit identified several areas of poor compliance with local guidelines regarding antibiotic prophylaxis and pre-operative urine screening. Specific feedback was given to relevant practitioners, practice was changed in the microbiology department and the local guideline was amended as a result. Unfortunately due to system pressures, no changes could be introduced to reduce the amount of time between pre-operative assessment and date of surgery although it was acknowledged that this may be a contributing factor to inappropriate antibiotic choice. A re-audit will be planned following presentation and discussion at the relevant departmental meetings. 
RECOMMENDATIONS: Feedback was given to relevant practitioners regarding use of co-amoxiclav, appropriate dosing of gentamicin, and sending and labelling of pre-operative urine samples for all patients. The microbiology department changed practice to start routinely releasing co-amoxiclav results for resistant isolates, to reduce the risk of this antibiotic being inappropriately selecting as prophylaxis. The local guideline was also amended to recommend microbiology discussion for prophylaxis in patients already on systemic antibiotics.recommend microbiology discussion for prophylaxis in patients already on systemic antibiotics.
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