title: Adherence to European Association of Urology Guidelines on Prophylactic Antibiotics: An Important Step in Antimicrobial Stewardship.
abstract: BACKGROUND
  The evolution of resistant pathogens is a worldwide health crisis and adherence to European Association of Urology (EAU) guidelines on antibiotic prophylaxis may be an important way to improve antibiotic stewardship and reduce patient harm and costs.
  
  
  OBJECTIVE
  To evaluate the prevalence of antibiotic-resistant bacterial strains and health care costs during a period of adherence to EAU guidelines in a tertiary referral urologic institution.
  
  
  METHODS
  A protocol for adherence to EAU guidelines for antibiotic prophylaxis for all urologic procedures was introduced in January 2011. Data for 3529 urologic procedures performed between January 2011 and December 2013 after protocol introduction were compared with data for 2619 procedures performed between January 2008 and December 2010 before protocol implementation. The prevalence of bacterial resistance and health care costs were compared between the two periods.
  
  
  METHODS
  The outcome measures were the proportion of resistant uropathogens and costs related to antibiotic consumption and symptomatic postoperative infection. We used χ2 and Fisher's exact tests to test the significance of differences.
  
  
  CONCLUSIONS
  The proportion of patients with symptomatic postoperative infection did not differ (180/3529 [5.1%] vs. 117/2619 [4.5%]; p=0.27). A total of 342 isolates from all patients with symptomatic postoperative infections were analysed. The rate of resistance of Escherichia coli to piperacillin/tazobactam (9.1% vs. 5.4%; p=0.03), gentamicin (18.3% vs. 11.2%; p=0.02), and ciprofloxacin (32.3% vs. 19.1%; p=0.03) decreased significantly after protocol introduction. The defined daily dose (DDD) use of ciprofloxacin fell from 4.2 to 0.2 DDD per 100 patient-days after implementation (p<0.001). Antibiotic drug costs (€76,980 vs. €36,700) and costs related to postoperative infections (€45,870 vs. €29,560) decreased following introduction of the protocol (p<0.001).
  
  
  CONCLUSIONS
  Adherence to EAU guidelines on antibiotic prophylaxis reduced antibiotic usage without increasing post-operative infection rate and lowered the prevalence of resistant uropathogens.
  
  
  RESULTS
  We analysed the impact of adherence to European Association of Urology guidelines on antibiotic prophylaxis for all surgical urologic procedures on the prevalence of infections and resistant bacterial strains and on costs. We found that adherence to the guidelines reduced the rate of bacterial resistance, in particular against piperacillin/tazobactam, gentamicin, and ciprofloxacin, and reduced costs without increasing the risk of postoperative infection after urologic procedures. We recommend adherence to the guidelines as an important part of antibiotic stewardship programmes.
authors.affiliation: Department of Urology, Santa Chiara Regional Hospital, Trento, Italy. Electronic address: ktommy@libero.it.
authors.forename: Tommaso
authors.initials: T
authors.lastname: Cai
authors.affiliation: Department of Urology, University of Naples, Naples, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Verze
authors.affiliation: Department of Public Health, University of Verona, Verona, Italy.
authors.forename: Anna
authors.initials: A
authors.lastname: Brugnolli
authors.affiliation: Department of Urology, Santa Chiara Regional Hospital, Trento, Italy.
authors.forename: Daniele
authors.initials: D
authors.lastname: Tiscione
authors.affiliation: Department of Urology, Santa Chiara Regional Hospital, Trento, Italy.
authors.forename: Lorenzo Giuseppe
authors.initials: LG
authors.lastname: Luciani
authors.affiliation: Department of Urology, Santa Chiara Regional Hospital, Trento, Italy.
authors.forename: Cristina
authors.initials: C
authors.lastname: Eccher
authors.affiliation: Department of Microbiology, Santa Chiara Regional Hospital, Trento, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Lanzafame
authors.affiliation: Department of Urology, Santa Chiara Regional Hospital, Trento, Italy.
authors.forename: Gianni
authors.initials: G
authors.lastname: Malossini
authors.affiliation: Klinik und Poliklinik für Urologie, Kinderurologie und Andrologie, Universitätsklinikum Giessen und Marburg GmbH, Justus-Liebig-Universität, Giessen, Germany.
authors.forename: Florian M E
authors.initials: FM
authors.lastname: Wagenlehner
authors.affiliation: Department of Urology, University of Naples, Naples, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Mirone
authors.affiliation: Department of Urology, Oslo University Hospital, Oslo, Norway.
authors.forename: Truls E
authors.initials: TE
authors.lastname: Bjerklund Johansen
authors.affiliation: Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: Robert
authors.initials: R
authors.lastname: Pickard
authors.affiliation: Department of Urology, University of Florence, Florence, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Bartoletti
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000191:economics / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis / Q000592:standards*; D002939:Ciprofloxacin / Q000627:therapeutic use; D024881:Drug Resistance, Bacterial; D004926:Escherichia coli / Q000187:drug effects; D005060:Europe; D005260:Female; D005839:Gentamicins / Q000627:therapeutic use; D019983:Guideline Adherence; D006801:Humans; D007709:Klebsiella / Q000187:drug effects; D008297:Male; D008875:Middle Aged; D010397:Penicillanic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D010878:Piperacillin / Q000627:therapeutic use; D000077725:Piperacillin, Tazobactam Drug Combination; D017410:Practice Guidelines as Topic; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use; D013520:Urologic Surgical Procedures / Q000009:adverse effects / Q000592:standards; D014572:Urology / Q000592:standards*
chemical_list: D000900:Anti-Bacterial Agents; D005839:Gentamicins; D000077725:Piperacillin, Tazobactam Drug Combination; D002939:Ciprofloxacin; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D010397:Penicillanic Acid; D010878:Piperacillin
keywords: Antimicrobial prophylaxis; Cost saving; Guidelines; Surgical urology; Urinary tract infection