Non-compliance with recommendations for the practice of antibiotic prophylaxis and risk of surgical site infection: results of a multilevel analysis from the INCISO Surveillance Network

Evaluation of the adherence to surgical antibiotic prophylaxis recommendations and associated factors in a University Hospital: A cross-sectional study

BACKGROUND

Surgical antibiotic prophylaxis (SAP) is an important preventive measure, aiming to minimize surgical site infections. However, despite evidence-based guidelines, adherence to SAP protocols remains suboptimal in clinical practice. The aim of this study was to assess the adequacy of SAP in a high-complexity hospital and investigate associated factors.

METHODS

A cross-sectional design was conducted, involving surgeries performed by expert teams in cardiology, urology, neurology, and gastrointestinal. SAP prescriptions were evaluated based on indication, antibiotic choice, dosage, and duration, according to the hospital protocol. Data analysis included descriptive statistics and association tests between protocol adherence and patient demographics, clinical variables, surgical teams, and types of surgeries.

RESULTS

Out of 1,864 surgeries, only 20.7% adhered to SAP protocols. Lower adherence rates were observed for antibiotic choice and duration of prophylaxis. Neurological surgeries exhibited significantly lower adherence, particularly concerning antibiotic choice and duration. Factors associated with nonadherence included elevated preoperative blood glucose levels, prolonged hospitalization, and extended surgical duration. Logistic regression analysis identified surgical teams as significant factors influencing protocol adherence.

CONCLUSIONS

Despite the relatively high adherence to antibiotic dosage, challenges persist in antibiotic choice and duration adjustment. Poor glycemic control, prolonged surgery, and surgical teams were variables associated with inappropriate practice.

What Is the Ideal Duration for Surgical Antibiotic Prophylaxis?

Background: Surgical antibiotic prophylaxis practice became common in the 1970s and has since become almost universal. The earliest articles used three doses over 12 hours with the first being administered before the start of the operation. Conclusions: The duration of prophylaxis has varied widely in practice over time, but an increasing body of evidence has supported shorter durations, most recently with recommendations in influential guidelines to avoid administration after the incision is closed.

Epidemiological manifestations and impact of healthcare-associated infections in Libyan national hospitals

BACKGROUND

Healthcare-associated infection is a serious global problem, particularly in developing countries. In North African countries, comprehensive research on the incidence and effects of such infections is rare. This study evaluated the epidemiology and determined the impact of healthcare-associated infections in Libyan national teaching hospitals.

METHODS

A prospective longitudinal study was carried out in Libya's four largest teaching and referral hospitals (Tripoli Medical Center, Tripoli-Central Hospital, Benghazi Medical Center, and Sabha Medical Center) from November 1, 2021, to October 31, 2022. The epidemiological events and the parameters incorporated in this study were based on the data published by the Libyan Centers for Disease Control. The surveillance was carried out on all patients admitted to the wards of medicine, surgery, intensive care, gynecology & obstetrics, and pediatrics in all four hospitals. Trained staff reviewed the medical records and compared the percentages of patients with healthcare-associated infections. Bio-statistical and multivariable logistic regression analyses were carried out to test the variables associated with healthcare-associated infections and the resulting deaths.

RESULTS

A total of 22,170 hospitalized patients in four hospitals were included in the study. Hospital-acquired infection was reported in 3037 patients (13.7%; 95% CI: 12.9-14.4%). The highest incidence was in Benghazi Medical Center (17.9%; 95% CI: 16.9-18.7%), followed by Sabha Medical Center (14.8%; 95% CI:14.9-16.51%). Surgical site infection was the most prevalent (31.3%), followed by ventilator-associated pneumonia (29.3%), urinary tract infection (26.8%), and bloodstream infection (12.6%). Patients with healthcare-associated infections experienced severe morbidity requiring intervention. New antimicrobial regimens were needed for 1836 patients (93%), and 752 patients (34%) required admission to intensive care. Surgical intervention, respiratory support, and inotropes were also needed as a consequence of HAI events.

CONCLUSIONS

The high incidence of healthcare-associated infections in Libyan hospitals should be considered a major problem and a serious burden. This should alert healthcare authorities at the national and hospital levels to the urgent need for preventive and control strategies to combat hospital-acquired infections.

