Appropriateness of Surgical Antibiotic Prophylaxis in Pediatric Patients in Italy

Study of the Practice of Surgical Antibiotic Prophylaxis Use for Elective Neurosurgical Cases in a Tertiary Hospital and Understanding the Rationale

BACKGROUND

This study aims to evaluate the adherence to surgical antibiotic prophylaxis (SAP) guidelines in elective neurosurgery and assess the impact on surgical site infection (SSI) rates in a tertiary teaching hospital in Malaysia.

METHOD

A retrospective review was conducted on patients who underwent elective neurosurgical procedures from January 1, 2021, to December 31, 2021, in a 1600-bed tertiary teaching hospital. The study assessed adherence to national and hospital SAP guidelines, focusing on the choice of antibiotic, dosage, timing, and duration. Additionally, a survey was conducted among neurosurgeons to evaluate their knowledge, attitudes, and practices regarding SAP.

RESULT

Out of 202 patients included, there was a 99% compliance rate with antibiotic choice and 69.8% with the antibiotic duration. The SSI rate was identified at 6.4%. The knowledge, attitudes, and practices survey highlighted a strong awareness of SAP guidelines among surgeons, albeit with variations in practice, particularly in antibiotic duration and choice of antibiotics.

CONCLUSIONS

While there is high adherence to the correct choice of antibiotic for SAP in elective neurosurgery, there are gaps in compliance with the recommended duration of antibiotic use. The study highlights the need for targeted interventions to improve adherence to SAP guidelines, which could potentially reduce the incidence of SSI in neurosurgery. Ongoing education and auditing are essential to optimize SAP practices and enhance patient outcomes in neurosurgery.

Point prevalence probing of antimicrobial prescription patterns from a developing country

BACKGROUND

Irrational use of antibiotics intensifies resistance and jeopardizes advances made in modern medicine. We aimed to conduct a baseline gap analysis survey on antibiotic prescription practices across Pakistan.

RESEARCH DESIGN AND METHODS

This multi-centered cross-sectional survey was conducted at six public sector tertiary care hospitals from February 2021 to March 2021. Data related to various variables including hospital infrastructure, policies and practices, monitoring and feedback, and epidemiological, clinical, and antibiotic prescription for surveyed patients was collected using World Health Organization (WHO) Point Prevalence Survey (PPS) methodology.

RESULTS

In a survey of 837 inpatients, 78.5% were prescribed antibiotics. Most commonly prescribed antimicrobial was ceftriaxone (21.7%), followed by metronidazole (17.3%), cefoperazone-sulbactam (8.4%), amoxicillin-clavulanate (6.3%), and piperacillin/tazobactam (5.9%). Surgical prophylaxis (36.7%) and community-acquired infections (24.7%) were the main reasons for antibiotic prescriptions. Single antibiotics were given to 46.7% of patients, 39.9% received a combination of two antibiotics, and 12.5% were prescribed three or more antibiotics. Among six hospitals surveyed, two had drug and therapeutic committees, three had infection prevention and control committees, and one had an antibiotic formulary.

CONCLUSION

Findings demonstrate high consumption of broad-spectrum antimicrobials and emphasize the importance of expanding antimicrobial stewardship programs among hospitals. Mentoring clinical teams could help rationalize antimicrobial use.

Quantifying Procedure-level Prophylaxis Misutilization in Pediatric Surgery: Implications for the Prioritization of Antimicrobial Stewardship Efforts

OBJECTIVE

To quantify procedure-level inappropriate antimicrobial prophylaxis utilization as a strategy to identify high-priority targets for stewardship efforts in pediatric surgery.

BACKGROUND

Little data exist to guide the prioritization of antibiotic stewardship efforts as they relate to prophylaxis utilization in pediatric surgery.

METHODS

This was a retrospective cohort analysis of children undergoing elective surgical procedures at 52 children's hospitals from October 2015 to December 2019 using the Pediatric Health Information System database. Procedure-level compliance with consensus guidelines for prophylaxis utilization was assessed for indication, antimicrobial spectrum, and duration. The relative contribution of each procedure to the overall burden of noncompliant cases was calculated to establish a prioritization framework for stewardship efforts.

