Compliance with surgical antibiotic prophylaxis--reporting from a statewide surveillance programme in Victoria, Australia

Evaluation of the practice of surgical antibiotic prophylaxis in a Zonal Referral Hospital in Mbujimayi, Democratic Republic of the Congo (DRC)

BACKGROUND

Surgical Antibiotic Prophylaxis (SAP) is helpful in preventing patients from developing Surgical Site Infections (SSI). In Mbujimayi, the documentation on the practice of SAP is outdated and inadequate. The last study was conducted more than 5 years ago. This study aims at assessing the compliance of the practice of antibiotic prophylaxis in the surgical and obstetrics-gynecology departments of the Bonzola Zonal Referral Hospital (BZRH) compared to the international standards.

METHODS

A prospective observational study was conducted from March 2020 to March 2021 involving 324 surgical patients who received antibiotic prophylaxis. Interventions were assessed as "compliant" if all the variables individually complied with the criteria for antibiotic prophylaxis use.

RESULTS

Three hundred and twenty-four patients were enrolled in this study. Compliance was found to be 87.35% for the indication for administration; 0.31% for the choice of the molecule; 3.65% for the time of the first administration; none for the duration of antibiotic prophylaxis. Therefore, the overall compliance was nil. This study shows a significant gap when the current practice in Mbujimayi town is compared to the recommendations of international societies.

CONCLUSION

SAP is often indicated in accordance with international recommendations in Mbujimayi. However, the choice of the molecule, the dosage, the time of first administration and the duration of SAP deviate from them. Thus, the compliance of SAP is nil.

Surgical Antibiotic Prophylaxis in an Era of Antibiotic Resistance: Common Resistant Bacteria and Wider Considerations for Practice

The increasing incidence of antimicrobial resistance (AMR) presents a global crisis to healthcare, with longstanding antimicrobial agents becoming less effective at treating and preventing infection. In the surgical setting, antibiotic prophylaxis has long been established as routine standard of care to prevent surgical site infection (SSI), which remains one of the most common hospital-acquired infections. The growing incidence of AMR increases the risk of SSI complicated with resistant bacteria, resulting in poorer surgical outcomes (prolonged hospitalisation, extended durations of antibiotic therapy, higher rates of surgical revision and mortality). Despite these increasing challenges, more data are required on approaches at the institutional and patient level to optimise surgical antibiotic prophylaxis in the era of antibiotic resistance (AR). This review provides an overview of the common resistant bacteria encountered in the surgical setting and covers wider considerations for practice to optimise surgical antibiotic prophylaxis in the perioperative setting.

Factors that influence adherence to surgical antimicrobial prophylaxis (SAP) guidelines: a systematic review

BACKGROUND

Despite the extensive research that has been conducted to date, practice often differs from established guidelines and will vary between individuals and organisations. It has been noted that the global uptake of local and international surgical antimicrobial prophylaxis (SAP) guidelines is poor with limited research investigating factors that affect guideline adherence. The purpose of this systematic review was to determine the reported barriers and enablers to the adherence of SAP guidelines.

METHODS

A search of the literature was performed using four electronic databases (CINAHL, EMBASE, PubMed and SCOPUS) for articles published in the English language from January 1998 to December 2018. Articles were included if they were solely related to SAP and discussed the barriers or enablers to SAP guideline adherence. Articles that assessed the adherence to a range of infection control measures or discussed adherence to antibiotic treatment guidelines rather than SAP guidelines were excluded from this review. Barriers and enablers were mapped to the Theoretical Domains Framework (TDF). The Mixed Methods Appraisal Tool was used to assess the quality of included studies.

RESULTS

A total of 1489 papers were originally retrieved, with 48 papers meeting the eligibility criteria. Barriers and enablers were mapped to 11 out of 14 TDF domains: knowledge, skills, social/professional role and identity, beliefs about capabilities, beliefs about consequences, reinforcement, memory, attention and decision processes, environmental context and resources, social influences, emotion and behavioural regulation. Barriers were further categorised into personal or organisational barriers, while enablers were arranged under commonly trialled interventions.

CONCLUSIONS

There are numerous factors that can determine the uptake of SAP guidelines. An identification and understanding of these factors at a local level is required to develop tailored interventions to enhance guideline adherence. Interventions, when used in combination, can be considered as a means of improving guideline use.

Assessment of implementation of antibiotic stewardship program in surgical prophylaxis at a secondary care hospital in Ras Al Khaimah, United Arab Emirates

Antibiotic overuse is a major factor for causing antibiotic resistance globally. However, only few studies reported the implementation and evaluation of antimicrobial stewardship programs in Gulf Cooperation Council. This study was conducted within 8-months periods to evaluate the effect of the newly implemented antibiotic stewardship program on improving the prescribing practice of surgical antibiotic prophylaxis in a secondary care hospital in the United Arab Emirates by releasing local hospital guidelines. The data of 493 in patients were documented in the predesigned patient profile form and the prescribing practice of surgical antibiotic prophylaxis for clean and clean-contaminant surgical procedures was compared and analyzed two months’ prior (period A) and post (period B) the implementation of antibiotic stewardship program. The 347 patient’s data (PD) were analyzed during period A and 146 PD during period B. The prescription of piperacillin/tazobactam was decreased from 2.4% from all surgical prophylaxis antibiotic orders in period A to 0% in period B. The appropriateness of the antibiotic therapy was found to differ non significantly for the selection of prophylactic antibiotic (p = 0.552) and for the timing of first dose administration (p = 0.061) between A and B periods. The total compliance was decreased non significantly (P = 0.08) from 45.3 to 40.2%. Overall, the guidelines have improved the prescribing practice of antibiotics prior to surgery. However, further improvement can be achieved by initiating educational intervention via cyclic auditing strategy.

