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International Journal of Urology (2014) 21, 628–629
doi: 10.1111/iju.12432
Perspectives in Urology
Antimicrobial stewardship in urology Takashi Deguchi1 and Tetsuro Matsumoto2 1
Department of Urology, Graduate School of Medicine, Gifu University, Gifu, and 2Department of Urology, University of Occupational and Environmental Health, Fukuoka, Japan
Correspondence: Takashi Deguchi M.D., Department of Urology, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu 501-1194, Japan. Email: [email protected] Received 8 January 2014; accepted 30 January 2014. Online publication 19 March 2014
The emergence and spread of antibiotic-resistant bacteria have been reported for various infections. Infections caused by such bacteria are associated with higher rates of patient morbidity and mortality, and increased healthcare costs. In our urological community, we have observed fluoroquinolone resistance in clinical strains of Escherichia coli isolated even from young women with acute uncomplicated cystitis.1 We have increasingly encountered some bacterial species that produce an extended spectrum β-lactamase in patients with complicated urinary tract infections.2 In male urethritis, oral regimens of fluoroquinolones or third-generation cephalosporins are no longer recommended for treatment of gonorrhea because of antibioticresistant Neisseria gonorrhoeae.3 In the urological community, clinical practice guidelines exist for antibiotic treatment and prophylaxis. The 2006 guidelines for perioperative antimicrobial prophylaxis in urological surgery were approved by the Japanese Urological Association (JUA).4 A survey on antimicrobial prophylaxis reported that of the principal JUA-certified urological training institutions, 6.5% “completely” and 69.7% “mainly” followed the guidelines. However, the guidelines were followed in 48.5% of open clean operations, 43.2% of prostate biopsies and 42.2% of cystoscopies.5 Antimicrobial prophylaxis in Europe also differs widely from recommended guidelines.6 For cystoscopy, ureteroscopy and clean operations, 40.5%, 73.5%, and 56.6%, respectively, of institutions routinely used antibiotic prophylaxis, although the European Association of Urology guidelines recommend no routine antimicrobial prophylaxis. Inappropriate and unnecessary antibiotic use allows the selection of antibiotic-resistant bacteria. Because the development of promising new antibiotics against emerging resistance cannot be expected, antibiotic resistance must be controlled in an efficient and timely manner to prolong the efficacy of existing antibiotics. Under such circumstances, antimicrobial stewardship (AMS) has been advocated to optimize antibiotic use. In 1997, the joint committee of the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America published guidelines for prevention of antimicrobial resistance in hospitals.7 In 2007, the committee published guidelines for developing an institutional program to enhance AMS8 that focus on development of effective hospital-based stewardship programs. The concepts of AMS include optimal selection, dose, and duration of treatment and control, and restriction of antibiotic use. Effective AMS combined with a comprehensive infection control program has limited the emergence and transmission of antibiotic-resistant bacteria in hospitals. Self-devised AMS programs have already been fostered in various medical communities and settings.9 Our urological community should also establish and practice comprehensive AMS strategies soon.10 They should involve every aspect for our members to engage in appropriate selection and optimal use of antibiotics. These aspects include education to make an accurate diagnosis of urological infections, including culture and antibiotic susceptibility testing of pathogens, to estimate infection risks in patients undergoing urological treatments, and to understand the pharmacokinetic and pharmacodynamic characteristics of antibiotics; dissemination of local trends in antibiotic resistance in pathogens; and enforcement (or at least encouragement) for our members to follow evidence-based guidelines on the treatment of urological infections and prophylaxis for urological surgery along with regular monitoring of members’ guideline observance rates. Our urological community cannot be allowed to be indifferent to optimal use of antibiotics in practice.