RESULTS

A total of 56,845 cases were included with an overall inappropriate utilization rate of 56%. The most common reason for noncompliance was unindicated utilization (43%), followed by prolonged duration (32%) and use of excessively broad-spectrum agents (25%). Procedures with the greatest relative contribution to noncompliant cases included cholecystectomy and repair of inguinal and umbilical hernias for unindicated utilization (63.2% of all cases); small bowel resections, gastrostomy, and colorectal procedures for use of excessively broad-spectrum agents (70.1%) and pectus excavatum repair and procedures involving the small and large bowel for prolonged duration (57.6%). More than half of all noncompliant cases were associated with 5 procedures (cholecystectomy, small bowel procedures, inguinal hernia repair, gastrostomy, and pectus excavatum).

CONCLUSIONS

Cholecystectomy, inguinal hernia repair, and procedures involving the small and large bowel should be considered high-priority targets for antimicrobial stewardship efforts in pediatric surgery.

Correlation Between Postoperative Antimicrobial Prophylaxis Use and Surgical Site Infection in Children Undergoing Nonemergent Surgery

Importance

Use of postoperative antimicrobial prophylaxis is common in pediatric surgery despite consensus guidelines recommending discontinuation following incision closure. The association between postoperative prophylaxis use and surgical site infection (SSI) in children undergoing surgical procedures remains poorly characterized.

Objective

To evaluate whether use of postoperative surgical prophylaxis is correlated with SSI rates in children undergoing nonemergent surgery.

Design, Setting, and Participants

This is a multicenter cohort study using 30-day postoperative SSI data from the American College of Surgeons' Pediatric National Surgical Quality Improvement Program (ACS NSQIP-Pediatric) augmented with antibiotic-use data obtained through supplemental medical record review from June 2019 to June 2021. This study took place at 93 hospitals participating in the ACS NSQIP-Pediatric Surgical Antibiotic Prophylaxis Stewardship Collaborative. Participants were children (<18 years of age) undergoing nonemergent surgical procedures. Exclusion criteria included antibiotic allergies, conditions associated with impaired immune function, and preexisting infections requiring intravenous antibiotics at time of surgery.

Exposures

Continuation of antimicrobial prophylaxis beyond time of incision closure.

Main Outcomes and Measures

Thirty-day postoperative rate of incisional or organ space SSI. Hierarchical regression was used to estimate hospital-level odds ratios (ORs) for SSI rates and postoperative prophylaxis use. SSI measures were adjusted for differences in procedure mix, patient characteristics, and comorbidity profiles, while use measures were adjusted for clinically related procedure groups. Pearson correlations were used to examine the associations between hospital-level postoperative prophylaxis use and SSI measures.

Results

Forty thousand six hundred eleven patients (47.3% female; median age, 7 years) were included, of which 41.6% received postoperative prophylaxis (hospital range, 0%-71.2%). Odds ratios (ORs) for postoperative prophylaxis use ranged 190-fold across hospitals (OR, 0.10-19.30) and ORs for SSI rates ranged 4-fold (OR, 0.55-1.90). No correlation was found between use of postoperative prophylaxis and SSI rates overall (r = 0.13; P = .20), and when stratified by SSI type (incisional SSI, r = 0.08; P = .43 and organ space SSI, r = 0.13; P = .23), and surgical specialty (general surgery, r = 0.02; P = .83; urology, r = 0.05; P = .64; plastic surgery, r = 0.11; P = .35; otolaryngology, r = -0.13; P = .25; orthopedic surgery, r = 0.05; P = .61; and neurosurgery, r = 0.02; P = .85).

Conclusions and Relevance

Use of postoperative surgical antimicrobial prophylaxis was not correlated with SSI rates at the hospital level after adjusting for differences in procedure mix and patient characteristics.

Preoperative antibiotic prophylaxis in mastectomy: A retrospective comparative analysis of 1413 patients with breast cancer

BACKGROUND AND OBJECTIVE

The reported rate of surgical site infections (SSIs) in breast cancer surgery varies widely in previous literature. The use of antibiotic prophylaxis is controversial but recommended by several guidelines. The aim of this study was to evaluate the efficacy of routine antibiotic prophylaxis in patients with breast cancer undergoing mastectomy.

METHODS

In this retrospective single-institution study, we reviewed 1413 consecutive female breast cancer patients who underwent mastectomy and/or axillary lymph node surgery between years 2012 and 2019. Prophylactic antibiotics for all patients undergoing mastectomy was introduced in our hospital in 2016 and before that the prophylaxis was prescribed individually on surgeons' preference. All patient records for 30 postoperative days were evaluated in detail and all SSIs were recorded. The rate of SSIs was compared between patients who received antibiotic prophylaxis and those who did not. A multivariate logistic regression model was used to define the odds ratio (OR) for the efficacy of antibiotic prophylaxis.