The Burden of Surgical Site Infection at Hospital Universiti Sains Malaysia and Related Postoperative Outcomes: A Prospective Surveillance Study

Surgical site infections (SSIs) are the most common healthcare-associated infections that occur among surgical patients. Surgical site infections result in longer hospital stays, hospital readmissions, and higher death and morbidity rates. The current study was designed to highlight the importance of such surveillance studies in a Malaysian surgical population with a motive to evaluate and revise concurrent infection control and prevention policies by exploring the burden of surgical site infection and identifying its associated risk factors for future considerations. In this prospective observational cohort study, a total of 216 patients admitted to a surgical ward were identified and studied. Of these 216 patients, 142 elective procedures and 74 emergency procedures were included in the study, of which 13 patients (9.2%) undergoing elective procedures and 15 (20.3%) patients undergoing emergency procedures were SSI positive (OR: 2.5, p = 0.02). Among surgical site infections, 21 were superficial and 7 were deep incisional SSI. No case of organ/space SSI was identified. The time taken for SSIs to develop ranged from 2-17 days with a median of 6 days. Risk factors such as presence of comorbidities (p = 0.011), major co-existing medical diagnosis ≥2 (p = 0.02), and pre-existing infection (p = 0.027) were statistically significant. SSI-positive patients experienced an increase in the post-operative length of hospital stay. In the current population, it was seen that identifying patients who were at high risk of malnutrition via MUST and the NNIS risk index will help clinicians in identifying high risk patients and in managing their patients appropriately. Identifying patients who were at high risk of malnutrition will also improve postoperative outcomes considerably.

Evaluation of antibiotic prophylaxis for gastrointestinal surgeries in a teaching hospital: An interventional pre-post study

Surgical site infections are related to a high morbidity, mortality and healthcare costs. Despite ample evidence demonstrating the effectiveness of antimicrobials to prevent surgical site infections, inappropriate timing, antibiotic selection and excessive continuation of antibiotics are common in practice. In this study, we compare the appropriateness of antibiotic prophylaxis in gastrointestinal surgery, before and after an evidence-based guideline implementation. One hundred patients were evaluated in each group. The implementation of the guideline resulted in significant reduction of incorrect use of antibiotics from 55% to 18% (P = 0.002). It also reduced duration of prophylactic antibiotics (43% vs. 23%, P = 0.025). Inappropriate doses diminished but not significantly (8% vs. 5%, P = 0.321). Based on our results, in more than half of of these cases patients received incorrect antibiotic prophylaxis regimens for gastrointestinal surgery in this hospital. Local guideline implementation can result in reduction of antibiotic use, dose and duration errors.

Individualized surgical antibiotic prophylaxis – why, when, and how?

"Surgical site infections (SSI) greatly concern clinicians, as they are associated with significant morbidity and mortality, prolonged hospitalization, and costs. Antibiotic prophylaxis plays a pivotal role among the procedures that are usually employed for the prevention of surgical-related infections. This narrative review aims to cover some of the particular situations when the clinician might consider individualizing antibiotic prophylaxis for a patient. With the rising incidence of multi-drug resistant bacteria carriage among not only hospitalized or institutionalized patients but also patients from the community, there might be a tendency to use extended-spectrum antibiotics for longer periods for surgical infection prevention. However, the inappropriate use of antibiotics increases the selection pressure, thus favoring the spreading of resistant bacteria. Moreover, specific patient characteristics or pathologies might need to be considered to customize the type, dose, or length of administration of an antibiotic as surgical prophylaxis. Using prosthetic material or prolonged surgeries with large fluid shifts are other situations when individualized antibiotic prophylaxis might be thought of. Keeping in mind that it is of utmost importance that everyone adheres to the current guidelines for surgical antibiotic prophylaxis, customization of local protocols according to well-thought-out strategies might prove beneficial in SSI prevention."

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.

Surgical antibiotic prophylaxis administration practices

SETTING

A referral hospital in Kavre, Nepal.

OBJECTIVES

To assess 1) compliance with National Antibiotic Treatment Guidelines (NATG), specifically, whether the administration of surgical antibiotic prophylaxis (SAP) (initial dosing and redosing) was in compliance with NATG for patients who were and were not eligible, and 2) development of surgical site infections (SSIs) among patients who underwent surgery in the Department of General Surgery (July-December 2019).

DESIGN

This was a retrospective cohort analysis.

RESULTS

The analysis included 846 patients, of which 717 (85%) patients were eligible for SAP and 129 (15%) were ineligible. Of those eligible, 708 (99%) received the initial dose; while 65 (50%) of the ineligible did not receive any dose. Of those who received the initial dose, 164 (23%) were eligible for redosing. Of these, only 23 (14%) received at least one redosing and 141 (86%) did not receive it. Overall compliance with NATG was achieved in 75% (632/846) of patients. SSIs occurred in 23 (3%) patients, 8 (35%) of whom did not have SAP administered according to NATG.

CONCLUSION

A relatively high overall compliance with NATG for SAP administration was reported. Recommendations were made to improve compliance among those who were ineligible for SAP and those who were eligible for redosing.

Indications and outcomes of emergency obstetric hysterectomy; a 5-year review at the Bafoussam Regional Hospital, Cameroon

BACKGROUND

Emergency Obstetric Hysterectomy (EOH) is removal of the uterus due to life threatening conditions within the puerperium. This life saving intervention is associated with life threatening complications. In our setting, little is known on EOH.

