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MP55-16 VARIATION IN PERIOPERATIVE ANTIBIOTIC PROPHYLAXIS FOR OUTPATIENT PEDIATRIC UROLOGIC PROCEDURES AT U.S. CHILDREN’S HOSPITALS
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THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Sunday, May 8, 2016
Source of Funding: None
MP55-16 VARIATION IN PERIOPERATIVE ANTIBIOTIC PROPHYLAXIS FOR OUTPATIENT PEDIATRIC UROLOGIC PROCEDURES AT U.S. CHILDREN’S HOSPITALS Katherine Hubert*, Teresa Bell, Brian Benneyworth, Mark Cain, Aaron Carroll, Indianapolis, IN INTRODUCTION AND OBJECTIVES: Guidelines recommend surgical antibiotic prophylaxis (SAP) for clean-contaminated procedures in children and no SAP for clean procedures. Prior studies demonstrate widely variable rates of SAP administration in children. The purpose of this study was to describe the variation in SAP for clean and cleancontaminated outpatient pediatric urologic procedures at U.S. children’s hospitals. METHODS: We performed a retrospective cohort study of patients <18 years of age undergoing clean or clean-contaminated (hypospadias, endoscopy) outpatient pediatric urologic procedures identified by CPT codes from January 2012 -December 2014 at U.S. children’s hospitals using the Pediatric Health Information System database. We excluded those who had concurrent nonurologic procedures or drainage of an abscess or infected wound. We compared antibiotic charges for clean vs. clean-contaminated procedures (Chi-square) and examined whether hospitals that were compliant with SAP recommendations for clean procedures were also compliant for clean-contaminated procedures (Pearson correlation coefficient). We examined the hospital-level variation in antibiotic rates using the coefficient of variation (standard deviation of antibiotic rate/mean) where higher values indicate greater variation. RESULTS: Of the 141,840 outpatients at 39 hospitals who met age criteria, 74 were excluded for drainage of an abscess or infected wound and 10,510 for a concurrent non-urologic procedure, leaving 131,256 for analysis. Median age was 34 months (range 1-215); 90.8% male; 61.5% white; 46.9% private insurance. Patients undergoing clean-contaminated procedures (n¼27,727) were significantly more
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Sunday, May 8, 2016
likely to have an antibiotic charge than those undergoing clean procedures (n¼103,529), (67.8% vs. 22.9%, p<0.005). Hospitals with antibiotic charges for clean procedures (non-compliant) were more likely to have antibiotic charges for clean-contaminated procedures (compliant) (r¼0.7, p¼0.01). At the hospital level, there was greater variation (range 9.8-97.8%) in compliance with SAP for clean-contaminated procedures (CV 0.36) compared to clean procedures (range 35.0%-98.2%) (CV 0.20). CONCLUSIONS: Hospitals tended to administer SAP regardless of wound classification. There was also greater variation in compliance with SAP guidelines for clean-contaminated procedures. Although local practices may explain this variation, our findings highlight the need for standardization of SAP. Source of Funding: none
MP55-17 URINARY TRACT INFECTION AFTER RETROGRADE URETHROGRAM IN CHILDREN: A MULTICENTER STUDY Neha Malhotra*, Jared Green, Cynthia Rigsby, Jane Holl, Earl Cheng, Emilie Johnson, Chicago, IL INTRODUCTION AND OBJECTIVES: Radiologic procedures such as retrograde urethrogram (RUG) and voiding cystourethrogram (VCUG) requiring catheterization and retrograde instillation of contrast carry an inherent risk of post-procedural urinary tract infection (ppUTI). However, the risk of ppUTI after RUG has not been well quantified. Prophylactic antibiotics may reduce the risk, but this benefit must be weighed against the risk of inducing antibiotic resistance. Our aims were to (1) describe the rate of ppUTI after RUG, and (2) examine the factors associated with use of antibiotics before, and ppUTI after, RUG. METHODS: We conducted a retrospective cohort study of children <18 years old undergoing RUG at 2 pediatric hospitals from 1/ 04-12/14. We excluded studies with concurrent VCUG and children with no follow-up. Descriptive statistics were used for demographic and clinical characteristics. ppUTI within 7 days of RUG was measured. Antibiotic prophylaxis was determined and relationships between clinical characteristics and receipt of pre-procedure antibiotics were evaluated using Fisher exact testing. RESULTS: 43 patients (98% male, median age 11.7 years) underwent 48 RUGs. The most common indications were trauma (27%), hypospadias (17%), and non-hypospadias (27%) stricture. Three patients (7%) had a history of posterior urethral valves (PUV), 1 had a neurogenic bladder (NGB); 27% had prior urethral surgery. 