Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey

Physician-reported barriers and challenges to antibiotic prescribing in surgical prophylaxis: a structured systematic review

Objectives

The purpose of the study is to identify and analyse the barriers in surgical procedures where antibiotic dissipation is habitual.

Methods

Extensive literature search is carried out using different electronic databases (PubMed, Europe PMC, PLoS and Google Scholar) between January 2000 and December 2020. The articles were selected purely based on the inclusion criteria. Only qualitative and cross-sectional studies were selected to reduce the risk of bias. The JBI and AXIS checklists were used to assessed the quality of the enrolled articles. Data extractions were done by using a predesigned standardized data collection form.

Key findings

A total of 2067 articles were electronically retrieved but only 14 articles met the eligibility criteria. About 15 902 healthcare professionals (HCPs) with an average response rate of 64.7% were pooled for evidence synthesis. The majority of respondents (50%) discussed different barriers in their practice site for surgical antibiotic prophylaxis (SAP) administration. Barriers were categorized into four themes: lack of guideline availability and knowledge, lack of adherence to guidelines, lack of guideline knowledge and adherence and physician perceptions or off-label practices. A total of 723 (56.3%) out of 1282 HCPs from nine different studies reported a lack of adherence to guidelines during the perioperative process. The majority of respondents in three studies, 318 (82%) out of 386 HCPs, reported that physicians’ perceptions play a crucial role in prescribing SAP during surgeries.

Conclusion

This study concluded that the barriers within the practice site play a decisive role in SAP optimization and therefore all HCPs are recommended to maintain local/standard guidelines and adhere to them while prescribing SAP.

What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice

OBJECTIVE

The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations.

BACKGROUND

In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework.

METHODS

A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model.

RESULTS

Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement).

CONCLUSIONS

Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.

Preoperative Antibiotic Prophylaxis in Elective Minor Surgical Procedures among Adults in Southern Italy

Little is known regarding the factors associated with surgical antibiotic prophylaxis (SAP) compliance in elective minor surgery. The purposes of this cross-sectional study were to identify the frequency of inappropriate SAP administration and to understand the characteristics associated with such inappropriateness in a sample of elective minor surgical procedures. The study was performed between May and July 2019 among a random sample of patients aged 18 years and older in seven public hospitals randomly selected in the Campania and Calabria Regions of Italy. Globally, only 45% of SAP approaches were deemed completely in accordance with the evidence-based guidelines. Patients with an ordinary admission, those who underwent local anesthesia, those receiving plastic and reconstructive and ophthalmology surgery, and those who had not received a prosthetic implant were more likely to receive an appropriate SAP approach; those receiving obstetrics, gynecological, and urological surgical procedures were less likely than those who underwent abdominal, vascular, and breast surgery. The course of antibiotic prophylaxis was not consistent with the guidelines in 48.5% procedures with one or more reasons for inappropriateness. Appropriate time of the SAP administration was more frequently observed in patients who were older, those with a Charlson comorbidity index of 0, those who did not receive a prosthetic implant, and those receiving plastic and reconstructive surgery; it was less likely in patients receiving obstetrics, gynecological, and urological surgeries compared with those who underwent abdominal, vascular, and breast surgery. Aspects of SAP that need to be improved are molecule choice, time of administration, and specific surgical procedures. Hospital managers should involve surgeons and anesthesiologists in initiatives tailored to optimize SAP prescribing.

USA Department of Defense audit of surgical antibiotic prophylaxis prescribing patterns in inguinal hernia repair

PURPOSE

Antibiotic prophylaxis in inguinal hernia repair (IHR) is contentious in literature and practice. In low-risk patients, for whom evidence suggests antibiotic prophylaxis is unnecessary, many surgeons still advocate for its routine use. This study surveys prescription patterns of Department of Defense (DoD) general surgeons.

METHODS

An anonymous survey was sent electronically to approximately 350 DoD general surgeons. The survey asked multiple-choice and free text answers about prescribing patterns and knowledge of current evidence for low-risk patients undergoing elective open inguinal hernia repair without mesh (OIHRWOM), open inguinal hernia repair with mesh (OIHRWM), or laparoscopic inguinal hernia repair (LIHR).