OBJECTIVES

To determine the prevalence, indications and outcomes of emergency obstetric hysterectomy while comparing both postpartum hysterectomy and caesarean hysterectomy.

METHODS

A 5-year hospital-based retrospective cohort study involving medical records of patients who underwent emergency obstetric hysterectomies between 1st January 2015 and 31st December 2019, was carried out at the Bafoussam Regional Hospital (BRH) from 1st February 2020 to 30th April 2020. Cases were classified as caesarean hysterectomy (CH) or postpartum hysterectomy (PH). Epidemiological data, indications, and complications of EOH were collected and analyzed in EPI-INFO 7.2.2.1. The chi-squared test was used to compare the two groups, and bivariate analysis was used to identify indicators of adverse outcomes of EOH. Statistical significance was set at p < 0.05.

RESULTS

There were 30 cases of emergency obstetric hysterectomy (24 caesarean hysterectomies and 6 postpartum hysterectomies), giving a prevalence rate of 3.75 per 1000 deliveries. The most common indication for CH, was intractable postpartum haemorrhage and uterine rupture (33.33% each), while abnormal placentation (50%) was commonly indicated for PH. Anaemia (both groups) (p = 0.013) and sepsis (PH group only, 33.33%) (p = 0.03) were the most statistically significant complications of EOH respectively. Absence of blood transfusion prior to surgery (p = 0.013) and prolonged surgery lasting 2 or more hours (p = 0.04), were significantly associated with a negative clinical outcome.

CONCLUSION

The prevalence of EOH is high. There were no differences in the sociodemographic profile, risk factors and indications of both groups. PH group was more likely to develop sepsis as complication. Lack of blood transfusion prior to surgery and prolonged surgeries were significantly associated to complication. Meticulous care and timely recognition of negative prognostic factors of delivery as well as those of EOH will help improve maternal outcomes of pregnancy.

Surgical antibiotic prophylaxis: is the clinical practice based on evidence?

Objective:

To assess the surgical antibiotic prophylaxis.

Methods:

This was a descriptive study performed at a public tertiary care university hospital gathering prescription, sociodemographic and hospitalization data of inpatients admitted in 2014 who used antimicrobial drugs. This data were obtained from the hospital electronic database. The antimicrobial data were classified according to the anatomical, therapeutic chemical/defined daily dose per 1,000 inpatients. An exploratory analysis was performed using principal component analysis.

Results:

A total of 5,182 inpatients were prescribed surgical antibiotic prophylaxis. Of the total antimicrobial use, 11.7% were for surgical antibiotic prophylaxis. The orthopedic, thoracic and cardiovascular postoperative units, and postoperative intensive care unit comprised more than half of the total surgical antibiotic prophylaxis use (56.3%). The duration of antimicrobial use of these units were 2.2, 2.0, and 1.4 days, respectively. Third-generation cephalosporins and fluoroquinolones had the longest use among antimicrobial classes.

Conclusion:

Surgical antibiotic prophylaxis was inadequate in the orthopedic, postoperative intensive care, thoracic and cardiovascular postoperative, gynecology and obstetrics, and otolaryngology units. Therefore, the development and implementation of additional strategies to promote surgical antibiotic stewardship at hospitals are essential.

Perioperative antimicrobial prophylaxis in adult patients: The first multicenter clinical practice audit with intervention in Greek surgical departments

OBJECTIVE

To audit clinical practice and implement an intervention to promote appropriate use of perioperative antimicrobial prophylaxis (PAP).

DESIGN

Prospective multicenter before-and-after study.

SETTING

This study was conducted in 7 surgical departments of 3 major Greek hospitals.

METHODS

Active PAP surveillance in adults undergoing elective surgical procedures was performed before and after implementation of a multimodal intervention. The surveillance monitored use of appropriate antimicrobial agent according to international and local guidelines, appropriate timing and duration of PAP, overall compliance with all 3 parameters and the occurrence of surgical site infections (SSIs). The intervention included education, audit, and feedback.

RESULTS

Overall, 1,447 patients were included: 768 before and 679 after intervention. Overall compliance increased from 28.2% to 43.9% (P = .001). Use of antimicrobial agents compliant to international guidelines increased from 89.6% to 96.3% (P = .001). In 4 of 7 departments, compliance with appropriate timing was already >90%; an increase from 44.3% to 73% (P = .001) and from 20.4% to 60% (P = .001), respectively, was achieved in 2 other departments, whereas a decrease from 64.1% to 10.9% (P = .001) was observed in 1 department. All but one department achieved a shorter PAP duration, and most achieved duration of ~2 days. SSIs significantly decreased from 6.9% to 4% (P = .026). After the intervention, it was 2.3 times more likely for appropriate antimicrobial use, 14.7 times more likely to administer an antimicrobial for the appropriate duration and 5.3 times more likely to administer an overall appropriate PAP.