52% of RUGs revealed no abnormalities; the most common abnormality was stricture (31%). Two (4%) studies were performed within 30 days of a clinical UTI and 10% of children had a positive urinalysis or culture within 30 days pre-RUG. Clinical UTI in the prior 30 days was not significantly associated with preRUG antibiotic use (1/29 patients on antibiotics (3%); 1/19 patients not on antibiotics (5%) had a pre-RUG UTI, p ¼ 1.0). Only 1 (2.1%; 95% CI 0 e 6.2%) child had a ppUTI. This was a 7 year-old uncircumcised male with a history of PUV, strictures and voiding dysfunction. He was asymptomatic, had a negative pre-RUG urine culture, and was not on antibiotics. RUG revealed a bulbar stricture. Seven days later, the child had a febrile E. coli UTI requiring admission. CONCLUSIONS: The risk of ppUTI after RUG is very low (2.1% in our study, maximum 6.2%). We were unable to evaluate for specific predictors of ppUTI due to the low incidence. Use of antibiotics was unrelated pre-RUG UTI. Given the low incidence of ppUTI, this study suggests that routine prophylaxis with antibiotics prior to RUG is not indicated. Prophylaxis for select patients (i.e. PUV or NGB) may be warranted. Source of Funding: None
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MP55-18 CAN WE RELY ON PYURIA AS A MARKER FOR UTI IN THE NEUROGENIC BLADDER?: AN 11 YEAR LONGITUDINAL ANALYSIS Ruthie Su*, Mari Palta, Amy Lim, Christina Sauder, Ellen Wald, Madison, WI INTRODUCTION AND OBJECTIVES: In this era of increasing antibiotic resistance, accurate diagnosis of infection before treatment is imperative. Urinary tract infection (UTI) is a leading cause of morbidity and healthcare utilization for patients with neurogenic bladder and also poses a major diagnostic dilemma. The interpretation of pyuria as a marker for UTI in these patients may be confounded by repeated catheterizations, asymptomatic bacteriuria, or reconstructive surgery. To determine the stability of pyuria in asymptomatic patients with neurogenic bladder we studied the effect of time, catheterization, and bladder surgery on the presence of urinary leukocytes. METHODS: All patients evaluated at our institution’s Spina Bifida Clinic since 2004 were eligible. Electronic records were reviewed and only results of microscopic urine analyses obtained the same day as routine, well clinic visits were included. Clean intermittent catheterization (CIC) status at the time of urine collection and bladder surgical history (ie: reimplant, augment, Mitrofanoff, vesicostomy) were recorded. Analysis of repeated measurements was done with SAS, using multi-level modeling with random effects. RESULTS: 53 patients (32 female, 21 male) were evaluated during well visits between March 2004 to March 2015. There were on average 10 visits (range 2-41) per person. 319 urine samples were included for analysis. 51% (27/53) of patients transitioned during the study period from spontaneously voiding to CIC. 28% (15/53) of patients underwent some form of bladder surgery. Pyuria increased on average with time, CIC, and bladder surgery but not significantly. Within individual variance was significant (p<0.001) and 6 times greater than between individual variance, accounting for 58%-86% of the total variation as age increased. Adjusting for age, CIC, or bladder surgery did not reduce intra-individual variance. CONCLUSIONS: Pyuria varies unpredictably in asymptomatic children with neurogenic bladder. Accordingly, pyuria does not appear to be useful as a point of care marker for UTI, underscoring the importance of the need to search for other inflammatory biomarkers in these complex patients. Source of Funding: None
MP55-19 UTILITY OF RETROGRADE URETEROCELEOGRAM IN MANAGEMENT OF COMPLEX URETEROCELE Michelle K Arevalo*, Dallas, TX; Juan Carlos Prieto, San Antonio, TX; Nicholas Cost, Aurora, CO; Geoffrey Nuss, Linda A Baker, Dallas, TX INTRODUCTION AND OBJECTIVES: Symptomatic pediatric ureterocele manifests diversely making evidence-based management impractical. Thus, detailed visualization of ureterocele anatomy prior to first surgical incision is invaluable. Retrograde ureteroceleogram (RUC) is a simple, underutilized radiologic technique that can be performed during cystoscopy. We sought to determine whether RUC changes surgical management by more accurately depicting the complex ureteral and ureterocele anatomy compared to the routine preoperative ureterocele imaging studies: ultrasound (US) and voiding cystourethrography (VCUG). METHODS: Patients who underwent surgical management of ureterocele between 2003-2015 were identified; those who received concomitant fluoroscopic RUC were selected for the case series. Data collected included demographics, preoperative evaluation, surgical interventions, and outcomes. RUC images were individually examined and the anatomic impression compared to previous renal US and VCUG. Novel RUC findings not previously appreciated by the preoperative evaluation were noted. RUC was performed by cystoscopically