Factors associated with antimicrobial choice for surgical prophylaxis in Australia

Background

Cefazolin is the most commonly recommended antimicrobial for surgical antimicrobial prophylaxis (SAP). However, the Australian Surgical National Antimicrobial Prescribing Survey revealed a wide range of antimicrobials prescribed for SAP. Inappropriate use of broad-spectrum antimicrobials is associated with increased patient harm and is a posited driver for antimicrobial resistance.

Objectives

To describe patient, hospital and surgical factors that are associated with appropriateness of the top five prescribed antimicrobials/antimicrobial classes for procedural SAP.

Methods

All procedures audited from 18 April 2016 to 15 April 2019 in the Surgical National Antimicrobial Prescribing Survey were included in the analysis. Estimated marginal means analyses accounted for a range of variables and calculated a rate of adjusted appropriateness (AA). Subanalyses of the top five audited antimicrobials/antimicrobial classes identified associations between variables and appropriateness.

Results

A total of 12 419 surgical episodes with 14 150 prescribed initial procedural doses were included for analysis. When procedural SAP was prescribed, appropriateness was low (57.7%). Allergy status, surgical procedure group and the presence of prosthetic material were positively associated with cefazolin and aminoglycoside appropriateness (P < 0.05). There were no significant positive associations with glycopeptides and third/fourth-generation cephalosporins. The use of broad-spectrum antimicrobials was the most common reason for inappropriate choice (67.9% of metronidazole to 83.3% of third/fourth-generation cephalosporin prescriptions).

Conclusions

Various factors influence appropriateness of procedural SAP choice. Identification of these factors provides targets for antimicrobial stewardship interventions, e.g. procedures where surgeons are regularly prescribing broad-spectrum SAP. These can be tailored to address local hospital prescribing practices.

Compliance with national guidelines for antibiotic prophylaxis in hip fracture patients: a quality assessment study of 13 329 patients in the Norwegian Hip Fracture Register

OBJECTIVE

We assessed compliance with new guidelines for prophylactic antibiotics in hip fracture surgery in Norway introduced in 2013.

DESIGN

The data from the Norwegian Hip Fracture Register was used to assess the proportion of antibiotics given according to the national guidelines.

SETTING

All hospitals in Norway performing hip fracture surgery in the period from 2011 to 2016.

PARTICIPANTS

We studied 13 329 hemiarthroplasties (HAs) for acute hip fracture.

MAIN OUTCOME MEASURE

Type and timing between first and last dose of prophylactic antibiotics compared with the national guidelines.

RESULTS

Before the guidelines were introduced, the recommended drugs cephalotin or clindamycin was used in only 86.2% of all HAs. In 2016, one of the two recommended drugs was administered in 99.2% of HAs. However, hospitals' adaption of the recommended administration of the two drugs improved slowly, and by the end of the study period, only three out of five HAs were performed with the correct drug administered in the correct manner. We found major differences in compliance between hospitals.

CONCLUSIONS

The change towards correct administration of antibiotic prophylaxis was varied both when investigating university and non-university hospitals. We suggest that both hospital leaders and the national Directorate of Health need to investigate routines for better dissemination of information and education to involved parties. Strong leadership concerning evidence-based guidelines on antibiotic prophylaxis in surgery may take away some autonomy from executing healthcare professionals, but will result in better patient care and antibiotic stewardship.

Evaluation of Pediatric Surgical Site Infections Associated with Colorectal Surgeries at an Academic Children's Hospital

Appropriate use of antibiotic prophylaxis (AP) is a key measure for the prevention of surgical site infections (SSI) in colorectal surgeries; however, despite the presence of national and international guidelines, compliance with AP recommendations remains low. The purpose of this study is to evaluate compliance with recommendations for the use of AP in children undergoing colorectal surgeries and to evaluate the effectiveness of antibiotics in the prevention of SSI. We collected demographic and clinical characteristics of patients who underwent colorectal surgeries, as well as microbiological and antimicrobial susceptibility data for patients who developed SSI. AP data were collected and compared with national guidelines. Antibiotic dosing and duration were most frequently in concordance with national guidelines, while antibiotic timing and selection had the lowest rates of compliance. Twelve of the 192 colorectal procedures evaluated resulted in SSI. Only 2 of the 12 children with SSI received appropriate AP for all four categories evaluated. Eight cases that resulted in SSI were due to organisms not covered by the recommended AP. We identified multiple areas for the improvement of AP in children undergoing colorectal surgery. A multidisciplinary approach to development of standardized protocols, educational interventions, and EHR-based algorithms may facilitate or improve appropriate AP use.

Influences on surgical antimicrobial prophylaxis decision making by surgical craft groups, anaesthetists, pharmacists and nurses in public and private hospitals

Background

Surgical antimicrobial prophylaxis (SAP) is a leading indication for antibiotic use in the hospital setting, with demonstrated high rates of inappropriateness. Decision-making for SAP is complex and multifactorial. A greater understanding of these factors is needed to inform the design of targeted antimicrobial stewardship interventions and strategies to support the optimization of SAP and its impacts on patient care.

Methods

A qualitative case study exploring the phenomenon of SAP decision-making. Focus groups were conducted with surgeons, anaesthetists, theatre nurses and pharmacists across one private and two public hospitals in Australia. Thematic analysis was guided by the Theoretical Domains Framework (TDF) and the Capabilities, Opportunities, Motivators-Behaviour (COM-B) model.

Results

Fourteen focus groups and one paired interview were completed. Ten of the fourteen TDF domains were identified as relevant. Thematic analysis revealed six significant themes mapped to the COM-B model, and subthemes mapped to the relevant TDF domains in a combined framework. Key themes identified were: 1) Low priority for surgical antimicrobial prophylaxis prescribing skills; 2) Prescriber autonomy takes precedence over guideline compliance; 3) Social codes of prescribing reinforce established practices; 4) Need for improved communication, documentation and collection of data for action; 5) Fears and perceptions of risk hinder appropriate SAP prescribing; and 6) Lack of clarity regarding roles and accountability.