CONCLUSION

An intervention based on education, audit, and feedback can significantly contribute to improvement of appropriate PAP administration; further improvement in duration is needed.

Issues beyond resistance: inadequate antibiotic therapy and bacterial hypervirulence

The administration of antibiotics while critical for treatment, can be accompanied by potentially severe complications. These include toxicities associated with the drugs themselves, the selection of resistant organisms and depletion of endogenous host microbiota. In addition, antibiotics may be associated with less well-recognized complications arising through changes in the pathogens themselves. Growing evidence suggests that organisms exposed to antibiotics can respond by altering the expression of toxins, invasins and adhesins, as well as biofilm, resistance and persistence factors. The clinical significance of these changes continues to be explored; however, it is possible that treatment with antibiotics may inadvertently precipitate a worsening of the clinical course of disease. Efforts are needed to adjust or augment antibiotic therapy to prevent the transition of pathogens to hypervirulent states. Better understanding the role of antibiotic-microbe interactions and how these can influence disease course is critical given the implications on prescription guidelines and antimicrobial stewardship policies.

Prevalence of and rationale for antimicrobial prescription during ambulatory care visits in Japan: a prospective, multicentre, cross-sectional study

OBJECTIVE

To determine the rate of outpatient antimicrobial use and the rationale for antimicrobial prescription.

DESIGN

A prospective, multicentre, cross-sectional study.

SETTING

Ambulatory care settings at community general hospitals.

PARTICIPANTS

A total of 1972 consecutive ambulatory visits by 1952 patients were included from 2 February 2020 to 13 February 2020. Visits resulting in hospital admission and regularly scheduled visits were excluded.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of ambulatory visits resulting in antimicrobial drug prescriptions. The secondary outcomes were the reasons for antimicrobial drug prescription and the proportion of unnecessary antimicrobial prescriptions among all antimicrobial drugs used for treatment.

RESULTS

The mean patient age was 53.8 (SD 25.8) years old, and the proportion of women was 52.6%. A total of 162 antimicrobial drugs were prescribed in 153 (7.8%) visits. The most common antimicrobial drugs were penicillins (n=48, 29.6%), followed by third-generation cephalosporins (n=35, 21.6%) and quinolones (n=20, 12.4%). Among all the antimicrobial drugs prescribed, 125 (77.2%), 18 (11.1%) and 11 (6.8%) were used for infection treatment, wound prophylaxis and surgical prophylaxis, respectively. Of the 125 antimicrobial drugs used for infection treatment, 60 (48.0%) were judged to be unnecessary.

CONCLUSIONS

One in every 13 ambulatory visits resulted in antimicrobial use in Japan. Three-fourths of the prescribed antimicrobial drugs were used for infection treatment, but approximately half of those drugs may have been unnecessary. Further efforts to reduce unnecessary antimicrobial drug use are needed.

TRIAL REGISTRATION NUMBER

UMIN000039360.

Impact of Reduced Preincision Antibiotic Infusion Time on Surgical Site Infection Rates: A Retrospective Cohort Study

OBJECTIVE

Our objective was to determine the impact of total preincision infusion time on surgical site infections (SSIs) and establish an optimal time threshold for subsequent prospective study.

BACKGROUND

SSIs remain a major cause of morbidity. Although regulated, the total time of infusion of preincision antibiotics varies widely. Impact of infusion time on SSI risk is poorly understood.

METHODS

All consecutive patients (n = 46,791) undergoing inpatient surgical intervention were retrospectively enrolled (2014-2015) and monitored for 1 year. Primary outcomes: the presence of SSI infection as predicted by reduced preoperative antibiotic infusion time.

SECONDARY OUTCOMES

preintervention compliance, the impact of a quality improvement algorithm to optimize infusion time compliance. Multivariate logistic regression of the retrospective cohort demonstrated predictors of infection. Receiver-operating characteristic analysis demonstrated the timing threshold predictive of infection. Cost impact of avoidable infections was analyzed.

RESULTS

Only 36.1% of patients received preincision infusion of vancomycin in compliance with national and institutional standards (60-120 min). Cephalosporin infusion times were 53 times more likely to be compliant [odds ratio (OR) 53.33, P < 0.001]. Vancomycin infusion times that were not compliant with national standards (less than standard 60-120 min) did not predict infection. However, significantly noncompliant, reduced preincision infusion time, significantly predicted SSI (<24.6 min infusion, AUC = 0.762). Vancomycin infusion, initiated too close to surgical incision, predicted increased SSI (OR = 4.281, P < 0.001). Implementation of an algorithm to improve infusion time, but not powered to demonstrate infection /reduction, improved vancomycin infusion start time (257% improvement, P < 0.001) and eliminated high-risk infusions (sub-24.6 min).

CONCLUSIONS

Initially, vancomycin infusion rarely met national guidelines; however, minimal compliance breach was not associated with SSI implications. The retrospective data here suggest a critical infusion time for infection reduction (24.6 min before incision). Prospective implementation of an algorithm led to 100% compliance. These data suggest that vancomycin administration timing should be studied prospectively.