Conflict of interest None declared. 628
© 2014 The Japanese Urological Association
Antimicrobial stewardship
References 1 Hayami H, Takahashi S, Ishikawa K et al. Nationwide surveillance of bacterial pathogens from patients with acute uncomplicated cystitis conducted by the Japanese surveillance committee during 2009 and 2010: antimicrobial susceptibility of Escherichia coli and Staphylococcus saprophyticus. J. Infect. Chemother. 2013; 19: 393–403. 2 Muratani T, Matsumoto T. Urinary tract infection caused by fluoroquinoloneand cephem-resistant Enterobacteriaceae. Int. J. Antimicrob. Agents 2006; 28 (Suppl 1): S10–13. 3 Ito M, Yasuda M, Yokoi S et al. Remarkable increase in central Japan in 2001–2002 of Neisseria gonorrhoeae isolates with decreased susceptibility to penicillin, tetracycline, oral cephalosporins, and fluoroquinolones. Antimicrob. Agents Chemother. 2004; 48: 3185–7. 4 Matsumoto T, Kiyota H, Matsukawa M et al. Japanese guidelines for prevention of perioperative infections in urological field. Int. J. Urol. 2007; 14: 890–909. 5 Togo Y, Taoka R, Yamamoto S et al. A questionnaire survey of antimicrobial prophylaxis to prevent perioperative infection in urological field in Japan. Nihon Hinyokika Gakkai Zasshi 2013; 104: 579–88.
© 2014 The Japanese Urological Association
6 Çek M, Tandog˘du Z, Naber K et al. Antibiotic prophylaxis in urology departments, 2005–2010. Eur. Urol. 2013; 63: 386–94. 7 Dellit TH, Owens RC, McGowan JE Jr et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin. Infect. Dis. 2007; 44: 159–77. 8 Shlaes DM, Gerding DN, John JF Jr et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Clin. Infect. Dis. 1997; 25: 58–99. 9 Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect. Control Hosp. Epidemiol. 2012; 33: 322–7. 10 Wagenlehner FM, Bartoletti R, Cek M et al. Antibiotic stewardship: a call for action by the urologic community. Eur. Urol. 2013; 64: 358–60.
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International Journal of Urology (2014) 21, 628–629
doi: 10.1111/iju.12432
Perspectives in Urology
Antimicrobial stewardship in urology Takashi Deguchi1 and Tetsuro Matsumoto2 1
Department of Urology, Graduate School of Medicine, Gifu University, Gifu, and 2Department of Urology, University of Occupational and Environmental Health, Fukuoka, Japan
Correspondence: Takashi Deguchi M.D., Department of Urology, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu 501-1194, Japan. Email: [email protected] Received 8 January 2014; accepted 30 January 2014. Online publication 19 March 2014
The emergence and spread of antibiotic-resistant bacteria have been reported for various infections. Infections caused by such bacteria are associated with higher rates of patient morbidity and mortality, and increased healthcare costs. In our urological community, we have observed fluoroquinolone resistance in clinical strains of Escherichia coli isolated even from young women with acute uncomplicated cystitis.1 We have increasingly encountered some bacterial species that produce an extended spectrum β-lactamase in patients with complicated urinary tract infections.2 In male urethritis, oral regimens of fluoroquinolones or third-generation cephalosporins are no longer recommended for treatment of gonorrhea because of antibioticresistant Neisseria gonorrhoeae.3 In the urological community, clinical practice guidelines exist for antibiotic treatment and prophylaxis. The 2006 guidelines for perioperative antimicrobial prophylaxis in urological surgery were approved by the Japanese Urological Association (JUA).4 A survey on antimicrobial prophylaxis reported that of the principal JUA-certified urological training institutions, 6.5% “completely” and 69.7% “mainly” followed the guidelines. However, the guidelines were followed in 48.5% of open clean operations, 43.2% of prostate biopsies and 42.2% of cystoscopies.5 Antimicrobial prophylaxis in Europe also differs widely from recommended guidelines.6 For cystoscopy, ureteroscopy and clean operations, 40.5%, 73.5%, and 56.6%, respectively, of institutions routinely used antibiotic prophylaxis, although the European Association of