NEW YORK (Reuters Health)  Urologists in the US Veterans Administration (VA) health system are overprescribing antimicrobials after common procedures instead of following the American Urological Association (AUA) guidelines, researchers say.

"Antibiotics are life-saving medications, but their use is associated with several risks, including antibiotic resistance, drug-related side effects and C. difficile," Dr. Daniel Livorsi of the University of Iowa Hospitals and Clinics in Iowa City told Reuters Health. "This seemingly unnecessary use of antibiotics is exposing patients to potential harm."

To assess discordance with AUA guidelines, Dr. Livorsi and colleagues manually reviewed medical records for 375 patients (mean age, 64; 98% men) from five VA centers who underwent either transurethral resection of a bladder tumor (TURBT), transurethral resection of the prostate (TURP) or ureteroscopy (URS). Twenty-five patients were randomly selected per procedure, per site.

Antimicrobial prescribing practices for 29,530 patients (mean age, 69; 98% men) across the national VA system were also analyzed, using administrative data. As reported online December 21 in JAMA Network Open, the medical record review showed periprocedural or postprocedural antimicrobial prescribing was guideline-discordant in 217 patients (57.9%), including inappropriate agent or inappropriate indication. 

Postprocedural antimicrobial agents

Similarly, postprocedural antimicrobial agents were continued beyond 24 hours in 211 patients (56.3%) and were guideline-discordant in 177 patients (83.9%), with a median duration of three days of unnecessary antimicrobial therapy. The analysis of national administrative data revealed that excessive postprocedural antimicrobial agents were prescribed in 10,988 patient records (37.2%), with a median of three excess days.

Analyses at the facility level found wide variation in excessive postprocedural antimicrobial use. For example, facilities with higher procedural counts for TURP were less likely to prescribe excessive postprocedural antimicrobial prophylaxis; however, a similar correlation was not seen for TURBT or URS. Further, the frequency of excessive postprocedural antimicrobial use within a given facility had statistically significant positive correlations across procedures, suggesting that facilities with higher rates of excessive use for one procedure also had higher rates for another procedure.

"I do not think our findings are unique to the VA," Dr. Livorsi noted. "There are at least two other non-VA studies that have evaluated the use of antibiotics after urologic procedures, and both found that antibiotics are frequently continued after urologic procedures for longer than is typically recommended." To prevent post-surgical infection, he said, "it is highly unusual to require antibiotics for more than 24 hours, and for many surgeries, it's recommended to use just a single antibiotic dose or even no antibiotics at all."

"The spread of antibiotic resistance is a major public health challenge," he added. "Reducing unnecessary antibiotic use in this setting is just one example of how physicians can be better stewards of antibiotics." "In many instances, urologists are simply over-cautious," Dr. Carl Olsson, Director of Quality Initiatives and Strategy in the Department of Urology, Icahn School of Medicine at Mount Sinai in New York City, said by email.

"But they may also be uninformed or unconvinced by data reviewed in the course of the development and/or updating of American Urological Association guidelines." "They should trust these guideline updates, which derive from dedicated study by their own specialty's clinical care leaders," he said.