Management of hospital-acquired infections among patients hospitalized at Zewditu memorial hospital, Addis Ababa, Ethiopia: A prospective cross-sectional study

BACKGROUND

Hospital-Acquired Infections (HAIs) are acquired when the patient is hospitalized for more than 48 hours. In Ethiopia data are scarce in management appropriateness of HAIs. Hence, this study was aimed to assess the prevalence and management of HAIs among patients admitted at Zewditu Memorial Hospital.

METHOD

A facility based prospective cross sectional study was conducted from March 1, 2017 to August 30, 2017. The sample was proportionally allocated among (medical, pediatrics, gynecology and obstetrics and surgical) wards, based on patient flow. Data were collected using data abstraction format and supplemented by key informant interview. Interview was made on eight physicians and four microbiologists who have been working in the wards during study period. Management appropriateness was assessed using Infectious Disease Society of America guideline and experts opinion (Infectious disease specialist). A multivariate logistic regression was used to identify factors associated with HAIs.

RESULT

The prevalence of HAIs was 19.8%. Surgical Site Infection (SSI) and pneumonia accounted for 20 (24.7%) of the infections. Culture and sensitivity was done for 24 (29.6%) patients. Of the 81 patients who developed HAIs, 54 (66.67%) of them were treated inappropriately. Physicians' response for this variation was information gap, forgetfulness, affordability and availability issue of first line medications. Younger age (AOR (Adjusted odds ratio) = 8.53, 95% CI: 2.67-27.30); male gender (AOR = 2.06, 95% CI: 1.01-4.22); longer hospital stay (AOR = 0.17, 95% CI: 0.06-0.51); and previous hospital admission (AOR = 3.22, 95% CI: 1.76-5.89); were independent predictors of HAIs.

CONCLUSION

Prevalence of HAIs and inappropriate management were substantially high in this study. Pneumonia and SSI were the common types of HAIs. Locally conformable guidelines could help to correct such problems.

Surgical Antibiotic Prophylaxis Use and Surgical Site Infection Pattern in Dessie Referral Hospital, Dessie, Northeast of Ethiopia

Background

Surgical site infections are the third (14%-16%) most frequent cause of nosocomial infections among hospitalized patients. They still form a large health problem and result in increased antibiotic usage, increased associated costs, and prolonged hospitalization and contribute to increased patient morbidity and mortality. Therefore, studies on surgical site infections and surgical antibiotic prophylaxis contribute to identifying surgical site infection rate and risk factor associated with it as well as for identifying the gap in surgical antibiotic prophylaxis practice.

Objective

To assess surgical antibiotic prophylaxis practice and surgical site infection among surgical patients.

Method

A hospital-based prospective observational study was conducted in 68 patients who underwent major surgery in Dessie Referral Hospital adult surgical wards between March 24 and April 25/2017. Descriptive and logistic regression analyses were performed to determine infection rate and risk factors for surgical site infections.

Result

Assessment of 68 patients who underwent major surgery revealed an overall surgical site infection rate of 23.4%. Prophylactic antibiotics were administered for 59 operations; of these, 33 (48.6%) had inappropriate timing of administration. A combination of ceftriaxone and metronidazole 28 (47.46%) was frequently used. Factors associated with surgical site infection were wound class, patient comorbid condition, duration of the procedure, the timing of administration, and omitting prophylaxis use.

Conclusion

This study indicated a higher rate of surgical site infection and also revealed that wound class, preexisting medical condition, prolonged duration of surgery, omitting of prophylaxis use, and inappropriate timing of administration were highly associated with surgical site infection.

Antibiotic prophylaxis with high-dose cefoxitin in bariatric surgery: an observational prospective single center study

BACKGROUND

The optimal dose of cefoxitin for antibiotic prophylaxis in obese patients remains uncertain. We evaluated the adequacy of a 4-gram dosing regimen of cefoxitin against the most frequent pathogens that infect patients undergoing bariatric surgery.

METHODS

This observational prospective study included obese patients who required bariatric surgery and a 4-gram dose of cefoxitin as an antibiotic prophylaxis. Serum concentrations were measured during surgery (incision, wound closure and in case of reinjection). The pharmacokinetic/pharmacodynamic (PK/PD) target was to obtain free cefoxitin concentrations above 4× MIC, from incision to wound closure (100% ƒT_>4xMIC). The targeted MIC was based on the worst-case scenario (the highest ECOFF value of Staphylococcus aureus, Enterobacteriaceae and anaerobic bacteria). The secondary outcomes were the factors related to underdosage.