RESULTS

110 DoD general surgeons consented to participate. 58.6, 95 and 84.2% of surgeons always administer antibiotic prophylaxis in OIHRWOM, OIHRWM, and LIHR, respectively. 37.9, 70.9, and 63.2% of surgeons believe that it reduces rates of surgical site infection in OIHRWOM, OIHRWM, and LIHR, respectively. The most common reasons for empirically prescribing antibiotic prophylaxis include "I think the evidence supports it" (27 of 72 responses), "I would rather be conservative and safe" (15 of 72 responses), and "I am following my hospital/department guidelines" (9 of 72 responses). 11.8, 40.8, and 32.9% of surgeons believe current evidence supports antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively. 50, 18.4, and 22.4% of surgeons believe current evidence refutes antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively.

CONCLUSION

The survey results indicate that the majority of practicing DoD general surgeons still empirically prescribe surgical antibiotic prophylaxis in IHR despite more conflicting opinions that it has no meaningful effect or that current evidence does not supports its use.

Supportive technology in collaborative research: proposing the STiCR framework

INTRODUCTION

Achieving a standard of clinical research at the pinnacle of the evidence pyramid is historically expensive and logistically challenging. Research collaboratives have delivered high-impact prospective multicentre audits and clinical trials by using trainee networks with a range of enabling technology. This review outlines such use of technology in the UK and provides a framework of recommended technologies for future studies.

METHODS

A review of the literature identified technology used in collaborative projects. Additional technologies were identified through web searches. Technologies were grouped into themes including access (networking and engagement), collaboration and event organisation. The technologies available to support each theme were studied further to outline relative benefits and limitations.

FINDINGS

Thirty-three articles from trainee research collaboratives were identified. The most frequently documented technologies were social media applications, website platforms and research databases. The Supportive Technologies in Collaborative Research framework is proposed, providing a structure for using the technologies available to support multicentre collaboration. Such technologies are often overlooked in the literature by established and start-up collaborative project groups. If used correctly, they might help to overcome the physical, logistical and financial barriers of multicentre clinical trials.

Knowledge, attitude and practice of surgical staff towards preoperative surgical antibiotic prophylaxis at an academic tertiary hospital in Sudan

Background

Surgical site infections (SSIs) are among the most common serious complications after surgery and associated with preventable morbidity, mortality, and increased health care costs. The use of surgical antimicrobial prophylaxis (SAP) is an effective measure that helps to protect against SSIs. This study aims to evaluate the knowledge, attitude, and practice of surgical staff towards preoperative antibiotic prophylaxis in surgery department at an academic tertiary hospital in Sudan.

Methodology

An observational descriptive study was conducted among doctors in the surgery department at an academic tertiary hospital in Sudan in order to assess their knowledge, attitude, and practice (KAP) towards surgical antibiotic prophylaxis (SAP). A four-section multiple-choice questionnaire was designed and hand-delivered to registered doctors in the surgery department at an academic tertiary hospital in Sudan. The WHO guidelines were used to evaluate the answers of the participants.

Results

Out of 56 doctors requested to participate in this study, only 49 responded and their response rate was 87.5%. Six (12.5%) surgeons had good knowledge about appropriate SAP. However, 16.3 and 24.5% of the respondents were aware of appropriate SAP in the case of Ig E-mediated reaction to penicillin and risk of Gram-negative infections, respectively. The surgeon's attitude score about the need for local and national guidelines for SAP was 98 and 100%, respectively. Accordance of the physician's practice with ASHP guidelines regarding timing of the first dosage of SAP was 35.4% while correct administration of an intraoperative dose was 42.9% in agreement with the guideline. 53.1% knows when to stop SAP after surgery correctly.

Conclusion

Although the participants in this study showed a positive attitude towards antibiotic prophylaxis guidelines, their knowledge and strict adherence to a protocolized practice per WHO checklist should be improved in order to reduce the incidence of preventable surgical site infections.

