title: Unplanned Hospital Return for Infection following Ureteroscopy-Can We Identify Modifiable Risk Factors?
abstract: OBJECTIVE
  Genitourinary infection after ureteroscopy with laser lithotripsy is a clinically significant event that may lead to expensive and morbid return to the hospital. We evaluate factors associated with infection after ureteroscopy with laser lithotripsy leading to unplanned hospital return.
  
  
  METHODS
  We performed a retrospective chart review evaluating all ureteroscopy with laser lithotripsy performed at a single academic institution from April 2011 to August 2014. Data were extracted including patient demographics, comorbidities, surgical encounter characteristics, preoperative urine culture status, antibiotic type/duration and compliance with the AUA Best Practice Statement for antibiotic prophylaxis. Bivariate and multivariate analyses were performed to determine factors associated with unplanned return to the hospital.
  
  
  RESULTS
  Among 550 patients undergoing ureteroscopy with laser lithotripsy 45% (248) were female with an average age of 56.8 (± 14.8) years. Overall 3.4% (19 patients) had an unplanned return for genitourinary infection, with most (78.9%, 15 of 19) requiring inpatient readmission. Overall compliance with AUA Best Practice Statement for antibiotic prophylaxis was 48.7% (268 of 550). Rates of infection related returns were higher in patients undergoing preoperative stenting (84.2% vs 58.6%, p=0.025), those with an operative time greater than 120 minutes (89.5% vs 32.6% p <0.001) and those for whom there was AUA Best Practice Statement compliance for antibiotic prophylaxis (78.9% vs 47.6%, p=0.007). These factors remained significant on multivariate analysis (p <0.05).
  
  
  CONCLUSIONS
  Preoperative stenting and longer operative time were associated with a greater likelihood of serious genitourinary infection after ureteroscopy with laser lithotripsy. These patients may warrant additional antibiotic prophylaxis but further research is needed to answer this question more definitively. Interestingly the AUA Best Practice Statement compliance for antibiotic prophylaxis was also associated with a higher risk of infection, underscoring the need for locally appropriate prophylaxis strategies and further study of optimal prophylaxis regimens.
authors.affiliation: Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire. Electronic address: rachel.a.moses@hitchcock.org.
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Moses
authors.affiliation: Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
authors.forename: Fady M
authors.initials: FM
authors.lastname: Ghali
authors.affiliation: Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
authors.forename: Vernon M
authors.initials: VM
authors.lastname: Pais
authors.affiliation: Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
authors.forename: Elias S
authors.initials: ES
authors.lastname: Hyams
mesh_terms: D000293:Adolescent; D000328:Adult; D001424:Bacterial Infections / Q000453:epidemiology* / Q000209:etiology*; D005260:Female; D006801:Humans; D017602:Lithotripsy, Laser / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology*; D012189:Retrospective Studies; D012307:Risk Factors; D018666:Ureteroscopy / Q000009:adverse effects*; D055815:Young Adult
keywords: delivery of health care; infection; patient readmission; ureteroscopy