Conclusions

SAP prescribing is a complex process that involves multiple professions across the pre-, intra- and post-operative surgical settings. The utilisation of behaviour change frameworks to identify barriers and enablers to optimal SAP prescribing supports future development of theory-informed antimicrobial stewardship interventions. Interventions should aim to increase surgeon engagement, enhance the prioritisation of and accountability for SAP, and address the underlying social factors involved in SAP decision-making, such as professional hierarchy and varied perceptions or risks and fears.

Appropriateness of Surgical Antimicrobial Prophylaxis Practices in Australia

IMPORTANCE

Surgical antimicrobial prophylaxis (SAP) is a common indication for antibiotic use in hospitals and is associated with high rates of inappropriateness.

OBJECTIVE

To describe the SAP prescribing practices and assess hospital, surgical, and patient factors associated with appropriate SAP prescribing.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, national, quality improvement study with retrospective analysis of data collected from Australian hospitals via Surgical National Antimicrobial Prescribing Survey audits from January 1, 2016, to June 30, 2018. Data were analyzed using multivariable logistic regression. Crude estimates of appropriateness were adjusted for factors included in the model by calculating estimated marginal means and presented as adjusted-appropriateness with 95% confidence intervals.

MAIN OUTCOMES AND MEASURES

Adjusted appropriateness and factors associated with inappropriate prescriptions.

RESULTS

A total of 9351 surgical episodes and 15 395 prescriptions (10 740 procedural and 4655 postprocedural) were analyzed. Crude appropriateness of total prescriptions was 48.7% (7492 prescriptions). The adjusted appropriateness of each surgical procedure group was low for procedural SAP, ranging from 33.7% (95% CI, 26.3%-41.2%) for dentoalveolar surgery to 68.9% (95% CI, 63.2%-74.5%) for neurosurgery. The adjusted appropriateness of postprocedural prescriptions was also low, ranging from 21.5% (95% CI, 13.4%-29.7%) for breast surgery to 58.7% (95% CI, 47.9%-69.4%) for ophthalmological procedures. The most common reason for inappropriate procedural SAP was incorrect timing (44.9%), while duration greater than 24 hours was the most common reason for inappropriate postprocedural SAP (54.3%).

CONCLUSIONS AND RELEVANCE

High rates of inappropriate procedural and postprocedural antimicrobial use were demonstrated across all surgical specialties. Reasons for inappropriateness, such as timing and duration, varied according to the type of SAP and surgical specialty. These findings highlight the need for improvement in SAP prescribing and suggest potential targeted areas for action.

Investigation of perioperative work processes in provision of antibiotic prophylaxis: a prospective descriptive qualitative study across surgical specialties in Norway

OBJECTIVE

Surgical site infections are known postoperative complications, yet the most preventable of healthcare-associated infections. Correct provision of surgical antibiotic prophylaxis (SAP) is crucial. Use of the WHO Safe Surgical Checklist (SSC) has been reported to improve provision of SAP, and reduce infections postoperatively. To understand possible mechanisms and interactions generating such effects, we explored the underlying work processes of SAP provision and SSC performance at the intersection of perioperative procedures and actual team working.

DESIGN

An ethnographic study including observations and in-depth interviews. A combination of deductive and inductive content analysis of the data was conducted.

SETTING

Operating theatres with different surgical specialities, in three Norwegian hospitals.

PARTICIPANTS

Observations of perioperative team working (40 hours) and in-depth interviews of 19 experienced perioperative team members were conducted. Interview participants followed a maximum variation purposive sampling strategy.

RESULTS

Analysis identified provision of SAP as a process of linked activities; sequenced, yet disconnected in time and space throughout the perioperative phase. Provision of SAP was handled in relation to several interactive factors: preparation and administration, prescription accuracy, diversity of prescription order systems, patient-specific conditions and changes in operating theatre schedules. However, prescription checks were performed either as formal SSC reviews of SAP items or as informal checks of relevant documents. In addition, use of cognitive reminders and clinical experiences were identified as mechanisms used to enable administration of SAP within the 60 min timeframe described in the SSC.

CONCLUSION

Provision of SAP was identified as a complex process. Yet, a key element in provision of SAP was the given 60 min. timeframe of administration before incision, provided in the SSC. Thus, the SSC seems beneficial in supporting timely SAP administration practice by either being a cognitive tool and/or as a cognitive intervention.

Validation of a Norwegian version of SURgical PAtient Safety System (SURPASS) in combination with the World Health Organizations' Surgical Safety Checklist (WHO SSC)

Introduction

Surgical safety checklists may contribute to reduction of complications and mortality. The WHO’s Surgical Safety Checklist (WHO SSC) could prevent incidents in operating theatres, but errors also occur before and after surgery. The SURgical PAtient Safety System (SURPASS) is designed to intercept errors with use of checklists throughout the surgical pathway.

Objective

We aimed to validate a Norwegian version of the SURPASS’ preoperative and postoperative checklists for use in combination with the already established Sign In, Time Out and Sign Out parts of the WHO SSC.

Methods and materials

The validation of the SURPASS checklists content followed WHOs recommended guidelines. The process consisted of six steps: forward translation; testing the content; focus groups; expert panels; back translation; and approval of the final version. Qualitative content analysis was used to identify codes and categories for adaption of the SURPASS checklist items throughout Norwegian surgical care. Content validity index (CVI) was used by expert panels to score the relevance of each checklist item. The study was carried out in a neurosurgical ward in a large tertiary teaching hospital in Norway.

Results

Testing the preoperative and postoperative SURPASS checklists was performed in 29 neurosurgical procedures. This involved all professional groups in the entire surgical patient care pathway. Eight clinical focus groups revealed two main categories: ‘Adapt the wording to fit clinical practice’ and ‘The checklist items challenge existing workflow’. Interprofessional scoring of the content validity of the checklists reached >80% for all the SURPASS checklists.

Conclusions

The first version of the SURPASS checklists combined with the WHO SSC was validated for use in Norwegian surgical care with face validity confirmed and CVI >0.80%.