Inguinal hernia repair in Nigeria: a survey of surgical trainees

PURPOSE

Africa's inguinal hernia burden is high with large numbers of untreated hernias. Mesh repair is recommended in developed countries, but the best repair in developing countries is unknown. Little is known about knowledge and practice of surgeons in Nigeria performing inguinal hernia repair. Surgical trainees can provide this information.

METHODS

A questionnaire-based survey was administered to surgical trainees from all over Nigeria who had attended the West African College of Surgeons' integrated revision course in Jos, on their practice and recommendations concerning elective inguinal hernia repair.

RESULTS

One hundred and nine surgical trainees (90.8%) consisting of 78 (71.6%) registrars and 30 (27.5%) senior registrars responded. Thirty-two (29.4%) used antibiotics routinely for inguinal hernia surgery. Ceftriaxone was the most widely used antibiotic (45%). Ninety-two (84.4%) respondents will perform this surgery as day case. Forty (36.7%) respondents stated modified Bassini repair as their preferred method of repair. Mesh repair was recommended by 93 (85.3%) respondents while 65 of 100 respondents (65%) recommended laparoscopic surgery. Of 103 respondents, 93 (90.3%) had performed inguinal hernia repair and 34 (33%), mesh repair. For 56 (51.4%) respondents, the most difficult part of open hernia surgery was sac dissection.

CONCLUSIONS

Surgical trainees in Nigeria perform more tissue-based inguinal hernia repair than mesh but majority would recommend both mesh repair and laparoscopic surgery. Majority found sac dissection as the most difficult part of open hernia surgery.

Savings from reducing low-value general surgical interventions

Background

Finding opportunities for improving efficiency is important, given the pressure on national health budgets. Identifying and reducing low-value interventions that deliver little benefit is key. A systematic literature evaluation was done to identify low-value interventions in general surgery, with further assessment of their cost.

Methods

A multiplatform method of identifying low value interventions was undertaken, including a broad literature search, a targeted database search, and opportunistic sampling. The results were then stratified by impact, assessing both frequency and cost.

Results

Seventy-one low-value general surgical procedures were identified, of which five were of high frequency and high cost (highest impact), 22 were of high cost and low frequency, 23 were of low cost and high frequency, and 21 were of low cost and low frequency (lowest impact). Highest impact interventions included inguinal hernia repair in minimally symptomatic patients, inappropriate gastroscopy, interval cholecystectomy, CT to diagnose appendicitis and routine endoscopy in those who had CT-confirmed diverticulitis. Their estimated cost was €153 383 953.

Conclusion

Low-value services place a burden on health budgets. Stopping only five high-volume, high-cost general surgical procedures could save the National Health Service €153 million per annum.

Network meta-analysis of antibiotic prophylaxis for prevention of surgical-site infection after groin hernia surgery

BACKGROUND

First-generation cephalosporins (such as cefazolin) are recommended as antibiotic prophylaxis in groin hernia repair, but other broad-spectrum antibiotics have also been prescribed in clinical practice. This was a systematic review and network meta-analysis to compare the efficacy of different antibiotic classes for prevention of surgical-site infection (SSI) after hernia repair.

METHODS

RCTs were identified that compared efficacy of antibiotic prophylaxis on SSI after inguinal or femoral hernia repair from PubMed and Scopus databases up to March 2016. Data were extracted independently by two reviewers. Network meta-analysis was applied to assess treatment efficacy. The probability of being the best antibiotic prophylaxis was estimated using surface under the cumulative ranking curve (SUCRA) analysis.

RESULTS

Fifteen RCTs (5159 patients) met the inclusion criteria. Interventions were first-generation (7 RCTs, 1237 patients) and second-generation (2 RCTs, 532) cephalosporins, β-lactam/β-lactamase inhibitors (6 RCTs, 619) and fluoroquinolones (2 RCTs, 581), with placebo as the most common comparator (14 RCTs, 2190). A network meta-analysis showed that β-lactam/β-lactamase inhibitors and first-generation cephalosporins were significantly superior to placebo, with a pooled risk ratio of 0·44 (95 per cent c.i. 0·25 to 0·75) and 0·62 (0·42 to 0·92) respectively. However, none of the antibiotic classes was significantly different from the others. SUCRA results indicated that β-lactam/β-lactamase inhibitors and first-generation cephalosporins were ranked first and second respectively for best prophylaxis.

