IMAGINE group: Assessing the EAU Guidelines

To address issues like non-adherence to CPGs, it is crucial to understand the factors that initiate and perpetuate these problematic behaviours, as well as identify elements that could help encourage positive behaviours. These non-adherence concerns become particularly troubling in urological care, where strong recommendations for or against interventions are derived from high-certainty evidence.

The Impact Assessment of Guidelines Implementation and Education (IMAGINE) group is an associated project of the European Association of Urology (EAU) Guidelines Office comprised of an international research assembly focussed on problems with implementation. Group members have expertise across disciplines and methodologies, including urology, epidemiology, psychology, sociology, implementation science, evidence-based medicine and clinical practice guideline development. Our goal is to make sure the right patient gets the right treatment at the right time. We also want to understand why some strong EAU recommendations, which are based on high-certainty evidence, are not followed and what can be done to reverse that situation.

By first determining if adherence patterns vary across Europe, and then identifying barriers and facilitators to adherence, optimistically we can design implementation strategies that can be tailored to both address barriers and leverage facilitators to reduce practice variation and suboptimal care.

Applying the prioritisation criteria of the IMAGINE group to pinpoint ”strong” recommendations grounded in ”high-certainty” evidence, we highlighted a pertinent matter in urology to explore in depth: refraining from the use of antibiotic prophylaxis to decrease the incidence of symptomatic urinary infection following cystoscopy.

Cystoscopy is frequently undertaken for diagnostic purposes, allowing for the examination of the bladder's interior lining. However, a drawback associated with cystoscopy is the potential for symptomatic urinary tract infection, either stemming from pre-existing colonisation or the introduction of bacteria during the procedure. Because cystoscopy is a widespread procedure, the potential for indiscriminate antibiotic usage raises concerns about adverse effects, increases healthcare costs, and contributes to antimicrobial resistance, a pressing global health issue.

Considering the minimal absolute risk of post procedural urinary tract infections in well-resourced countries, the extensive frequency of procedures and the ever-increasing risk of contributing to the rise in antimicrobial resistance, the EAU Urological Infections Guidelines panel unanimously recommends against the use of antibiotic prophylaxis for patients undergoing urethrocystoscopy (whether flexible or rigid) - a “strong” recommendation with level 1a evidence.

Currently, there is a lack of comprehensive data on the use of antibiotic prophylaxis before cystoscopy in Europe. Our initial objective is to understand national and international patterns of use of antibiotic prophylaxis during cystoscopy across the 31 countries within the IMAGINE network. These countries were selected based on the endorsement of the EAU Guidelines by their national societies.

To achieve this, the IMAGINE group designed an observational cross-sectional study using a retrospective audit of recent practices regarding antibiotic prophylaxys before cystoscopy in a multicentre international setting. We used our custom data collection platform, where each user is assigned a unique ID and password, ensuring access only to their individual data and prohibiting the ability to view information from other participating sites. This analysis ensures compliance with GDPR regulations by not collecting or processing personally identifiable data. As a service evaluation, this study does not necessitate sponsor and ethics review board approval. Data will be encrypted and securely stored on ISO27001-compliant servers in Europe. To preserve anonymity, numerical codes will be employed for each country in the presentation of results.

We created a concise induction survey to be distributed by representatives of the national urological societies in the 31 IMAGINE network countries, all of whom have been successfully recruited from previous studies. Within the induction survey, we inquire as to whether the representatives possess national guidelines. If affirmative, we seek to determine whether these national guidelines align with the EAU recommendations for antibiotic prophylaxis in cystoscopy. In cases where discrepancies exist, we request clarification on the nature of these differences.

We have designed a database to collect information about the number of cystoscopies performed, the reason for cystoscopy, the use of urine diagnostics before cystoscopy and if any antibiotic medication was given. To mitigate for selection biases, a random date generator suggests the dates and cases for participation. This study is already underway and we hope to have the results ready for publication soon.

This audit is the first step to determine if further investigation is needed to gain a more profound understanding of the conditions that may lead urologists to deviate from established guidelines. This insight can then guide strategies aimed at facilitating the cessation of inappropriate antibiotic prophylaxis before cystoscopy. This is another study aligned with IMAGINE’s aims to measure baseline adherence to EAU Guidelines recommendations across Europe and to identify barriers which drive non-adherence. Beyond this, next steps will include designing evidence-based interventions to help implement best practices, providing an opportunity to contribute to implementation science, to harmonise our practices, and to provide patients with the best care.

This article first appeared in the 2024 Congress News edition of the European Urology Today.