Urology guidelines recommend no routine antimicrobial prophylaxis. Inappropriate and unnecessary antibiotic use allows the selection of antibiotic-resistant bacteria. Because the development of promising new antibiotics against emerging resistance cannot be expected, antibiotic resistance must be controlled in an efficient and timely manner to prolong the efficacy of existing antibiotics. Under such circumstances, antimicrobial stewardship (AMS) has been advocated to optimize antibiotic use. In 1997, the joint committee of the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America published guidelines for prevention of antimicrobial resistance in hospitals.7 In 2007, the committee published guidelines for developing an institutional program to enhance AMS8 that focus on development of effective hospital-based stewardship programs. The concepts of AMS include optimal selection, dose, and duration of treatment and control, and restriction of antibiotic use. Effective AMS combined with a comprehensive infection control program has limited the emergence and transmission of antibiotic-resistant bacteria in hospitals. Self-devised AMS programs have already been fostered in various medical communities and settings.9 Our urological community should also establish and practice comprehensive AMS strategies soon.10 They should involve every aspect for our members to engage in appropriate selection and optimal use of antibiotics. These aspects include education to make an accurate diagnosis of urological infections, including culture and antibiotic susceptibility testing of pathogens, to estimate infection risks in patients undergoing urological treatments, and to understand the pharmacokinetic and pharmacodynamic characteristics of antibiotics; dissemination of local trends in antibiotic resistance in pathogens; and enforcement (or at least encouragement) for our members to follow evidence-based guidelines on the treatment of urological infections and prophylaxis for urological surgery along with regular monitoring of members’ guideline observance rates. Our urological community cannot be allowed to be indifferent to optimal use of antibiotics in practice.
Conflict of interest None declared. 628
© 2014 The Japanese Urological Association
Antimicrobial stewardship
References 1 Hayami H, Takahashi S, Ishikawa K et al. Nationwide surveillance of bacterial pathogens from patients with acute uncomplicated cystitis conducted by the Japanese surveillance committee during 2009 and 2010: antimicrobial susceptibility of Escherichia coli and Staphylococcus saprophyticus. J. Infect. Chemother. 2013; 19: 393–403. 2 Muratani T, Matsumoto T. Urinary tract infection caused by fluoroquinoloneand cephem-resistant Enterobacteriaceae. Int. J. Antimicrob. Agents 2006; 28 (Suppl 1): S10–13. 3 Ito M, Yasuda M, Yokoi S et al. Remarkable increase in central Japan in 2001–2002 of Neisseria gonorrhoeae isolates with decreased susceptibility to penicillin, tetracycline, oral cephalosporins, and fluoroquinolones. Antimicrob. Agents Chemother. 2004; 48: 3185–7. 4 Matsumoto T, Kiyota H, Matsukawa M et al. Japanese guidelines for prevention of perioperative infections in urological field. Int. J. Urol. 2007; 14: 890–909. 5 Togo Y, Taoka R, Yamamoto S et al. A questionnaire survey of antimicrobial prophylaxis to prevent perioperative infection in urological field in Japan. Nihon Hinyokika Gakkai Zasshi 2013; 104: 579–88.
© 2014 The Japanese Urological Association
6 Çek M, Tandog˘du Z, Naber K et al. Antibiotic prophylaxis in urology departments, 2005–2010. Eur. Urol. 2013; 63: 386–94. 7 Dellit TH, Owens RC, McGowan JE Jr et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin. Infect. Dis. 2007; 44: 159–77. 8 Shlaes DM, Gerding DN, John JF Jr et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Clin. Infect. Dis. 1997; 25: 58–99. 9 Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect. Control Hosp. Epidemiol. 2012; 33: 322–7. 10 Wagenlehner FM, Bartoletti R, Cek M et al. Antibiotic stewardship: a call for action by the urologic community. Eur. Urol. 2013; 64: 358–60.
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