Trial registration number

NCT01872195.

Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures

Postoperative wound infections represent an important source of morbidity and mortality in children. Perioperative antibiotic prophylaxis has been shown to decrease the risk of developing infections and hospital guidelines surrounding antibiotic use exist to standardize patient care. Despite supporting evidence, rates of compliance with guidelines vary. Quality improvement initiatives have been introduced to improve compliance with intraoperative antibiotic guidelines. Thorough infection surveillance, including antibiotic provision in presurgical checklists, computerized voice antibiotic administration prompts, and national feedback systems are now increasingly common. Few studies have been conducted investigating the effectiveness of prophylactic antibiotics in children. Outcome measures such as morbidity and mortality and return to the operating room can be used to examine the relationship between antibiotic use and patient outcome but these measures are limited in that they occur infrequently or are subjective and difficult to measure. Metrics such as days alive out of hospital and length of hospital stay may be useful alternatives for ongoing monitoring of infections and identifying improvements in patient outcomes. Guidelines on antibiotic prophylaxis have facilitated an increase in the correct provision of perioperative antibiotics and a reduction in the incidence of postoperative infection. Measures of patient outcome such as days alive out of hospital and length of hospital stay are easy to collect and calculate but further work is needed to confirm the utility of these measures for monitoring infection rates.

[Evaluation of surgical antibiotic prophylaxis in a Tunisian University Hospital]

Antibiotic prophylaxis (ATBP) is one of the specific measures for the prevention of surgical site infections, whose impact has been quantified in clean or clean-contaminated surgery. Our study aims to evaluate the conformity of ATBP practices and the adherence to the prescribing protocols adopted in our Hospital. We conducted a clinical audit retrospective observational study, evaluating antibiotic prophylaxis practices in our Hospital in the month of March 2015. The primary study endpoint was the overall compliance of the observed practices with the 5 major criteria defined by the French National Authority for Health (FNAH). We followed the guidelines of the French Society of Anesthesia and Intensive Care published in 2010. The study included 150 patients who had undergone surgery in the Department of General Surgery, Orthopaedics and Urology. The overall compliance rate was 33.3%. The compliance with each of the 5 major criteria defined by the FNAH was 74% for the indication; 84% for the time between injection and incision; 60% for the choice of ATB; 89.3% for the dose of the first injection and 72% for the duration of ATBP. The compliance was variable depending on the Department; better compliance was reported in the Department of Urology, in scheduled surgery and when the prescriber was an anesthetist-resuscitator. A global strategy including organization, education and restriction, could lead to a real improvement in the rate of compliance with ATBP practices. Successive audits should be carried out regularly in order to evaluate the impact of the undertaken actions.

Surgical Antibiotic Prophylaxis and Risk for Postoperative Antibiotic-Resistant Infections

BACKGROUND

Antibiotic-resistant infections have high rates of morbidity and mortality, and exposure to antibiotics is the crucial risk factor for development of antibiotic resistance. If surgical antibiotic prophylaxis (SAP) increases risk for antibiotic-resistant infections, prophylaxis may cause net harm, even if it decreases overall infection rates.

STUDY DESIGN

This retrospective cohort study included adults who underwent elective surgical procedures and developed infections within 30 postoperative days. Procedures from multiple disciplines were included if SAP was considered discretionary by current guidelines. Postoperative antibiotic-resistant infections were defined as positive culture results from any site within 30 postoperative days, showing intermediate or nonsusceptibility across 1 or more antibiotic classes. Surgical antibiotic prophylaxis included use of antibiotics within any class and at any dose from 1 hour before first incision until the end of the operation.

RESULTS

Among 689 adults with postoperative infections, 338 (49%) had postoperative resistant infections. Use of SAP was not associated with postoperative antibiotic-resistant infections (odds ratio [OR] 0.99; 95% CI 0.67 to 1.46). This result remained robust when the SAP definition was extended to antibiotics given within 4 hours before first incision (OR 0.94; 95% CI 0.63 to 1.40) and when the follow-up window was narrowed to 14 days (OR 0.82; 95% CI 0.50 to 1.34). Previous antibiotic-resistant infections were associated with risk for postoperative antibiotic-resistant infections (OR 1.81; 95% CI 1.16 to 2.83).

CONCLUSIONS

Use of SAP was not associated with risk for postoperative antibiotic-resistant infections in a large cohort of patients with postoperative infections. This provides important reassurance regarding use of surgical antibiotic prophylaxis.

Antibiotic prophylaxis in thyroid surgery

Use of antibiotic prophylactic (AP) in clean surgery is still controversial. We reviewed the literature of the last 10 years to identify the best way to approach the use of prophylactic antibiotic in thyroid surgery. In thyroid surgery, it is a highly controversial topic primarily due to the lack of evidence in "support" of or "against" antibiotic use. In this review, the authors analyze the literature on the use of AP in thyroid surgery in order to evaluate if the available data support or contradict this use routinely.

What are the similarities and differences in antimicrobial prescribing between Australian public and private hospitals?

BACKGROUND

Identifying themes associated with inappropriate prescribing in Australian public and private hospitals will help target future antimicrobial stewardship initiatives.

AIMS

To describe current antimicrobial prescribing practices, identify similarities and differences between hospital sectors and provide target areas for improvement specific to each hospital sector.

METHODS

All hospitals included in the study were part of the 2014 national antimicrobial prescribing survey and conducted one of the following: a whole hospital point prevalence survey, serial point prevalence surveys or a sample of randomly selected patients. Data on the types of antibiotics used, their indications for use and the quality of prescription based on compliance with national and local prescribing guidelines were collected.