RESULTS

A total of 335 patients underwent mastectomy without antibiotic prophylaxis and 1078 with prophylaxis. The rate of SSIs was 6.9% in patients who received prophylaxis and 6.3% in patients without prophylaxis (p = 0.70). The rate of SSIs was similar before and after the introduction of regular antibiotic prophylaxis and there was no difference in any of the patient subgroups investigated. In multivariable logistic regression analysis, the OR for antibiotic prophylaxis was 1.04 (95% CI: 0.62-1.73, p = 0.88).

CONCLUSIONS

Routine use of antibiotic prophylaxis did not reduce the rate of SSIs in mastectomy. Unselective antibiotic prophylaxis for all patients does not seem mandatory in mastectomy.

Surgical Antibiotic Prophylaxis in Children Undergoing Surgery: A Systematic Review and Meta-Analysis

Background: To establish the role of surgical antibiotic prophylaxis (SAP) in the prevention of surgical site infection (SSI) in children undergoing surgery. Design: A systematic review and meta-analysis of six databases: MEDLINE (PubMed), EMBASE, CINAHL Plus, Cochrane Library, Web of Science, and Scopus. Study Selection: Included studies (irrespective of design) compared outcomes in children undergoing surgery, aged 0 to 21 years who received SAP with those who did not, with SSI as an outcome, using the U.S. Centers for Disease Control and Prevention (CDC) definitions for SSI. Data Extraction: Two independent reviewers applied eligibility criteria, assessed the risk of bias, and extracted data. Results: A total of six randomized control trials and 26 observational studies including 202,593 surgical procedures among 202,405 participants were included in the review. The pooled odds ratio of SSI was 1.20; (95% confidence interval [CI], 0.91-1.58) comparing those receiving SAP with those not receiving SAP, with moderate heterogeneity in effect size between studies (τ² = 0.246; χ² = 69.75; p < 0.001; I² = 57.0%). There was insufficient data on many factors known to be associated with SSI, such as cost, length of stay, re-admission, and re-operation; it was therefore not possible to perform subanalyses on these. Conclusions: This review and metanalysis did not find a preventive action of SAP against SSI, and our results suggest that SAP should not be used in surgical wound class (SWC) I procedures in children. However, considering the poor quality of included studies, the principal message of this study is in highlighting the absence of quality data to drive evidence-based decision-making in SSI prevention in children, and in advocating for more research in this field.

Adherence to Perioperative Antibiotic Prophylaxis Recommendations and Its Impact on Postoperative Surgical Site Infections

Introduction Surgical site infections (SSIs) are common and carry a significant risk of morbidity and mortality and lead to increased healthcare costs. Perioperative antibiotic prophylaxis decreases the risk of SSIs. There are several guidelines on the use of perioperative antibiotic prophylaxis. The American College of Surgeons (ACS) recommends weight-based antibiotic administration within 60 minutes prior to (two hours for vancomycin/fluoroquinolones) incision and redosing by drug half-life. There are limited data regarding adherence to existing recommendations. Furthermore, there are scarce data on the relationship between adherence to recommendations and the risk of postoperative SSI. Objectives In this study, we aimed to assess the adherence to ACS guidelines for perioperative antimicrobial prophylaxis in the Seattle Children's Hospital (SCH) National Surgical Quality Improvement Program (NSQIP) pediatric cohort and to determine whether adherence to ACS guidelines is associated with a decreased risk of SSI. the secondary objective was to identify risk factors associated with SSI in our patient population. Materials and methods We conducted a secondary analysis of an institutional NSQIP pediatric data cohort between Jan 1, 2012, and Dec 31, 2017. We calculated summary statistics to assess adherence to ACS recommendations and fit a logistic regression model to identify factors associated with the risk of SSI. Patients who did not receive antibiotic prophylaxis were excluded. Results  A total of 6,072 surgeries among 5,532 patients met the inclusion criteria. Adherence was achieved for weight-based dosing in 35% of surgeries, administration prior to the incision in 91%, administration within 60 minutes (two hours for vancomycin/fluoroquinolones) in 86%, correct redosing in 97%, and to all recommendations in 29%. There were no significant associations between any adherence metrics and SSI, although confidence intervals were wide for some metrics. Factors associated with SSI when adherence was met included urgent case status, wound class 2 or 4, the American Society of Anesthesiologists (ASA) class 2-5, and surgery duration. Conclusion There was varying adherence to ACS recommendations on antibiotic prophylaxis in our cohort. More evidence is needed to better understand the effects of adherence to any or all components of the recommendations on SSI. We identified a group of pediatric patients at risk of SSI and a need for further research and targeted interventions.

