Reducing candidaemia risk in urology patients: Revised algorithm & Pharmacist-Led Implementation

Background: Candidaemia is an invasive infection with high morbidity and mortality. All urology procedures carry risk of post-operative infection. Risk mitigation strategies include preoperative urine culture and treatment of cultured organism(s) regardless of symptoms. After zero cases of candidaemia for two years, there were five cases in elective urology patients within 15 weeks between June- September 2021. This increased incidence of candidaemia amongst these patients prompted multidisciplinary investigation. Methods: Single centre case series, in a 250-bed hospital which annually performs 2000-2500 elective urology surgeries. Affected patients were elderly with multiple comorbidities. Notably, four of five patients had prior indwelling ureteral stents. All five patients had preoperative bacteriuria requiring antibiotics and one patient had pre-operative candiduria. Results: Hypotheses including sterilisation failure, surgical instrument contamination, or surgical technique issues were unfounded. We propose that pre-operative duration of antibacterial therapy, particularly in the setting of ureteral stent biofilm, is a significant factor for candiduria. A new prescribing algorithm for urology patients was devised. Antibiotic treatment duration in asymptomatic patients with indwelling urinary tract foreign material was reduced from 14 to 3 days, and from 14 to 7 days in symptomatic patients. Dedicated pharmacist resources were allocated to support this change and pre-operatively manage these patients. These interventions led to zero candidaemia cases over the subsequent 21 months, along with zero post-operative bacterial bloodstream infections.