RESULTS

Two hundred and two hospitals (166 public and 36 private) comprising 10 882 patients and 15 967 antimicrobial prescriptions were included. Public hospitals had higher proportions of prescriptions for treatment (81.5% vs 48.4%) and medical prophylaxis (8.8% and 4.6%), whilst private hospitals had significantly higher surgical prophylaxis use (9.6% vs 46.9%) (P < 0.001). In public hospitals, the main reasons for non-compliance of treatment prescriptions were spectrum being too broad (30.5%) while in private it was incorrect dosing. Prolonged duration was the main reason for non-compliance among surgical prophylaxis prescriptions in both types of hospitals.

CONCLUSIONS

Australian hospitals need to target specific areas to improve antimicrobial use. Specifically, unnecessary broad-spectrum therapy should be a priority area in public hospitals, whilst emphasis on curtailing antimicrobial overuse in surgical prophylaxis needs to be urgently addressed across in the private hospital sector.

Timing of preoperative antibiotic prophylaxis in 54,552 patients and the risk of surgical site infection: A systematic review and meta-analysis

The aim of the study was to assess the effect of timing of preoperative surgical antibiotic prophylaxis (SAP) on surgical site infection (SSI) and compare the different timing intervals.The benefit of routine use of SAP prior to surgery has long been recognized. However, the optimal timing has not been defined. For the purpose of developing recommendations for the World Health Organization guideline for SSI prevention, a systematic review and meta-analysis of all relevant evidence was conducted.Major medical databases were searched from 1990 to 2016. The primary outcome was SSI after preoperative-SAP comparing different timing intervals. Adjusted odds ratios (OR) with 95% confidence intervals (CI) were extracted and pooled for each comparison with a random effects model.Fourteen papers with 54,552 patients were included in this review. In a quantitative analysis, there was no significant difference when SAP was administered 120-60 minutes prior to incision compared to administration 60-0 minutes prior to incision. Studies investigating different timing intervals within the last 60 minutes time frame reported contradictive results. The risk of SSI almost doubled when SAP was administered after first incision (OR:1.89; 95%CI:[1.05-3.40]) and was 5 times higher when administered more than 120 minutes prior to incision (OR5.26; 95%CI:[3.29-8.39]).Administration of antibiotic prophylaxis more than 120 minutes before incision or after incision is associated a higher risk of surgical site infections than administration less than 120 minutes before incision. Within this 120-minute time frame prior to incision, no differential effects could be identified. The broadly accepted recommendation to administer prophylaxis within a 60-minute time frame prior to incision could not be substantiated.

Assessment of surgical antimicrobial prophylaxis in Orthopaedics and Traumatology Surgical Unit of a Tertiary Care Teaching Hospital in Addis Ababa

BACKGROUND

Prophylactic antimicrobials have a starring role in prevention of surgical site infection. This study assesses the practice of surgical antimicrobial prophylaxis (SAP) and development of surgical site infection (SSI) based on patient chart review in patients who underwent surgery in the Orthopaedics and Traumatology Surgical Unit of Tikur Anbesa Specialized Hospital (TASH).

RESULTS

Majority of the patients 144 (72%) were males. 108 (54%) of the surgical wounds were clean and 63 (31%) were clean contaminated. 160 (80%) patients received preoperative prophylaxis, of these 153 (96%) received postoperative prophylaxis as well. 34 (17%) patients did not receive preoperative antimicrobial prophylaxis, while 6 (3%) patients had no record about preoperative antimicrobial prophylaxis. Among those who received preoperative antimicrobial prophylaxis the time of administration was not recorded in 87 (54%) of the patient charts and 36 (23%) patients had preoperative antimicrobial prophylaxis greater than 2 h prior to incision. Among the 188 (94%) patients that received postoperative antimicrobial prophylaxis; the duration of administration was more than 72 h in 114 (61%) patients, while only 8 (4%) received for less than 24 h after surgery. Ceftriaxone 309 (70%) was the most prescribed agent for prophylaxis. 32 (16%) patients developed surgical site of infection. Using odds ratio age equal to or above 50, clean contaminated and contaminated surgical wounds were not statistically associated with increased risk of SSI.

CONCLUSION

Most patients who underwent surgery received prophylactic antimicrobials; nevertheless, the practice was not aligned with standard guidelines' recommendations and patients developed surgical site infections.

Adherence to Surgical Antibiotic Prophylaxis Guidelines in New South Wales, Australia: Identifying Deficiencies and Regression Analysis of Contributing Factors

BACKGROUND

Surgical antibiotic prophylaxis is frequently reported in the literature to be suboptimal, a finding having both clinical and public health implications. This study aimed to calculate rates and patterns of adherence to guidelines at two sites and identify extrinsic contributing factors.

METHODS

A retrospective analysis was conducted over two 12-mo periods during 2013-2014 at the metropolitan Blacktown Hospital and regional Lismore Base Hospital, New South Wales, Australia. A group of 400 patients undergoing abdominal general surgery was selected via simple random sampling (n = 200 per site). Medical records were reviewed, and prophylactic antibiotic regimens were compared with the Australian guideline, Therapeutic Guidelines: Antibiotic (v. 14) with respect to drug choice, dosage, timing of administration, and duration of administration.

RESULTS

The overall rate of adherence to the guidelines was 16.5% at Blacktown Hospital and 19.5% at Lismore Base Hospital. At each site, prophylaxis was administered to more than 95% of patients and was inappropriately withheld in 4%. Drug choice was the most frequent error type, specifically involving inappropriate omission of metronidazole and use of newer-generation cephalosporins. Errors in the timing of administration also were frequent, with prophylaxis typically occurring excessively early. Logistic regression identified emergency surgery as independently associated with prophylactic errors in both the Blacktown Hospital (p < 0.001) and the Lismore Base Hospital cohorts (p = 0.020).

CONCLUSIONS

Adherence to antibiotic prophylactic guidelines was poor at both the metropolitan and regional sites. Choice of antibiotic and timing of administration were identified as major error types. Consideration should be given to multidisciplinary involvement of anesthetists, implementation of focused interventions with an emphasis on emergency settings, and further research correlating antibiotic use with clinical significance.