Synergistical Starvation and Chemo-Dynamic Therapy for Combating Multidrug-Resistant Bacteria and Accelerating Diabetic Wound Healing

The application of the antibiotic drug has dramatically decreased the infection and promoted the development of surgery, but drug-resistant bacteria appeared along with the abuse of antibiotics. Especially, wound in diabetic patients provides more glucose for bacteria resulting in poor wound healing. Therefore, it is imminent to explore advanced agents for combating multidrug-resistant bacteria and accelerating diabetic wound healing. Herein, metal-organic frameworks based nanoreactors loaded with glucose oxidase (GOx) and peroxidase-like bovine hemoglobin (BHb) are designed to construct an effective cascaded catalytic antibacterial system. Therein, GOx can cost the glucose, and release H₂ O₂ simultaneously, which can then be transformed into hydroxyl radicals by BHb. As a result, the as-prepared nanoreactors can play the roles of both starving and killing toward the multidrug-resistant bacteria. Furthermore, the produced gluconic acid can reduce the pH of working condition, which is beneficial for both the enhancement of peroxidase activity and the inhibition of the bacteria growth. More importantly, the constructed nanoreactors can be degraded and excreted from the body in the form of feces, which render the as-proposed nanoreactors qualified as effective and safe materials for both combating multidrug-resistant bacteria in vitro and accelerating the diabetic wound healing in vivo of the mouse model.

Appropriateness of Antibiotic Prescription for Prophylactic Purposes among Italian Dental Practitioners: Results from a Cross-Sectional Study

The primary objective of this study was to investigate the pattern of antibiotic prescription for prophylaxis purposes among Italian DPs (dental practitioners). A nationwide cross-sectional study was conducted using a multi-stage sampling design. A structured questionnaire was used to collect socio-demographic data and information about antibiotic prophylaxis (AP) prescriptions for selected dental diagnoses and surgical procedures. The presence of an indication and appropriateness of AP were defined according to international guidelines. In total, 563 DPs answered the questionnaire (response rate 52.6%). The proportions of DPs who prescribed AP in the presence of an indication ranged from 39.1% for luxation injury with soft tissue trauma to 73.1% for dental implants, whilst DPs who prescribed AP in healthy patients ranged from 41.9% in luxation injury with soft tissue trauma to 70.3% for bone grafting. The course of AP reported by DPs was not consistent with the guidelines in 70.9% of explored procedures. A high proportion of AP prescriptions before dental procedures were unnecessary. This highlights the urgent need to incorporate recommendations for best practices into national and local protocols as soon as they are established. Specific antibiotic stewardship strategies targeted to DPs should be implemented and assessed for effectiveness in improving prescribing of antibiotics.

Antimicrobial Resistance in Pathogens Isolated from Blood Cultures: A Two-Year Multicenter Hospital Surveillance Study in Italy

Background: Antimicrobial resistance (AMR) is one of the most concerning issues in medicine today. The objectives of this study were to investigate the AMR distribution of the blood-borne pathogens isolated over a two-year period in an Italian region. Methods: A retrospective electronic record review of laboratory-confirmed bloodstream infections (BSIs) was done, and data from three major diagnostic laboratories were used. Twelve invasive clinically important bacteria species were included in the sample. Results: During the study period, 1228 positive BSIs were collected. The most common pathogens were Coagulase-negative Staphylococcus (CoNS) (29.7%), Staphylococcus aureus (19.1%) and Escherichia coli (15.9%). With regard to the AMR pattern, 31.7% of CoNS and 28.1% of Staphylococcus aureus were oxacillin-resistant, and almost half of the Enterococci showed resistance to high-level gentamicin. Among Gram-negative species, 11.7% of Escherichia coli and 39.5% of Klebsiella pneumoniae were carbapenem-resistant. Among the non-fermentative Gram-negative bacteria, the most frequently combined AMR pattern was aminoglycosides and fluoroquinolones (48.4% in A. baumannii and 14.6% in P. aeruginosa). Conclusion: The results display an alarming prevalence of AMR among hospital isolated pathogens, consistently higher than the European average. Information from surveillance systems to better characterize the trend in the incidence of AMR at local and national levels is needed.

