title: The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious complications after radical cystectomy.
abstract: OBJECTIVE
  Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort to decrease the rate of infectious complications, we instituted a broader, culture-based preoperative antimicrobial regimen, including fungal coverage, and studied its effect on infectious complications after RC.
  
  
  METHODS
  In May 2013, antimicrobial prophylaxis for RC was changed at our institution after review of previous positive cultures. Ampicillin-sulbactam 3g, gentamicin 4mg/kg, and fluconazole 400mg replaced cefoxitin. Patients undergoing RC from May 2011 to May 2014 were included. Before and after implementation of the new regimen, 30-day infectious complications (positive blood culture, urinary tract infection, wound infection, abscess, and pneumonia) and adverse events (Clostridium difficile, readmission, and mortality) were compared. Multivariate logistic regression was used to identify independent risk factors for infection while controlling for covariates.
  
  
  RESULTS
  In total, 386 patients were studied (258 before the change and 128 after). The overall infection rate decreased with the new regimen (41% vs. 30%, P = 0.043) with improvements in wound (14% vs. 6%, P = 0.025) and fungal (10% vs. 3%, P = 0.021) infections. Median length of stay decreased from 8 (interquartile range [IQR]: 7-12) to 7 (IQR: 7-10) days (P = 0.008). On multivariate analysis, the new regimen decreased the risk of infections (odds ratio [OR] = 0.58, 95% CI [0.35-0.99], P = 0.044) whereas body mass index, operating room time, smoking, and total parenteral nutrition increased the risk (all P< 0.05).
  
  
  CONCLUSIONS
  Risk factors for infection after RC include body mass index, operating room time, smoking, and total parenteral nutrition use. Changing from cefoxitin to broader, culture-directed antimicrobial prophylaxis, based on institutional data to include antifungal coverage, decreased postoperative infections.
authors.affiliation: Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL. Electronic address: pariserj@gmail.com.
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Pariser
authors.affiliation: Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL.
authors.forename: Blake B
authors.initials: BB
authors.lastname: Anderson
authors.affiliation: Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL.
authors.forename: Shane M
authors.initials: SM
authors.lastname: Pearce
authors.affiliation: Department of Pharmaceutical Services, University of Chicago Pritzker School of Medicine, Chicago, IL.
authors.forename: Zhe
authors.initials: Z
authors.lastname: Han
authors.affiliation: Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Rodriguez
authors.affiliation: Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL.
authors.forename: Emily
authors.initials: E
authors.lastname: Landon
authors.affiliation: Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL.
authors.forename: Jennifer C
authors.initials: JC
authors.lastname: Pisano
authors.affiliation: Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL.
authors.forename: Norm D
authors.initials: ND
authors.lastname: Smith
authors.affiliation: Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL.
authors.forename: Gary D
authors.initials: GD
authors.lastname: Steinberg
mesh_terms: D000368:Aged; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D015653:Cystectomy / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D005658:Fungi / Q000187:drug effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011183:Postoperative Complications / Q000188:drug therapy*; D011379:Prognosis; D012307:Risk Factors; D013530:Surgical Wound Infection / Q000188:drug therapy* / Q000382:microbiology; D001749:Urinary Bladder Neoplasms / Q000382:microbiology / Q000473:pathology / Q000601:surgery*
chemical_list: D000890:Anti-Infective Agents
keywords: Antibacterial Agents; Antibiotic Prophylaxis; Antifungal Agents; Cystectomy; Infection