RESULTS

Two hundred patients were included. The mean age of the patients was 46 (±12) years-old, and the mean BMI was 45.8 (±6.9) kg/m² Bypass surgery was the preferred technique (84%). The percentages of patients who met the PK/PD target (100% fT_>4xMIC) of cefoxitin were 37.3%, 1.1% and 0% for S. aureus, Enterobacteriaceae and anaerobic bacteria, respectively. BMIs below 50 kg/m² (OR 0.29, 95% CI [0.11-0.75], P = 0.0107) and a shorter duration of surgery (OR 0.97, 95% CI [0.95-0.99], P = 0.004) were associated with reaching the target concentrations.

CONCLUSIONS

In obese patients undergoing bariatric surgery, a regimen of 4 grams of cefoxitin led to an inadequate coverage for most common pathogens. A longer surgery duration and BMI over 50 kg/m² increase the risk of underdosage.

Antimicrobial Prophylaxis Redosing Reduces Surgical Site Infection Risk in Prolonged Duration Surgery Irrespective of Its Timing

BACKGROUND

Long-duration surgery requires repeated administration of antimicrobial prophylaxis (amp). Amp "redosing" reduces incidence of surgical site infections (SSI) but is frequently omitted. Clinical relevance of redosing timing needs to be investigated. Here, we evaluated the effects of compliance with amp redosing and its timing on SSI incidence in prolonged duration surgery.

METHODS

Data from >9000 patients undergoing visceral, trauma, or vascular surgery with elective or emergency treatment in two tertiary referral Swiss hospitals were analyzed. All patients had to receive amp preoperatively and redosing, if indicated. Antibiotics used were cefuroxime (1.5 or 3 g, if weight >80 kg), or cefuroxime and metronidazole (1.5 and 0.5 g, or 3 and 1 g doses, if weight >80 kg). Alternatively, in cases of known or suspected allergies, vancomycin (1 g), gentamicin (4 mg/Kg), and metronidazole or clindamycin (300 mg) with or without ciprofloxacin (400 mg) were used. Association of defined parameters, including wound class, ASA scores, and duration of operation, with SSI incidence was explored.

RESULTS

In the whole cohort, SSI incidence significantly correlated with duration of surgery (ρ = 0.73, p = 0.031). In 593 patients undergoing >240 min long interventions, duration of surgery was the only parameter significantly (p < 0.001) associated with increased SSI risk, whereas wound class, ASA scores, treatment areas, and emergency versus elective hospital entry were not. Redosing significantly reduced SSI incidence as shown by multivariate analysis (OR 0.60, 95% CI 0.37-0.96, p = 0.034), but exact timing had no significant impact.

CONCLUSIONS

Long-duration surgery associates with higher SSI incidence. Irrespective of its exact timing, amp redosing significantly decreases SSI risk.

Prevalence of antimicrobial use and active healthcare-associated infections in acute care hospitals: a multicentre prevalence survey in Japan

OBJECTIVE

To determine the prevalence of antimicrobial drug use and active healthcare-associated infections (HAIs) and to evaluate the appropriateness of antimicrobial therapy in acute care hospitals in Japan.

DESIGN

A prospective multicentre cross-sectional study.

PARTICIPANTS

All hospitalised patients on a survey day.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of patients receiving any antimicrobial agents. The secondary outcome was the proportion of patients with active HAIs. The reasons for antimicrobial drug use and appropriateness of antibiotic therapy were also investigated.

RESULTS

Eight hundred twenty eligible patients were identified. The median patient age was 70 years (IQR 55-80); 380 (46.3%) were women, 150 (18.3%) had diabetes mellitus and 107 (13.1%) were immunosuppressive medication users. The proportion of patients receiving any antimicrobial drugs was 33.5% (95% CI 30.3% to 36.8%). The proportion of patients with active HAIs was 7.4% (95% CI 5.6% to 9.2%). A total of 327 antimicrobial drugs were used at the time of the survey. Of those, 163 (49.8%), 101 (30.9%) and 46 (14.1%) were used for infection treatment, surgical prophylaxis and medical prophylaxis, respectively. The most commonly used antimicrobial drugs for treatment were ceftriaxone (n=25, 15.3%), followed by piperacillin-tazobactam (n=22, 13.5%) and cefmetazole (n=13, 8.0%). In the 163 antimicrobial drugs used for infection treatment, 62 (38.0%) were judged to be inappropriately used.

CONCLUSIONS

The prevalence of antimicrobial use and active HAIs and the appropriateness of antimicrobial therapy in Japan were similar to those of other developed countries. A strategy to improve the appropriateness of antimicrobial therapy provided to hospitalised patients is needed.

TRIAL REGISTRATION NUMBER

UMIN000033568.