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.

Trends in the use of surgical antibiotic prophylaxis in general pediatric surgery: Are we missing the mark for both stewardship and infection prevention?

BACKGROUND

The purpose of this study was to assess compliance with antimicrobial spectrum guidelines in the use of surgical antibiotic prophylaxis (SAP) in pediatric surgery.

METHODS

A retrospective cohort study of children undergoing elective clean-contaminated and clean surgical procedures with foreign body implantation using the Pediatric Health Information System database (10/2015-6/2018) was performed. Compliance rates with consensus guidelines surrounding appropriate spectrum of SAP coverage were calculated for each procedure. Undertreatment was defined as the use of SAP with inappropriately narrow coverage (or omission altogether), while overtreatment was defined as inappropriately broad coverage.

RESULTS

Eight procedure groups including a total of 15,708 patients were included. Overall, 44% of cases received inappropriate prophylaxis, of which 58% were considered undertreatment and 42% overtreatment. Procedures with the highest rates of overtreatment included small bowel procedures (77%), colorectal procedures (29%), and hepatobiliary procedures (20%), while the highest rates of undertreatment were associated with placement of tunneled central venous catheters and ports (43%), hepatobiliary procedures (24%), and colorectal procedures (20%).

CONCLUSION

Noncompliance with the recommended spectrum of coverage for surgical antibiotic prophylaxis is common in pediatric surgery, with both over and undertreatment being common themes. Improved compliance is needed to optimize both antibiotic stewardship and infection prevention.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Adherence to evidence-based recommendations for surgical site infection prevention: Results among Italian surgical ward nurses

BACKGROUND

The aims of the study were to assess the level of knowledge, the attitudes and the adherence to evidence-based recommendations for surgical site infection (SSI) prevention and to describe any influences that may motivate nurses to adopt evidence-based practices for SSI prevention.

METHODS

The present study was a national cross-sectional survey conducted from June to November 2017. For each hospital that agreed to participate, 30 nurses were randomly selected. The questionnaire was aimed at exploring socio-demographic and practice characteristics, knowledge of, attitudes toward, and reported practices regarding evidence-based procedures for SSI prevention.

RESULTS

Out of 55 hospitals that were contacted, 36 agreed to participate (a response rate of 65%). Of the original sample of 1313 nurses, a total of 1305 returned the questionnaire, a response rate of 99.4%. Regarding knowledge, only 53.8% knew that preoperative hair removal, if necessary, should take place shortly before surgery, and 28.9% of the sample did not know the right definition of "bundle". Over three quarters of participants stated that they always perform hand antisepsis before and after biological sample collection while 9.7% considered that wearing gloves during this practice is sufficient to prevent SSI. Furthermore, 91% of nurses reported that they always performed hand antisepsis before and after invasive procedures.

CONCLUSION

The study findings highlight the areas that were most lacking in nurses' training and for which targeted activities are needed. These data could support healthcare managers to implement interventions focused at enabling adherence to effective prevention practices to reduce risk to all patients.

Surgical antimicrobial prophylaxis and its dose appropriateness among paediatric patients in a Nigerian teaching hospital

Surgical antimicrobial prophylaxis (SAP) prevents incision site infection. We assessed SAP compliance with existing international guidelines, evaluated the appropriateness of the antimicrobial doses, and determined the risk factors for antimicrobial under-dosing. A retrospective chart review was performed for patients who under-went surgery and administered antimicrobial prophylaxis. Compliance with SAP guidelines was evaluated. Antimicrobial doses were categorized as under-, normal-, or over-dose. Of the 303 surgical patients, 97.7% received SAP and complete compliance was achieved in 5.6%. Of the 550 antimicrobial prescriptions, metronidazole (42.7%) and cefuroxime (34.7%) were the most prescribed. Over- (31.5%), under- (44.5%), and normal- dosing (24.0%) were recorded, respectively. None of the factors evaluated predicted the risk of antimicrobial under-dosing. Full compliance with international SAP guidelines was poor in our study. Correct timing, re-dosing, and duration of antimicrobial use were the most violated. Most antimicrobials were under-dosed, suggesting a need for national and institutional SAP guidelines.

Evaluation of hospital readmissions for surgical site infections in Italy

Background

The objectives of this investigation are to assess the prevalence of hospital readmissions for surgical site infections (SSIs) in patients aged ≥18 in Italy and to describe the clinical characteristics of these patients and evaluate the possible association with readmission for SSIs.

