Drastic Drop in Antibiotic Overuse for Common Urology Procedure: How They Did It

NEW ORLEANS -- Using a tool to classify patients' infection risk and providing education and systems-level changes in the urology department safely reduced prophylactic antibiotic use around cystoscopy, according to a single-center study.

Total antibiotic use dropped nearly 30% with the combined approach, a significant difference compared with before the intervention, said Kelly R. Pekala, MD, of the University of Pittsburgh Medical Center, during a press briefing here at the annual meeting of the American Urological Association (AUA).

Even so, there was no increase in infection reported within 30 days of cystoscopy, Pekala reported. Infection rates in the 3 months before intervention and during the 12-month intervention period remained constant at around 2%, they fell to less than 1% in the 3 months following the implementation of the intervention.

Antibiotic overprescribing is associated with antibiotic resistance, which is responsible for about 23,000 deaths annually in the U.S. and 100,000 deaths worldwide, Pekala noted. For that reason, the AUA's 2019 antibiotic guidelines for cystoscopy broke with the traditional universal antibiotic prophylaxis in favor of using oral antibiotics only if there is a break in the mucosal barrier; they also eliminated fluoroquinolones as the antibiotic of choice.

To increase adherence to that guideline, Pekala's institution launched the intervention, which included:

• Formal education with a grand rounds presentation to department faculty regarding the risks of antimicrobial resistance associated with overprescribing antibiotics
• Modification of electronic health record order sets
• Clinic staff education
• The introduction of surveys and individual audit feedback

To obtain baseline data, Pekala and her colleagues retrospectively reviewed the urology clinic schedule for the 3 months prior to the intervention and identified all 473 patients who underwent cystoscopy. Then they completed a literature review and designed a cystoscopy survey to be given to patients that was based on previous protocols and AUA guidelines in order to identify those who were at high risk of infection.

The clinic started using the survey during the 12-month intervention period in which 2,137 cystoscopies were done. Another 417 cystoscopies occurred in the 3-month post-intervention period.

According to the defined protocol, about 65% of patients in their study were identified as at high risk of infection, leaving 35% for whom antibiotics were not indicated, Pekala reported. The study population had an average age in their 60s and was mostly male.

In the pre-intervention period, 99% of patients were administered antibiotics, the majority of which were fluoroquinolones -- a class of drug that the FDA warns should be reserved for patients when no alternative treatment options are available for uncomplicated urinary tract infection. However, during and after the intervention phase, fluoroquinolone use decreased significantly to 15% and 6.5%, respectively.

In addition, utilization rates of recommended antibiotics increased to 91% and persisted post-intervention.

"This type of study is not easy to do," commented Adam B. Weiner, MD, of Northwestern Medicine in Chicago, who moderated the press briefing, "This was a lot of steps and involved a lot of components in the intervention to ultimately get to that very dramatic change in antibiotic prescribing." He asked Pekala which of the intervention's components is most important if other urology departments want to replicate it.

"I think the survey was the anchor to get people to really make a significant change in their clinical practice," she said. "It was really easy for our medical assistants to administer, and it made it so that our physicians didn't really have to think about it, which really helped drive the intervention."

Also, informing the clinicians about the data behind the guidelines during the grand rounds presentations helped, as did individual discussions, she said, when asked about faculty buy-in.

"There was some resistance initially from people who have been giving antibiotics for years and years for these procedures," she acknowledged. "But, there's always going to be some resistance to change."

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