Evaluation of Antibiotic Prophylaxis and Discharge Prescriptions in the General Surgery Department

Introduction Although there are international guidelines for surgical antibiotic prophylaxis (SP), the use of inappropriate SP is still a common problem. Most studies investigated SP applications in clean and clean-contaminated cases. However, antibiotics in the discharge prescriptions of these cases have not been adequately investigated. In this study, we aimed to examine the antibiotics in SP applications and discharged prescriptions together and to find out the causes of inappropriate use. Materials and methods We retrospectively evaluated the data of patients admitted to our general surgery wards between 2014 and 2015. Patients with clean or clean-contaminated wound category operations were included. The patients were evaluated in terms of convenience of SP (choice of antibiotics, compliance with an indication for SP, timing of the first dose, SP>24 hours, and discharge prescription). In addition, to interpret the results, a questionnaire has been performed for the surgeons in the same clinics. Results A total of 1205 patients with clean and clean-contaminated wound class operation were enrolled in this study. The total accuracy rate of SP was 7.1%. SP application with the correct indication and timing of the first dose was compatible with guidelines: 55.6% and 81.9%, respectively. SP was applied >24 hours at 60.2% and antibiotic prescribing carried out after discharge at 80.6% of patients. According to questionnaire results, the use of SP over 24 hours and the prescription of antibiotics during discharge were: drain usage, hyperthermia, leukocytosis, surgeons feeling of comfort, avoidance of patients, and their relatives' reactions. Conclusion The total accuracy rate of SP rate was low in the present study and in surgeons prescribing the SP after discharge. In light of the present study, we suggest that discharge prescriptions should also be reviewed in clinics who have a high inappropriate surgical antibiotic prophylaxis rate.

Evaluation of antimicrobial prophylaxis use and rate of surgical site infection in surgical ward of Wachemo University Nigist Eleni Mohammed Memorial Hospital, Southern Ethiopia: prospective cohort study

BACKGROUND

Surgical site infection (SSI) is the foremost infection in the overall patient population, affecting up to 66% of operated patients and with a frequency up to nine times more than in developed countries. This study aimed to determine the rate, associated factors of surgical site infection, and identification of causative agents and their antimicrobial susceptibility in surgical ward of Wachemo University Nigist Eleni Mohamed Memorial Hospital (WUNEMMH), Southern Ethiopia.

METHOD

Prospective cohort study involving 255 patients who underwent surgical procedure in WUNEMMH from January 1 to September 1, 2017. We extracted data from medical chart, operational and anesthesia note by direct observation and interviewer administered semi-structured questionnaire which was validated. We collected wound specimens and processed it based on standard operating procedure, and disc-diffusion antibiotic susceptibility test was done. Data analysis was done using SPSS version 22.0. Factors significantly associated were identified using logistic regression model at P-value < 0.05 and 95%CI.

RESULT

Forty-two patients (16.5%) developed SSIs. The most causative organism of surgical site infection was Klebsiella pneumoniae (60%).Ciprofloxacin and ceftriaxone were sensitive antibiotics. Surgery waiting time more than 7 days [ARR = 2.48 (95%CI(1.28-4.79),P = 0.007], Operation time more than 1 h.[ARR = 2.13(95%CI(1.18-3.86),P = 0.012], and administering antibiotic before 1 h of operation [ARR = 5.05(95%CI(1.79-14.21),P = 0.002], smoking [ARR = 8.01 (95% CI (2.15 29.84),P = 0.002] were independently associated with surgical site infections.

CONCLUSION

The rate of SSI was relatively high. Klebsiella pneumoniae was found to be the most causative agent for SSI. Organisms causing SSI were sensitive to commonly used antimicrobial agents in WUNEMMH.

Incidence and risk factors for potentially suboptimal serum concentrations of vancomycin during cardiac surgery

AIM

To investigate the incidence and risk factors for vancomycin concentrations less than 10 mg/L during cardiac surgery.

METHODS

In this prospective study, patients undergoing cardiac surgery received a single dose of 1000 mg of vancomycin. Multiple arterial samples were drawn during surgery. Exclusion criteria were hepatic dysfunction; renal dysfunction; ongoing infectious diseases; solid or hematologic tumors; severe insulin-dependent diabetes; body mass index of < 17 or > 40 kg/m²; pregnancy or lactation; antibiotic, corticosteroid, or other immunosuppressive therapy; vancomycin or nonsteroidal anti-inflammatory drug therapy in the previous 2 wk; chemotherapy or radiation therapy in the previous 6 mo; allergy to vancomycin or cefazolin; drug abuse; cardiac surgery in the previous 6 mo; previous or scheduled organ transplantation; preoperative stay in the intensive care unit for more than 24 h; emergency procedure or lack of adequate preparation for surgery; and participation in another trial.

