Urinary Tract Infections After Urogynecologic Surgery: Risk Factors, Timeline, and Uropathogens

IF 4.3 4区 医学 Q1 OBSTETRICS & GYNECOLOGY Obstetrical & Gynecological Survey Pub Date : 2023-10-01 DOI:10.1097/ogx.0000000000001207
Carrie E. Jung, Lie H. Chen, Linda T. Brubaker, Shawn A. Menefee
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Abstract

ABSTRACT Postoperative urinary tract infection (PO-UTI) is seen in 6.4%–32% of stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP) surgeries despite perioperative antibiotic prophylaxis. Postoperative complications associated with PO-UTI include increased mortality and longer hospitalization. Increasing prevalence of resistance to antibiotics and antibiotic stewardship principles necessitate both the improvement of infection prevention strategies and judicious antibiotic prescriptions. Four factors are known to increase PO-UTI risk: (1) recurrent UTI (RUTI) history, (2) preoperative UTI, (3) day-of-surgery UTI, and (4) prolonged postoperative catheterization. This study intended to determine (1) risk factors of PO-UTI and PO-RUTI, (2) preoperative and postoperative UTI temporal distribution, and (3) detected uropathogens in a large database. The study used medical record data of all SUI/POP surgical procedures performed in the Kaiser Southern California Hospital system from January 1, 2008 to December 31, 2016 for women 18 years of age or older. Procedures used Current Procedural Terminology codes for identifying and subcategorizing surgical procedures and their route (SUI or POP; abdominal or vaginal, respectively). The study-wide definition of UTI was as follows: (1) positive standard urine culture of greater than 10 5 CFU/mL of ≤2 uropathogens, or (2) prescription of urinary antibiotics prescribed for the indication of UTI symptoms. The analysis consisted of 21,063 urogynecologic surgical procedures performed on 20,051 women (33,626 POP and/or SUI procedures), with 22,641 UTI events being diagnosed in 10,091 women. Mean age was 56.9 years, and mean BMI was 29.1. The cohort underwent surgery for only SUI (35.4%), only POP (32.7%), or POP/SUI combined (31.9%). In the 13.5 months postoperatively, 11,976 UTIs were diagnosed in 6733 women. The first month experienced a sharp increase compared with the preoperative year, the second month increased further, and the third month showed leveling of PO-UTI incidence. Prescribed antibiotics captured most UTI events (13,337 or 58.3%). Prescribed antibiotics, in order of most-prescribed to least-prescribed, were as follows: ciprofloxacin (33.7%), cephalexin (21.4%), nitrofurantoin (20.4%), and sulfamethoxazole-trimethoprim (17.6%). The study determined that most PO-UTIs occurred within the first 2 months, with many of these being diagnosed within 2 weeks of surgery. For those patients already having a history of RUTI, RUTI significantly increases in postoperative year 1 when compared with the preoperative year. All patients undergoing SUI procedures had increased PO-RUTI risks compared with their POP-only group peers. Escherichia coli was the most common pathogen found. Risk and event timing were affected by surgical indication: although surgery for only SUI had a lower 6-week PO-UTI risk, it was counterintuitively associated with a higher PO-RUTI risk. Multivariate regression revealed predictable risk factors for PO-UTI: OAB, history of diabetes, history of preoperative UTI within 6 weeks of surgery, history of RUTI, stent and catheter placement. A more confusing finding was the association of a vaginal estrogen prescription with increased short-term PO-UTI risk, possibly related to its use in women with a history of RUTI, but more probably related to the postmenopausal status of many of the women in the dataset. The study recommends preoperative assessment with the purpose of identifying and eliminating UTIs within 6 weeks before surgery, as well as development of protocols for enhanced prophylaxis for women at increased risk such as diabetics and women with preoperative RUTI.
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泌尿妇科手术后尿路感染:危险因素、时间和尿路病原体
术后尿路感染(PO-UTI)见于6.4%-32%的应激性尿失禁(SUI)和/或盆腔器官脱垂(POP)手术,尽管围手术期抗生素预防。PO-UTI相关的术后并发症包括死亡率增加和住院时间延长。日益普遍的抗生素耐药性和抗生素管理原则需要改进感染预防策略和明智的抗生素处方。已知有四个因素会增加PO-UTI风险:(1)复发性UTI (RUTI)病史,(2)术前UTI,(3)手术当天UTI,(4)术后延长导尿时间。本研究旨在确定(1)PO-UTI和PO-RUTI的危险因素,(2)术前和术后UTI的时间分布,(3)在大型数据库中检测尿路病原体。该研究使用了2008年1月1日至2016年12月31日在凯撒南加州医院系统进行的所有SUI/POP手术的医疗记录数据,这些手术针对的是18岁及以上的女性。使用现行程序术语代码对外科手术及其路径进行识别和分类(SUI或POP;腹部或阴道分别)。全研究范围内对尿路感染的定义为:(1)标准尿培养≥105 CFU/mL≤2种尿路病原菌阳性,或(2)有尿路感染症状指征的尿路抗生素处方。该分析包括对20,051名女性进行的21,063例泌尿妇科手术(33,626例POP和/或SUI手术),在10,091名女性中诊断出22,641例尿路感染事件。平均年龄56.9岁,平均BMI为29.1。该队列仅因SUI(35.4%)、POP(32.7%)或POP/SUI合并(31.9%)接受手术。术后13.5个月,6733名妇女中有11976例尿路感染被诊断出来。第1个月与术前相比急剧增加,第2个月进一步增加,第3个月PO-UTI发生率趋于平缓。处方抗生素捕获了大多数尿路感染事件(13,337或58.3%)。处方抗生素从多到少依次为:环丙沙星(33.7%)、头孢氨苄(21.4%)、呋喃妥因(20.4%)、磺胺甲恶唑-甲氧苄啶(17.6%)。该研究确定,大多数po - uti发生在前2个月内,其中许多在手术后2周内被诊断出来。对于已有RUTI病史的患者,术后1年RUTI较术前显著升高。所有接受SUI手术的患者与仅接受pop手术的患者相比,PO-RUTI风险增加。大肠杆菌是最常见的病原体。风险和事件时间受手术指征的影响:尽管仅SUI的手术具有较低的6周PO-UTI风险,但与较高的PO-RUTI风险相反。多因素回归显示可预测的PO-UTI危险因素:OAB、糖尿病史、术前6周内UTI史、RUTI史、支架和导管放置。一个更令人困惑的发现是阴道雌激素处方与短期PO-UTI风险增加的关联,可能与有RUTI病史的女性使用有关,但更可能与数据集中许多女性的绝经后状态有关。该研究建议术前评估,目的是在手术前6周内识别和消除尿路感染,并制定方案,加强对糖尿病患者和术前尿路感染妇女等风险增加的妇女的预防。
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来源期刊
CiteScore
2.70
自引率
3.20%
发文量
245
审稿时长
>12 weeks
期刊介绍: ​Each monthly issue of Obstetrical & Gynecological Survey presents summaries of the most timely and clinically relevant research being published worldwide. These concise, easy-to-read summaries provide expert insight into how to apply the latest research to patient care. The accompanying editorial commentary puts the studies into perspective and supplies authoritative guidance. The result is a valuable, time-saving resource for busy clinicians.
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