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Is antibiotic prophylaxis necessary before midurethral sling procedures for female stress incontinence? A decision analysis

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Abstract

Introduction and hypothesis

A recent randomized controlled trial (RCT) with and without prophylactic antibiotics (pABX) for midurethral slings (MUS) was terminated early owing to lower than predicted infectious complications in both groups. Adequate power required an unattainable sample size. Because of low infectious risks, omitting pABX may be justified. Since an RCT was not feasible, we aimed to use decision analysis modeling to determine if pABX are necessary for MUS.

Methods

We created a decision analysis model comparing 1-year quality adjusted life years (QALYs) between women who do and do not receive pABX for MUS. The model included complications that might differ depending on whether antibiotics were given, such as allergic reaction to pABX (mild/severe), vulvovaginal candidiasis, urinary tract infections including pyelonephritis, pseudomembranous colitis, wound infection, and mesh erosion. Multiple one-way sensitivity analyses confirmed model robustness.

Results

One year after MUS, women who did not receive pABX had higher average QALYs than pABX (0.989 vs 0.977). This difference is less than published minimally important differences (MID) for utilities, suggesting that the strategies are comparable. Ultimately, pABX increased some complications and reduced others with an overall minimal effect on outcomes. Very few thresholds were identified, indicating model robustness and strengthening our conclusions.

Conclusions

Women had slightly higher overall QALY when pABX were not given, but not greater than the MID. Since infectious complications are rare, our model suggests that pABX might be an unnecessary precaution because of similar outcomes with and without pABX.

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References

  1. Shamliyan TA, Kane RL, Wyman J, Wilt TJ (2008) Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 148:459–473

    Article  PubMed  Google Scholar 

  2. Jonsson Funk M, Levin P, Wu JM (2012) Trends in Surgical management of Stress urinary incontinence. Obstet Gynecol 119:845–851

    Article  PubMed  Google Scholar 

  3. Oliphant SS, Wang L, Bunker CH, Lowder JL (2009) Trends in stress urinary incontinence inpatient procedures in the United States, 1979–2004. Am J Obstet Gynecol 200:521.e1–521.e6

    Article  Google Scholar 

  4. Wu JM, Gandhi MP, Shah AD, Shah JY, Fulton RG, Weidner AC (2011) Trends in inpatient urinary incontinence surgery in the USA, 1998–2007. Int Urogynecol J 11:1437–1443

    Article  Google Scholar 

  5. Wolf JS Jr, Bennett CJ, Dmochowski RR et al (2008) Urologic surgery antimicrobial prophylaxis best practice policy panel. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol 179:1379–1390

    Article  PubMed  Google Scholar 

  6. Van Eyk N, van Schalkwyk J, Infectious Disease Committee (2012) Antibiotics prophylaxis in gynaecologic procedures. J Obstet Gynaecol Can 34:382–391

    PubMed  Google Scholar 

  7. Falagas ME, Athanasiou S, Iavazzo C, Tokas T, Antsaklis A (2008) Urinary tract infections after pelvic floor gynecologic surgery: prevalence and effect of antimicrobial prophylaxis. A systematic review. Int Urogynecol J Pelvic Floor Dysfunct 19:1165–1172

    Article  PubMed  Google Scholar 

  8. ACOG Committee Opinion on Practice Bulletins-Gynecology (2009) ACOG practice bulletin no. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 113:1180–1189

    Google Scholar 

  9. Morrill MY, Schimpf MO, Abed H et al (2012) Antibiotic prophylaxis for selected gynecologic surgeries. Int J Gynaecol Obstet 120:10–15

    Article  PubMed  Google Scholar 

  10. Harmanli O, Hong EK, Rubin R, Jones KA, Boyer RL, Metz S (2012) Is antibiotic prophylaxis necessary for midurethral sling procedures? A series of 174 cases without preoperative antibiotics. Int Urogynecol J 23:621–623

    Article  PubMed  Google Scholar 

  11. Harmanli O, Boyer RL, Metz SA et al (2011) Double-blinded randomized trial of preoperative antibiotics in midurethral sling procedures and review of the literature. Int Urogynecol J 22:1249–1253

    Article  PubMed  Google Scholar 

  12. UpToDate. UpToDate, Inc. http://www.uptodate.com. Accessed 1 December 2011

  13. Lee CE, Zembower TR, Fotis MA, Postelnick MJ, Greenberger PA, Peterson LR, Noskin GA (2000) The incidence of antimicrobial allergies in hospitalized patients: implications regarding prescribing patterns and emerging bacterial resistance. Arch Intern Med 160:2819–2822

    Article  CAS  PubMed  Google Scholar 

  14. Napoli DC, Neeno TA (2000) Anaphylaxis to benzathine penicillin G. Pediatr Asthma Allergy Immunol 14:329–333

    Article  Google Scholar 

  15. Czaja CA, Scholes D, Hooton TM, Stamm WE (2007) Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis 45:273–280

    Article  PubMed  Google Scholar 

  16. Ward G, Jorden RC, Severance HW (1991) Treatment of pyelonephritis in an observation unit. Ann Emerg Med 20:258–261

    Article  CAS  PubMed  Google Scholar 

  17. Pepin J, Valiquette L, Alary ME, Villemure P, Pelletier A, Forget K, Pepin K, Chouniard D (2004) Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ 171:466–472

    Article  PubMed Central  PubMed  Google Scholar 

  18. Sutkin G, Alperin M, Meyn L, Wiesenfeld HC, Ellison R, Zyczynski HM (2010) Symptomatic urinary tract infections after surgery for prolapse and/or incontinence. Int Urognyecol J 21:955–961