Adherence to guidelines for surgical antibiotic prophylaxis: a review

Context and objectives

The appropriate use of antibiotic prophylaxis in the perioperative period may reduce the rate of infection in the surgical site. The purpose of this review was to evaluate adherence to guidelines for surgical antibiotic prophylaxis.

Methods

The present systematic review was performed according to the Cochrane Collaboration methodology. The databases selected for this review were: Medline (via PubMed), Scopus and Portal (BVS) with selection of articles published in the 2004–2014 period from the Lilacs and Cochrane databases.

Results

The search recovered 859 articles at the databases, with a total of 18 studies selected for synthesis. The outcomes of interest analyzed in the articles were as follows: appropriate indication of antibiotic prophylaxis (ranging from 70.3% to 95%), inappropriate indication (ranging from 2.3% to 100%), administration of antibiotic at the correct time (ranging from 12.73% to 100%), correct antibiotic choice (ranging from 22% to 95%), adequate discontinuation of antibiotic (ranging from 5.8% to 91.4%), and adequate antibiotic prophylaxis (ranging from 0.3% to 84.5%).

Conclusions

Significant variations were observed in all the outcomes assessed, and all the studies indicated a need for greater adherence to guidelines for surgical antibiotic prophylaxis.

Effects of an Educational Module in Rationalizing Surgical Prophylaxis

Assessment of current antibiotic prescribing patterns is an important step towards appropriate use of antimicrobial agents. This study was planned to know the surgical prophylaxis practices and the influence of educational intervention. In this educational interventional study, only clean and clean-contaminated surgeries were included. Preinterventional study was done by collecting data regarding the use of surgical prophylaxis in the Department of Surgery. After analyzing the preinterventional data, educational intervention was done. A pretest questionnaire was given to all the surgeons to assess knowledge and practice of surgical prophylaxis in our institute. The questionnaire was designed to collect information regarding the use of prophylactic antibiotic, its duration, time of administration, and prevention of surgical site infections (SSI). In our study, third-generation cephalosporin was used in maximum cases in preinterventional analysis and prophylaxis was continued for 3-5 days. Surgeon's decision in selecting a prophylactic agent was based on information taken from departmental colleagues or drug companies. Two or more doses of antibiotic were used even when duration of surgery did not exceed more than two and half hours. Definite improvement was seen after the education where single antibiotic was used as prophylactic drug and the first dose of antibiotic was administered 30 to 60 min before incision. This shows that educational intervention makes a change in antibiotic prescribing habit. Hence, there is an urgent need for adoption of specific guidelines to ensure standardization of surgical antibiotic prophylaxis practices in hospitals.

Diminishing Surgical Site Infections in Australia: Time Trends in Infection Rates, Pathogens and Antimicrobial Resistance Using a Comprehensive Victorian Surveillance Program, 2002–2013

OBJECTIVE

To evaluate time trends in surgical site infection (SSI) rates and SSI pathogens in Australia.

DESIGN

Prospective multicenter observational cohort study.

SETTING

A group of 81 Australian healthcare facilities participating in the Victorian Healthcare Associated Infection Surveillance System (VICNISS).

PATIENTS

All patients underwent surgeries performed between October 1, 2002, and June 30, 2013. National Healthcare Safety Network SSI surveillance methods were employed by the infection prevention staff at the participating hospitals.

INTERVENTION

Procedure-specific risk-adjusted SSI rates were calculated. Pathogen-specific and antimicrobial-resistant (AMR) infections were modeled using multilevel mixed-effects Poisson regression.

RESULTS

A total of 183,625 procedures were monitored, and 5,123 SSIs were reported. Each year of observation was associated with 11% risk reduction for superficial SSI (risk ratio [RR], 0.89; 95% confidence interval [CI], 0.88–0.90), 9% risk reduction for deep SSI (RR, 0.91; 95% CI, 0.90–0.93), and 5% risk reduction for organ/space SSI (RR, 0.95; 95% CI, 0.93–0.97). Overall, 3,318 microbiologically confirmed SSIs were reported. Of these SSIs, 1,174 (35.4%) were associated with orthopedic surgery, 827 (24.9%) with coronary artery bypass surgery, 490 (14.8%) with Caesarean sections, and 414 (12.5%) with colorectal procedures. Staphylococcus aureus was the most frequently identified pathogen, and a statistically significant increase in infections due to ceftriaxone-resistant Escherichia coli was observed (RR, 1.37; 95% CI, 1.10–1.70).

CONCLUSIONS

Standardized SSI surveillance methods have been implemented in Victoria, Australia. Over an 11-year period, diminishing rates of SSIs have been observed, although AMR infections increased significantly. Our findings facilitate the refinement of recommended surgical antibiotic prophylaxis regimens and highlight the need for a more expansive national surveillance strategy to identify changes in epidemiology.

Infect Control Hosp Epidemiol 2015;00(0): 1–8

DRUGS system enhancing adherence of Chinese surgeons to antibiotic use guidelines during perioperative period

Objective

Irrational use of antimicrobial agents for preventing postoperative SSIs is a common phenomenon in China, which results in more bacterial resistance, higher hospital infection rates, extra costs of antimicrobial agents. The aim of the study is to evaluate the effect of Drug Rational Usage Guidelines System (DRUGS) on the surgeon's prescription behavior of antimicrobial agents.

Methods

10 common surgical operations which included 1543 cases (where 778 cases using paper-based guidelines and 765 cases using DRUGS) were selected and their demographic and clinical data were collected. The selected operations include thyroid resection, breast mass resection, myomectomy, etc. The evaluation criteria were antibiotic administrative categories, the time of initial dose, duration of administration, length of stay, the costs of antibiotics, SSIs and drug adverse reactions(ADR).