CONCLUSION

β-Lactam/β-lactamase inhibitors followed by first-generation cephalosporins ranked as the most effective SSI prophylaxis for adult patients undergoing groin hernia repair.

Antibiotic prophylaxis in open inguinal hernia repair: a literature review and summary of current knowledge

More than 1 million inguinal hernia repairs are performed in Europe and the US annually. Although antibiotic prophylaxis is not required in clean, elective procedures, the routine use of implants (90% of inguinal hernia repairs are performed with mesh) makes the topic controversial. The European Hernia Society does not recommend routine antibiotic prophylaxis for elective inguinal hernia repairs. However, the latest randomized controlled trial, published by Mazaki et al., indicates that the use of prophylaxis is effective for the prevention of surgical site infection. Unnecessary prophylaxis contributes to the development of bacterial resistance and significantly increases healthcare costs. This review documents clinical trials on inguinal hernia repairs with mesh and summarizes the current knowledge. It also tries to solve certain problems, namely: what constitutes a real risk factor, late-onset infection, and how the "surgical environment" impacts on the need to use antibiotic prophylaxis.

The effectiveness of i.v. cefuroxime prophylaxis of surgical site infection after elective inguinal hernia repair with mesh: A retrospective observational study

PURPOSE

The efficacy of routine antibiotic prophylaxis for prevention of surgical site infection (SSI) after elective inguinal hernia repair with a mesh patch remains uncertain. The authors of a recent Cochrane meta-analysis based on 17 randomized trials were unable to draw a definitive conclusion on this subject. The purpose of this study was to determine the effectiveness of prophylactic antibiotics for prevention of SSI after elective inguinal hernia repair with mesh and the risk factors for SSI.

METHODS

All low-risk patients who underwent elective inguinal hernia repair with mesh at our institution between 2010 and 2015 were enrolled in this study, with the exception of patients with recurrent hernias or immunosuppressive diseases. All patients received a single intravenous (i.v.) injection of cefuroxime (1.5 g) within 2 h prior to surgery at the discretion of the surgeon. SSI was defined using criteria of the Centers for Disease Control and Prevention. The variables which could influence the rate of SSI were analyzed by multivariate analysis to determine the independent risk factors for SSI.

RESULTS

Among the 605 patients who underwent elective inguinal hernia repair with mesh during the study period, 553 were eligible for enrolment in the study. Of these, 331 received a single dose of cefuroxime preoperatively. The overall SSI rate was 5.4 %; 9.4 % of those patients who did not receive preoperative antibiotic prophylaxis developed SSI versus 2.8 % of those who did receive prophylaxis (P = 0.001). All infections were superficial. Factors independently associated with SSI were advanced age, smoking and preoperative stay.

CONCLUSIONS

The incidence of SSI among low-risk patients who did and did not receive preoperative antibiotic prophylaxis after elective inguinal hernia repair with mesh differed significantly, particularly among patients of advanced age, smokers and patients with a prolonged preoperative stay in the hospital.

Clinical trial networks in orthopaedic surgery

The aim of this study was to review the role of clinical trial networks in orthopaedic surgery. A total of two electronic databases (MEDLINE and EMBASE) were searched from inception to September 2013 with no language restrictions. Articles related to randomised controlled trials (RCTs), research networks and orthopaedic research, were identified and reviewed. The usefulness of trainee-led research collaborations is reported and our knowledge of current clinical trial infrastructure further supplements the review. Searching yielded 818 titles and abstracts, of which 12 were suitable for this review. Results are summarised and presented narratively under the following headings: 1) identifying clinically relevant research questions; 2) education and training; 3) conduct of multicentre RCTs and 4) dissemination and adoption of trial results. This review confirms growing international awareness of the important role research networks play in supporting trials in orthopaedic surgery. Multidisciplinary collaboration and adequate investment in trial infrastructure are crucial for successful delivery of RCTs.

Cite this article: Bone Joint Res 2014;3:169–74.