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Friday, October 16, 2020

Evaluation of the Effect of Routine Antibiotic Administration after Uterine Artery Embolization on Infection Rates


Clinical question
What is the effectiveness of routine administration of post-procedure antibiotics after uterine artery embolization (UAE) to prevent procedure-related infections?

Take-away point
No increased rate of infections were seen after UAE for fibroids when post-procedure antibiotics were discontinued.

Reference
Evaluation of the Effect of Routine Antibiotic Administration after Uterine Artery Embolization on Infection Rates. Graif, A. et al. Journal of Vascular and Interventional Radiology, Volume 31, Issue 8, 1263-1269.

Click here for abstract

Study design
Single-center retrospective cohort study

Funding source
No funding

Setting
Private hospital: Christiana Care Health System, Newark, DE




Visual synopsis


Summary


Given the increasing need for antibiotic stewardship and further development of UAE treatment, a single-center retrospective cohort study was performed to address the infection rate following UAE for fibroids when no post-procedure antibiotics were given. In 2018 the SIR last recommended the use of pre-procedure antibiotics for UAE. However, post-procedure antibiotics are not recommended unless there is evidence of possible infection. Despite these recommendations, many patients still receive a post-procedure course of antibiotics. Previous UAE studies acknowledge post-procedure antibiotic use, however no subgroup analyses regarding specific antibiotic usage were performed. In the HOPEFUL study (Hysterectomy Or Percutaneous Embolisation For Uterine Leiomyoma), it showed benefit from expected general side effects after the procedure, but no overall effect in the rate of infections. Therefore, this study aims to address the effectiveness of routine administration of post-procedure antibiotics after UAE in the prevention of procedure-related infection.

At this private institution prior to 2016, patients who received routine pre and post procedure antibiotics (n=217) were compared to those after 2016, where no post-procedure antibiotics (n=158) were given. Pre-procedure antibiotics for the no-antibiotics group consisted of weight based dose of IV cefazolin, whereas the post-procedure antibiotics group received IV 500mg ciprofloxacin. Post-procedure antibiotics were oral ciprofloxacin 500mg twice daily for five days. These two groups were compared for infectious complications with primary endpoints being an infectious complication requiring therapy with antibiotics, re-admission or surgical intervention within three months. Infections were subsequently classified as minor or major. The secondary endpoint was 90-day mortality. Demographics were similar between the two groups, though the no-antibiotics group had a significantly higher rate of diabetes and a lower rate of adenomyosis. The procedure was similar in each group with regards to arteries embolized, number of vials used and procedural steps. However, in the antibiotics group patients received only embospheres, whereas in the no post-procedure antibiotics group patients received embospheres, embozene or both.

No statistically significant difference was seen between the number of infections (P=.66) when comparing the post-procedure antibiotics group (4/217, 1.8%) to the no-antibiotics group (2/158, 1.3%). Overall infection rate was (6/375, 1.6%), occurring at a median of 15.5 days. Overall minor complications (3/375, 0.8%) did not differ between the groups. The primary symptom was malodorous vaginal discharge, requiring empiric oral antibiotic therapy. Overall major complication rates also did not differ between the groups (3/375, 0.8%). Major infectious complications resulted in two patients who underwent hysterectomy and one patient receiving a myomectomy. No 90-day mortalities were seen. Regardless of antibiotic usage, infectious rates and complications found in this study mirror previous large retrospective studies and meta-analyses. The authors conclude that post-procedure antibiotic prophylaxis after UAE did not result in increased rates of minor or major infectious complications.

Commentary


This study helps underscore the current SIR antibiotic recommendations and encourages practitioners to use post-procedure antibiotic prophylaxis cautiously. Previous studies lacked the clarity behind specific antibiotic usage and regimens that this study addresses. However, there are a few aspects to this paper regarding power, type of study, and the differences between the two groups that should be considered.

This study lacks power given its smaller sample size and generalizability due to its single-center retrospective nature. Due to the lack of power, they were not able to perform regression analyses based on types of particles used and characterization of fibroid disease, both of which may play a role in procedure related infections. Reassuringly, this study has similar infectious rates when compared to previous large prospective studies. Differences between the two groups that should be considered are differing pre-procedure antibiotic regimen, variation of embolization particles and their loss to follow up rate. Though complications were low and similar to previous studies, overall 50% of complications were minor and 50% were major. The main minor complication noted was malodorous discharge. This may also be underreported or not fully captured given the 13.4% of those lost to follow up. Overall, this is an important study that guides the decision on whether or not to prescribe post-procedure antibiotic prophylaxis in UAE.

Post Author
Marissa Stumbras, MD
Interventional Radiology Resident, PGY2
Oregon Health & Science University

@MarissaStumbras

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