Results

The antimicrobial agents were mostly administrated within 0.5 h to 2 h before incision, 656 patients (85.75%) were intervened with DRUGS and 256 (32.90%) with paper-based guidelines according to the protocol. For the clean wounds incision, 547 patients (91.62%) were within 24 h of withdrawal antibiotics with using paper-based guidelines versus 91 (14.79%) with using DRUGS. A total of 19 kinds of antibiotics were used in the 1543 cases. The leading three on the list of frequency were piperacillin and sulbactam sodium, cefathiamidine and cefoperazone. While after the intervention, the list of frequency changed to cefazolin, cefathiamidine, cefoperazone. The average hospital stay was (7.00±4.31)d with paper-based guidelines and (2.54±1.57)d with DRUGS, respectively. The average cost of antibiotics was ¥(3481.36±2584.46) with paper-based guidelines and ¥(1693.39±1478.27) with DRUGS, respectively. However, there were no significant differences in the incidence of SSIs and ADR between two groups.

Conclusion

In this study, the increased availability of antibiotic guidelines at the time of drug ordering, combined with DRUGS, was associated with an enhanced surgeon adherence to guidelines.

Compliance with surgical antibiotic prophylaxis at an Australian teaching hospital

BACKGROUND

Surgical antibiotic prophylaxis (SAP) is one practice proven to prevent surgical site infections.

METHODS

Compliance of SAP choice, timing, and duration with guidelines was assessed utilizing prospectively collected surgical site infection (SSI) surveillance data from January 2008 through September 2010.

RESULTS

Antibiotic choice was adequate or optimal in 97% of cardiac and orthopedic joint replacement procedures and 89% of colorectal procedures. In 6% to 8% of surgical procedures, SAP was not administered within 1 hour of the incision. SAP was continued beyond 24 hours in 20% of cardiac operations and 13% of colorectal procedures. Numerous combinations of antibiotics were used for prophylaxis, including ticarcillin/clavulanic acid in 67% of colorectal procedures. Many choices were not in keeping with both local and international recommendations. Deep SSI rates for cardiac procedures were above the state aggregate rate in 2010 only, whereas SSI rates for colorectal surgery were in excess of the state aggregate rate for all quarters. Antimicrobial-resistance data indicate a gradual increase in extended-spectrum β-lactamase-producing bacteria.

CONCLUSION

In cardiac and colorectal surgery, the optimal choice of SAP is seldom administered, and duration of SAP is excessively long. More education and communication are required to improve these practices.

Point-prevalence study of inappropriate antibiotic use at a tertiary Australian hospital

A point-prevalence study at a tertiary Australian hospital found 199 of 462 inpatients (43%) to be receiving antibiotic therapy. Forty-seven per cent of antibiotic use was discordant with guidelines or microbiological results and hence considered inappropriate. Risk factors for inappropriate antibiotic prescribing included bone/joint infections, the absence of infection, creatinine level >120 µmol/L, carbapenem or macrolide use and being under the care of the aged care/rehabilitation team. In the setting of finite antimicrobial stewardship resources, identification of local determinants for inappropriate antibiotic use may enable more targeted interventions.

Surgeons' adherence to guidelines for surgical antimicrobial prophylaxis - a review

Surgical site infections are the most common nosocomial infection among surgical patients. Patients who experience surgical site infections are associated with prolonged hospital stay, rehospitalisation, increased morbidity and mortality, and costs. Consequently, surgical antimicrobial prophylaxis (SAP), which is a very brief course of antibiotic given just before the surgery, has been introduced to prevent the occurrence of surgical site infections. The efficacy of SAP depends on several factors, including selection of appropriate antibiotic, timing of administration, dosage, duration of prophylaxis and route of administration. In many institutions around the globe, evidence-based guidelines have been developed to advance the proper use of SAP. This paper aims to review the studies on surgeons' adherence to SAP guidelines and factors influencing their adherence. A wide variation of overall compliance towards SAP guidelines was noted, ranging from 0% to 71.9%. The misuses of prophylactic antibiotics are commonly seen, particularly inappropriate choice and prolonged duration of administration. Lack of awareness of the available SAP guidelines, influence of initial training, personal preference and influence from colleagues were among the factors which hindered the surgeons' adherence to SAP guidelines. Immediate actions are needed to improve the adherence rate as inappropriate use of SAP can lead to the emergence of a strain of resistant bacteria resulting in a number of costs to the healthcare system. Corrective measures to improve SAP adherence include development of guidelines, education and effective dissemination of guidelines to targeted surgeons and routine audit of antibiotic utilisation by a dedicated infection control team.

Current British veterinary attitudes to the use of perioperative antimicrobials in small animal surgery

A questionnaire was sent to 2951 mixed and small animal veterinary practices to examine the use of perioperative antimicrobials in cats and dogs in the UK. The percentage of respondents who always used antimicrobials in two surgical procedures classified according to NRC criteria as 'clean' was 25.3 per cent for removal of a 1&emsp14;cm cutaneous mass and 32.1 per cent for routine prescrotal castration. Factors considered important in decision-making about when to use antimicrobial agents included immunosuppression, presence of a drain, degree of wound contamination, potential for spillage of visceral contents and implantation of prosthesis. The most common antimicrobial agents mentioned were potentiated amoxicillin (98.0 per cent), amoxicillin (60.5 per cent), clindamycin (21.8 per cent), enrofloxacin (21.7 per cent), cephalexin (18.6 per cent) and metronidazole (12.7 per cent). Forty-three per cent of all responding veterinarians listed a long-acting preparation for perioperative use. The routes used were subcutaneous (76.1 per cent), intravenous (25.8 per cent), intramuscular (19.8 per cent), oral (13.5 per cent) and topical (7.7 per cent). Antimicrobials were given before surgery (66.6 per cent), during surgery (30.2 per cent), immediately after surgery (12.0 per cent) and after surgery (6.3 per cent). This survey has identified the suboptimal use of perioperative antimicrobials in small animal surgery with improvements needed with respect to timing, duration, choice of antimicrobial and a more prudent selection of surgical cases requiring prophylaxis.