Methods

A retrospective epidemiological study was conducted between January and May 2015 considering a sample of patients aged ≥18 years admitted to the surgical wards of two hospitals in Naples and undergoing surgery in the year 2014.

Results

3.8% of patients had been readmitted and 28.8% of them were readmitted to hospital due to SSIs. The multiple logistic regression model showed that readmissions for SSIs were significantly more common in smokers (odds ratio [OR] = 3.14; 95% confidence interval [CI] = 1.13-8.69), in patients with immunosuppression status (OR = 8.28; 95% CI = 1.76-38.87), in patients with low serum albumin (OR = 3.07; 95% CI = 1.05-9.01) and in patients who had undergone a surgical procedure classified as contaminated (OR = 10:44; 95% CI = 3.11-35.01) compared with those that had undergone a surgical procedure classified as clean.

Conclusions

The results point to the need that hospital infection prevention strategies are implemented in order to reduce morbidity and mortality for patients. Moreover, the measures taken to prevent infections would lead to a reduction in health spending since almost one third of readmissions to the hospital in our study were due to SSIs.

Antibiotic prescriptions to adults with acute respiratory tract infections by Italian general practitioners

Purpose

The overuse, misuse, and underuse of antimicrobial agents often lead to the spread of antibiotic-resistant microorganisms. The aim of our study was to describe the pattern of antibiotic prescriptions for acute respiratory tract infections (RTIs) among the adult population and the factors associated with antibiotic prescribing.

Patients and methods

The study involved patients who visited a general practitioner with suspected acute RTI. Patients with diagnosis of acute sinusitis, acute pharyngitis, acute bronchitis, and influenza were included in the study. We evaluated the presence of an indication for antibiotic therapy for selected diseases according to international guidelines. The appropriateness of any prescribed molecule was also evaluated.

Results

A total of 1,979 cases of acute RTIs were included: 1,196 (60.4%) pharyngitis, 359 (18.2%) bronchitis, 234 (11.8%) influenza, and 190 (9.6%) sinusitis. An antibiotic prescription was given in 67.3% of the consultations and was not indicated by the guidelines in 66.5% of the total RTIs. Macrolides were the most frequently prescribed antibiotics accounting for 32.5% of all those prescribed, followed by amoxicillin with clavulanic acid (31.1%) and fluoroquinolones (14.2%). The highest overprescription was associated with pharyngitis (65.9%) and the lowest with influenza (4.9%). A throat swab was performed only in 11 of all the patients with a diagnosis of acute pharyngitis.

Conclusion

The present study showed a very high frequency of nonevidence-based prescription of antibiotics at the primary care level. Future improvement programs should focus on development of evidence-based guidelines, access to postgraduate training, and better availability of diagnostic tools.

Improvisation versus guideline concordance in surgical antibiotic prophylaxis: a qualitative study

PURPOSE

Surgical antibiotic prophylaxis (SAP) is a common area of antimicrobial misuse. The aim of this study was to explore the social dynamics that influence the use of SAP.

METHODS

20 surgeons and anaesthetists from a tertiary referral hospital in Australia participated in semi-structured interviews focusing on experiences and perspectives on SAP prescribing. Interview data were analysed using the framework approach.

RESULTS

Systematic analysis of the participants' account of the social factors influencing SAP revealed four themes. First, antibiotic prophylaxis is treated as a low priority with the competing demands of the operating theatre environment. Second, whilst guidelines have increased in prominence in recent years, there exists a lack of confidence in their ability to protect the surgeon from responsibility for infectious complications (thus driving SAP over-prescribing). Third, non-concordance prolonged duration of SAP is perceived to be driven by benevolence for the individual patient. Finally, improvisation with novel SAP strategies is reported as ubiquitous, and acknowledged to confer a sense of reassurance to the surgeon despite potential non-concordance with guidelines or clinical efficacy.

CONCLUSIONS

Surgical-specific concerns have thus far not been meaningfully integrated into antimicrobial stewardship (AMS) programmes, including important dynamics of confidence, trust and mitigating fear of adverse infective events. Surgeons require specific forms of AMS support to enact optimisation, including support for strong collaborative ownership of the surgical risk of infection, and intra-specialty (within surgical specialties) and inter-specialty (between surgery, anaesthetics and infectious diseases) intervention strategies to establish endorsement of and address barriers to guideline implementation.