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A clinical affiliate of
The Mount Sinai Hospital
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
Full service integrated urology group practice Commenced operations as a single practice in
July 2006 Presently 112 physicians in 51 offices in the
greater NY metropolitan area Nassau, Suffolk, Queens, Westchester,
Manhattan, Rockland and the Bronx Approximately 980,000 active patient records
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
Also provide ancillary services necessary for the care of the urology patient Full service laboratory (clinical and AP) Six multi-use facilities▪ 11 linear accelerators with stereotactic capability▪ Accredited full service outpatient surgery
facilities Perform approximately 1.5% of all GU services in the
US
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
Recognized need to standardize processes Desire to provide “best in class” services Implemented robust review processes Quality management Utilization review Compliance
Identified prostate biopsy infection rate as major quality index
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
Historical sepsis rate 8%, 3.1% with single dose ciprofloxacin prophylaxis1
Since then, multiple studies with a variety of pharmaceutical and mechanical prep
Concerns regarding increased rate of infectious complications after biopsy2
1Kapoor DA, Klimberg IW, Malek GH, et al. Single-dose oral ciprofloxacin versus placebo for prophylaxis during transrectal prostate biopsy. Urology1998; 52:552–558
2Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM. Complications after prostate biopsy: data from SEER-Medicare. J Urol. 2011 Nov;186(5):1830-4
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
Infection information collected via two methods Self reported at M/M conferences EMR surveillance
Commenced reviews June 2008
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
First data collation August 2008 Post biopsy sepsis rate 3.1% Substantial variation in prophylaxis regimens▪ Most commonly used was 1-3 peri-procedure doses of
PO ciprofloxacin▪ No standard use of mechanical prep
Most common organism identified was quinolone resistant E. coli
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
QM committee performed comprehensive literature review
Recognized that objective data on patterns of drug resistance needed
Utilized hospital antibiograms as a resource Physicians on staff at 75 regional hospitals Selected geographically representative hospitals
for source data
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
Initial protocol: All patients should be given double antibiotic therapy; any oral
therapy should begin 1-2 days before the procedure, to continue on the day of the procedure and for a minimum of 2 days after the procedure; any parenteral antibiotic(s) should be given on the day of the procedure, one hour before it is performed
The antibiotics used for prophylaxis should be from two different classes of antibiotics and at least one of them should be bacteriocidal
All patients should perform an enema (at least a Fleet enema) on the morning of the procedure; consideration should be given to an enema the night before the procedure as well
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
Protocol mandated by IMP Board 11/2008 First quarter sepsis rate after implementation
1.67%:
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
0
0.5
1
1.5
2
2.5
3
3.5
Baseline 2009 2010 2011 2012
3.1
1.33
0.93 1.02 0.93
Seps
is R
ate
(%)
Year
Sepsis Rate After Prostate Biopsy, 2009-2012
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
Overall 4 year sepsis rate: 0.95% Implementation of protocol prevented 662 cases
of sepsis Extended protocol to placement of fiducial
markers in 2009 Sepsis rate 0.80%
A clinical affiliate of
The Mount Sinai Hospital
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A clinical affiliate of
The Mount Sinai Hospital
Review of antibiotic resistant patterns demonstrates that “cookie-cutter” prophylaxis regimens unlikely to be effective
Implementation of frequently updatedevidence-based prophylaxis regimens can substantially reduce infectious complications from prostate biopsy