The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis

BACKGROUND

Surgical site infection (SSI) is an adverse event in which a close relation between process of care and outcome has been demonstrated: administration of antibiotic prophylaxis decreases the risk of SSI. In our tertiary referral centre, a SURgical PAtient Safety System (SURPASS) checklist was developed and implemented. This multidisciplinary checklist covers the entire surgical pathway and includes, among other items, administration of antibiotic prophylaxis before induction of anaesthesia. The aim of this study was to determine the effect of SURPASS implementation on timing of antibiotic prophylaxis.

METHODS

A retrospective analysis was performed on two cohorts of patients: one cohort of surgical patients that underwent surgery before implementation of the checklist and a comparable cohort after implementation. The interval between administration of antibiotic prophylaxis and incision was compared between the two cohorts.

RESULTS

A total of 772 surgical procedures were included. More than half of procedures were gastro-intestinal; others were vascular, trauma and hernia repair procedures. After implementation, the checklist was used in 81.4% of procedures. The interval between administration of antibiotic prophylaxis and incision increased from 23.9 minutes before implementation of SURPASS to 29.9 minutes after implementation (p = 0.047). In procedures where the checklist was used, the interval increased to 32.9 minutes (p = 0.004). The proportion of patients that did not receive antibiotics until after the incision decreased significantly.

CONCLUSION

The use of the SURPASS checklist leads to better compliance with regard to the timing of antibiotic prophylaxis administration.

Practice guideline adherence and health care outcomes--use of prophylactic antibiotics during surgery in Taiwan

RATIONALE, AIMS AND OBJECTIVES

To evaluate adherence to guidelines for prophylactic antibiotic use in total knee replacement (TKR) and total hip replacement (THR) procedures and to examine the associations between guideline adherence and health care outcomes.

METHODS

Using nationwide health insurance claims data, all adult inpatients undergoing TKR or THR procedures at teaching hospitals from 2002 to 2006, were included. Guideline adherence rates were assessed every year according to the national guidelines introduced in 2004. Multiple regression analyses with generalized estimating equations models were used to examine the relationships between the deliberate variables.

RESULTS

The guideline adherence rates stably increased from 14.07% in 2002 to 28.34% in 2006. The 2006 dataset included 12 863 observations. The results revealed that guideline adherence was negatively associated with length of stay and health care expenses with beta = -0.0207 and -0.0087, respectively (P < 0.0001). The 30-day readmission rate was 1.54% among the patients seen in 2006, and it was significantly different between the two groups, with 0.90% of the adherence group and 1.82% of the non-adherence group being readmitted (P = 0.0002).

CONCLUSIONS

The guideline adherence for prophylactic use of antibiotics is improving in Taiwan and is associated with a shorter length of stay, fewer medical expenses and lower 30-day readmission rates. Promoting evidence-based practice guidelines may be beneficial to patients and health care providers.

Timing of surgical antibiotic prophylaxis administration: complexities of analysis

Background

The timing of prophylactic antibiotic administration is a patient safety outcome that is recurrently tracked and reported. The interpretation of these data has important implications for patient safety practices. However, diverse data collection methods and approaches to analysis impede knowledge building in this field. This paper makes explicit several challenges to quantifying the timing of prophylactic antibiotics that we encountered during a recent study and offers a suggested protocol for resolving these challenges.

Challenges

Two clear challenges manifested during the data extraction process: the actual classification of antibiotic timing, and the additional complication of multiple antibiotic regimens with different timing classifications in a single case. A formalized protocol was developed for dealing with incomplete, ambiguous and unclear documentation. A hierarchical coding system was implemented for managing cases with multiple antibiotic regimens.

Interpretation

Researchers who are tracking prophylactic antibiotic timing as an outcome measure should be aware that documentation of antibiotic timing in the patient chart is frequently incomplete and unclear, and these inconsistencies should be accounted for in analyses. We have developed a systematic method for dealing with specific problematic patterns encountered in the data. We propose that the general adoption of a systematic approach to analysis of this type of data will allow for cross-study comparisons and ensure that interpretation of results is on the basis of timing practices rather than documentation practices.

Surveillance of hospital-acquired infections in Australia – One Nation, Many States

Surveillance programmes for hospital-acquired infections differ amongst the Australian states. Victoria, New South Wales, Queensland and South Australia have recent substantial initiatives in development of statewide programmes. Whilst the definitions for surgical site infections (SSIs) and bloodstream infections (BSI) developed by the Australian Infection Control Association (AICA) do not differ from the US National Nosocomial Infection Surveillance (NNIS) programme definitions for SSI and intensive care unit (ICU) acquired central line-associated BSI, only two states use NNIS risk adjustment methods in reporting infection rates. Differences exist in the surgical procedures under surveillance, ICU surveillance, hospital-wide BSI surveillance, staff health immunization surveillance, process measures such us surgical antibiotic prophylaxis and small hospital programmes. Only in the area of antibiotic use surveillance has national consensus been reached. In Victoria, NNIS risk adjustment had limited usefulness in predicting SSIs, especially after coronary artery bypass graft (CABG) surgery. Ventilator-associated pneumonia (VAP) surveillance had limited acceptance, and is not undertaken in other states. Regular reporting of surgical antibiotic prophylaxis data has been followed by improvement in choice of antibiotic in some procedures. The South Australian programme for the surveillance of multiresistant organisms (MROs) has documented substantial improvement in meticillin-resistant Staphylococcus aureus (MRSA) morbidity over time coincident with the introduction of hand hygiene programmes and other measures. In Queensland, statewide monitoring of needlestick injuries is established. In Victoria, the small hospital programme concentrated on process measures, and in Queensland with a standardized investigation pathways for "signal" events. Data quality presented substantial challenges in small Victorian hospitals. Whilst state-based programmes have facilitated communication between hospitals and their coordinating centre, Australia still lacks national coordination and a national database on hospital infections. The differing approaches of the states illustrate many of the fundamental questions facing hospital infection surveillance today.