    Article  Google Scholar 

  19. Swartz M, Ching C, Gill B, Li J, Rackley R, Vasavada S, Goldman HB (2010) Risk of infection after midurethral synthetic sling surgery: are postoperative antibiotics necessary? Urology 75:1305–1308

    Article  PubMed  Google Scholar 

  20. Xu J, Schwartz K, Bartoces M, Monsur J, Severson RK, Sobel JD (2008) Effect of antibiotics on vulvovaginal candidiasis: a MetroNet study. J Am Board Fam Med 21:261–268

    Article  PubMed  Google Scholar 

  21. McClelland RS, Richardson BA, Hassan WM, Graham SM, Kiarie J, Baeten JM, Mandaliya K, Jaoko W, Ndinya-Achola JO, Holmes KK (2009) Prospective study of vaginal bacterial flora and other risk factors for vulvovaginal candidiasis. J Infect Dis 199:1883–1890

    Article  PubMed Central  PubMed  Google Scholar 

  22. Chen CC, Collins SA, Rodgers AK, Paraiso MF, Walters MD, Barber MD (2007) Perioperative complications in obese women vs. normal-weight women who undergo vaginal surgery. Am J Obstet Gynecol 197:98e1–98e8

    Google Scholar 

  23. Shepherd JP, Lowder JL, Jones KA, Smith KJ (2011) Retropubic and transobturator midurethral slings: a decision analysis to compare outcomes including efficacy and complications. Int Urogynecol J 22:1437–1443

    Article  Google Scholar 

  24. Skoczylas LC, Shepherd JP, Smith KJ, Lowder JL (2012) Managing mesh exposure following vaginal prolapse repair: a decision analysis comparing conservative versus surgical treatment. Int Urogynecol J 24:119–125

    Article  PubMed  Google Scholar 

  25. Tufts University Cost-Effectiveness Analysis Registry. Tufts Medical Center Institute for Clinical Research and Health Policy Studies. https://research.tufts-nemc.org/cear4/. Accessed 1 December 2011

  26. Gold MR, Franks P, McCoy KI, Fryback DG (1998) Toward consistency in cost-utility analyses. Med Care 36:778–792

    Article  CAS  PubMed  Google Scholar 

  27. Walters SJ, Brazier JE (2005) Comparison of the minimally important difference for two health state utility measures: EQ-SD and SF-6D. Qual Life Res 14:1523–1532

    Article  PubMed  Google Scholar 

  28. Richter HE, Albo ME, Zyczynski HM et al (2010) Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med 362:2066–2076

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  29. Ross S, Robert M, Swaby C et al (2009) Transobturator tape compared with tension free vaginal tape for stress incontinence. Obstet Gynecol 114:1287–1294

    Article  PubMed  Google Scholar 

  30. Houwert RM, Roovers JPWR, Venema PL et al (2010) Outcome and complications of retropubic and transobturator slings translated into surgical therapeutic indices. Am J Obstet Gynecol 202(75):e1–e7

    PubMed  Google Scholar 

  31. Ingber MS, Vasavada SP, Firoozi F et al (2010) Incidence of perioperative urinary tract infection after single-dose antibiotic therapy for midurethral slings. Urology 76:830–834

    Article  PubMed  Google Scholar 

  32. Nygaard I, Brubaker L, Chai TC et al (2011) Risk factors for urinary tract infection following incontinence surgery. Int Urogynecol J 22:1255–1265

    Article  PubMed  Google Scholar 

  33. Barber MF, Kleeman S, Karram MM et al (2008) Transobturator tape compared with tension free vaginal tape for the treatment of stress incontinence. Obstet Gynecol 111:611–621

    Article  PubMed  Google Scholar 

  34. AUA position statement on the use of vaginal mesh for the surgical treatment of stress urinary incontinence. American Urological Association Board of Directors. http://www.auanet.org/content/aua-policies/position-statements/stress-urinary-incontinence.cfm. Accessed 18 November 2012

  35. Yokoyama M, Yoshida S, Saito K, Koga F, Masuda H, Kobayashi T, Kawakami S, Kihaa K (2009) Discarding antimicrobial prophylaxis for transurethral resection of bladder tumor: a feasibility study. Int J Urol 16:61–63

    Article  PubMed  Google Scholar 

  36. Cundiff GW, Mclenan MT, Bent AE (1999) Randomized trial of Antibiotic prophylaxis for combined urodynamics and cystourethroscopy. Obstet Gynecol 83:749–752

    Article  Google Scholar 

  37. Kramer MS, MacLellan AM, Ciampi A, Etezadi-Amoli J, Leduc DG (1990) Parents’ vs. physicians’ utilities (values) for clinical outcomes in potentially bacteremic children. J Clin Epidemiol 43:1319–1325

    Article  CAS  PubMed  Google Scholar 

  38. Wells CD, Murrill WB, Arguedas MR (2004) Comparison of health-related quality of life preferences between physicians and cirrhotic patients: implications for cost-utility analyses in chronic liver disease. Dig Dis Sci 49:453–458

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15213, USA

    Jonathan P. Shepherd

  2. Department of Obstetrics and Gynecology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA

    Keisha A. Jones & Oz Harmanli

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  1. Jonathan P. Shepherd
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  2. Keisha A. Jones
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  3. Oz Harmanli
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Correspondence to Jonathan P. Shepherd.

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Shepherd, J.P., Jones, K.A. & Harmanli, O. Is antibiotic prophylaxis necessary before midurethral sling procedures for female stress incontinence? A decision analysis. Int Urogynecol J 25, 227–233 (2014). https://doi.org/10.1007/s00192-013-2180-1

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  • DOI: https://doi.org/10.1007/s00192-013-2180-1

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