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Sunday, May 8, 2016
Source of Funding: None
MP55-16 VARIATION IN PERIOPERATIVE ANTIBIOTIC PROPHYLAXIS FOR OUTPATIENT PEDIATRIC UROLOGIC PROCEDURES AT U.S. CHILDREN’S HOSPITALS Katherine Hubert*, Teresa Bell, Brian Benneyworth, Mark Cain, Aaron Carroll, Indianapolis, IN INTRODUCTION AND OBJECTIVES: Guidelines recommend surgical antibiotic prophylaxis (SAP) for clean-contaminated procedures in children and no SAP for clean procedures. Prior studies demonstrate widely variable rates of SAP administration in children. The purpose of this study was to describe the variation in SAP for clean and cleancontaminated outpatient pediatric urologic procedures at U.S. children’s hospitals. METHODS: We performed a retrospective cohort study of patients <18 years of age undergoing clean or clean-contaminated (hypospadias, endoscopy) outpatient pediatric urologic procedures identified by CPT codes from January 2012 -December 2014 at U.S. children’s hospitals using the Pediatric Health Information System database. We excluded those who had concurrent nonurologic procedures or drainage of an abscess or infected wound. We compared antibiotic charges for clean vs. clean-contaminated procedures (Chi-square) and examined whether hospitals that were compliant with SAP recommendations for clean procedures were also compliant for clean-contaminated procedures (Pearson correlation coefficient). We examined the hospital-level variation in antibiotic rates using the coefficient of variation (standard deviation of antibiotic rate/mean) where higher values indicate greater variation. RESULTS: Of the 141,840 outpatients at 39 hospitals who met age criteria, 74 were excluded for drainage of an abscess or infected wound and 10,510 for a concurrent non-urologic procedure, leaving 131,256 for analysis. Median age was 34 months (range 1-215); 90.8% male; 61.5% white; 46.9% private insurance. Patients undergoing clean-contaminated procedures (n¼27,727) were significantly more
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Sunday, May 8, 2016
likely to have an antibiotic charge than those undergoing clean procedures (n¼103,529), (67.8% vs. 22.9%, p<0.005). Hospitals with antibiotic charges for clean procedures (non-compliant) were more likely to have antibiotic charges for clean-contaminated procedures (compliant) (r¼0.7, p¼0.01). At the hospital level, there was greater variation (range 9.8-97.8%) in compliance with SAP for clean-contaminated procedures (CV 0.36) compared to clean procedures (range 35.0%-98.2%) (CV 0.20). CONCLUSIONS: Hospitals tended to administer SAP regardless of wound classification. There was also greater variation in compliance with SAP guidelines for clean-contaminated procedures. Although local practices may explain this variation, our findings highlight the need for standardization of SAP. Source of Funding: none
MP55-17 URINARY TRACT INFECTION AFTER RETROGRADE URETHROGRAM IN CHILDREN: A MULTICENTER STUDY Neha Malhotra*, Jared Green, Cynthia Rigsby, Jane Holl, Earl Cheng, Emilie Johnson, Chicago, IL INTRODUCTION AND OBJECTIVES: Radiologic procedures such as retrograde urethrogram (RUG) and voiding cystourethrogram (VCUG) requiring catheterization and retrograde instillation of contrast carry an inherent risk of post-procedural urinary tract infection (ppUTI). However, the risk of ppUTI after RUG has not been well quantified. Prophylactic antibiotics may reduce the risk, but this benefit must be weighed against the risk of inducing antibiotic resistance. Our aims were to (1) describe the rate of ppUTI after RUG, and (2) examine the factors associated with use of antibiotics before, and ppUTI after, RUG. METHODS: We conducted a retrospective cohort study of children <18 years old undergoing RUG at 2 pediatric hospitals from 1/ 04-12/14. We excluded studies with concurrent VCUG and children with no follow-up. Descriptive statistics were used for demographic and clinical characteristics. ppUTI within 7 days of RUG was measured. Antibiotic prophylaxis was determined and relationships between clinical characteristics and receipt of pre-procedure antibiotics were evaluated using Fisher exact testing. RESULTS: 43 patients (98% male, median age 11.7 years) underwent 48 RUGs. The most common indications were trauma (27%), hypospadias (17%), and non-hypospadias (27%) stricture. Three patients (7%) had a history of posterior urethral valves (PUV), 1 had a neurogenic bladder (NGB); 27% had prior urethral surgery. 52% of RUGs revealed no abnormalities; the most common abnormality was stricture (31%). Two (4%) studies were performed within 30 days of a clinical UTI and 10% of children had a positive urinalysis or culture within 30 days pre-RUG. Clinical UTI in the prior 30 days was not significantly associated with preRUG antibiotic use (1/29 patients on antibiotics (3%); 1/19 patients not on antibiotics (5%) had a pre-RUG UTI, p ¼ 1.0). Only 1 (2.1%; 95% CI 0 e 6.2%) child had a ppUTI. This was a 7 year-old uncircumcised male with a history of PUV, strictures and voiding dysfunction. He was asymptomatic, had a negative pre-RUG urine culture, and was not on antibiotics. RUG revealed a bulbar stricture. Seven days later, the child had a febrile E. coli UTI requiring admission. CONCLUSIONS: The risk of ppUTI after RUG is very low (2.1% in our study, maximum 6.2%). We were unable to evaluate for specific predictors of ppUTI due to the low incidence. Use of antibiotics was unrelated pre-RUG UTI. Given the low incidence of ppUTI, this study suggests that routine prophylaxis with antibiotics prior to RUG is not indicated. Prophylaxis for select patients (i.e. PUV or NGB) may be warranted. Source of Funding: None
e743
MP55-18 CAN WE RELY ON PYURIA AS A MARKER FOR UTI IN THE NEUROGENIC BLADDER?: AN 11 YEAR LONGITUDINAL ANALYSIS Ruthie Su*, Mari Palta, Amy Lim, Christina Sauder, Ellen Wald, Madison, WI INTRODUCTION AND OBJECTIVES: In this era of increasing antibiotic resistance, accurate diagnosis of infection before treatment is imperative. Urinary tract infection (UTI) is a leading cause of morbidity and healthcare utilization for patients with neurogenic bladder and also poses a major diagnostic dilemma. The interpretation of pyuria as a marker for UTI in these patients may be confounded by repeated catheterizations, asymptomatic bacteriuria, or reconstructive surgery. To determine the stability of pyuria in asymptomatic patients with neurogenic bladder we studied the effect of time, catheterization, and bladder surgery on the presence of urinary leukocytes. METHODS: All patients evaluated at our institution’s Spina Bifida Clinic since 2004 were eligible. Electronic records were reviewed and only results of microscopic urine analyses obtained the same day as routine, well clinic visits were included. Clean intermittent catheterization (CIC) status at the time of urine collection and bladder surgical history (ie: reimplant, augment, Mitrofanoff, vesicostomy) were recorded. Analysis of repeated measurements was done with SAS, using multi-level modeling with random effects. RESULTS: 53 patients (32 female, 21 male) were evaluated during well visits between March 2004 to March 2015. There were on average 10 visits (range 2-41) per person. 319 urine samples were included for analysis. 51% (27/53) of patients transitioned during the study period from spontaneously voiding to CIC. 28% (15/53) of patients underwent some form of bladder surgery. Pyuria increased on average with time, CIC, and bladder surgery but not significantly. Within individual variance was significant (p<0.001) and 6 times greater than between individual variance, accounting for 58%-86% of the total variation as age increased. Adjusting for age, CIC, or bladder surgery did not reduce intra-individual variance. CONCLUSIONS: Pyuria varies unpredictably in asymptomatic children with neurogenic bladder. Accordingly, pyuria does not appear to be useful as a point of care marker for UTI, underscoring the importance of the need to search for other inflammatory biomarkers in these complex patients. Source of Funding: None
MP55-19 UTILITY OF RETROGRADE URETEROCELEOGRAM IN MANAGEMENT OF COMPLEX URETEROCELE Michelle K Arevalo*, Dallas, TX; Juan Carlos Prieto, San Antonio, TX; Nicholas Cost, Aurora, CO; Geoffrey Nuss, Linda A Baker, Dallas, TX INTRODUCTION AND OBJECTIVES: Symptomatic pediatric ureterocele manifests diversely making evidence-based management impractical. Thus, detailed visualization of ureterocele anatomy prior to first surgical incision is invaluable. Retrograde ureteroceleogram (RUC) is a simple, underutilized radiologic technique that can be performed during cystoscopy. We sought to determine whether RUC changes surgical management by more accurately depicting the complex ureteral and ureterocele anatomy compared to the routine preoperative ureterocele imaging studies: ultrasound (US) and voiding cystourethrography (VCUG). METHODS: Patients who underwent surgical management of ureterocele between 2003-2015 were identified; those who received concomitant fluoroscopic RUC were selected for the case series. Data collected included demographics, preoperative evaluation, surgical interventions, and outcomes. RUC images were individually examined and the anatomic impression compared to previous renal US and VCUG. Novel RUC findings not previously appreciated by the preoperative evaluation were noted. RUC was performed by cystoscopically