RESULTS

Over a 1-year period, 236 patients were enrolled, and a total of 1682 serum vancomycin concentrations (median 7/patient) were measured. No vancomycin levels under 10 mg/L were recorded in 122 out of 236 patients (52%), and 114 out of 236 patients (48%) were found to have at least 1 serum sample with a vancomycin level < 10 mg/L; 54 out of 236 patients (22.9%) had at least 5 serum samples with a vancomycin level lower than 10 mg/L. Vancomycin infusion was administered for 60 min in 97 out of 236 patients (41%). In 47 patients (20%), the duration of infusion was longer than 60 min, and in 92 patients (39%) the duration of infusion was shorter than 60 min. The maximum concentration and area under the concentration-time curve were significantly higher in patients with no vancomycin levels less than 10 mg/L (P < 0.001). The multivariate analysis identified female gender, body mass index (BMI) > 25 kg/m², and creatinine clearance above 70 mL/min as risk factors for vancomycin levels less than 10 mg/L.

CONCLUSION

Results of this study identified female gender, BMI > 25 kg/m², and creatinine clearance above 70 mL/min as risk factors for suboptimal vancomycin serum concentration during cardiac surgery; no relationship was found between infusion duration and vancomycin levels less than 10 mg/L. These findings call attention to the risk of facilitating the emergence of vancomycin-resistant methicillin-resistant Staphylococcus aureus strains.

Magnitude and Determinant Factors of Surgical Site Infection in Suhul Hospital Tigrai, Northern Ethiopia: A Cross-Sectional Study

BACKGROUND

Surgical site infections (SSIs) are the most common hospital-acquired infection among surgical patients and remains a major clinical issue. In Ethiopia, despite many studies, the magnitude and associated factors of SSIs are not well documented and differ among regions. The aim of this study was to identify the magnitude and associated factors of SSIs in Suhul Hospital, Northern Ethiopia.

METHODS

An institution-based cross-sectional study was conducted from February 2-March 31, 2016, in Shire Suhul Hospital. A total of 280 post-operative patients were included and were selected using simple random sampling. A pre-tested interviewer administrated the questionnaire used to collect relevant information. Data were cleaned, entered, and analyzed using SPSS Version 20. Bivariable and multivariable logistic regression was employed to identify the predictors at p < 0.05.

RESULTS

Of the 281 potential study subjects, 280 participated. The mean age of the study subjects was 34.5 years (standard deviation [SD} ±15.6). The prevalence of SSI was 11.1% (95% confidence interval [CI] 7.34-14.67), and in the multivariable logistic regression analysis, four independent determinants emerged as associated with SSI: post-operative hospital stay from 8-14 days (odds ratio [OR] 7.97; 95% CI 1.70-37.38); history of alcohol use (OR 0.04; 95% CI 0.004-0.43); use of local anesthesia (OR 8; CI 1.010-63.398); and dirty incision classification (OR 17; CI 1.249-232.362).

CONCLUSION

The magnitude of SSI was high. A hospital stay for more than a week, a history of alcohol consumption, use of local anesthesia, and dirty incision classification were associated independently with a higher risk of SSI. Due attention should be given to infection prevention control methods; and more has to be done to manage dirty and contaminated sites, maintain a strict sterile environment and aseptic surgical techniques, and implement the World Health Organization surgical safety protocol. Efforts should be made to improve appropriate and timely discharge among surgical clients. Prospective longitudinal studies ought to be conducted considering SSI after hospital discharge.

Auditing and Improving Surgical Antibiotic Prophylaxis

BACKGROUND

There is extensive evidence of the efficacy of anti-microbial drugs in preventing infections from surgical efforts. Our objective was to describe the results obtained in our annual surgical antibiotic prophylaxis (SAP) audit in the years 2013-2017.

METHODS

This was a retrospective observational study of SAP in surgical procedures carried out between 2013 and 2017 in a tertiary-level hospital. We examined the results from the services of general surgery, vascular surgery, neurosurgery, the breast unit, otolaryngology, maxillofacial surgery, traumatology, urology, pediatric surgery, gynecology, and plastic surgery.

RESULTS

Establishment of six process quality indicators and their evaluation in the annual audit were carried out by the pharmacy service for approximately 500 operations. The indicators that had a high percentage of compliance were indication for SAP, choice of anti-microbial agent, dose and route of administration, and administration of an intra-operative dose when this was appropriate. In contrast, time of administration of the first dose and duration of prophylaxis had a worse percentage of compliance.

CONCLUSIONS

Compliance with the SAP protocols in our hospital is high. We consider that these better results are attributable to the establishment of quality indicators of SAP and to the annual audit that evaluates said indicators. Communication of the results obtained in the audit to the surgical services, which have as part of their objectives included in their management contracts compliance with said SAP protocols, encourages improvement. The use of prophylaxis kits is an improvement strategy that facilitates the correct choice of anti-microbial agent and prevents SAP from being prolonged inappropriately.

[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.

From guidelines to practice: a pharmacist-driven prospective audit and feedback improvement model for peri-operative antibiotic prophylaxis in 34 South African hospitals

Background

Few data exist on the implementation of process measures to facilitate adherence to peri-operative antibiotic prophylaxis (PAP) guidelines in Africa.

Objectives

To implement an improvement model for PAP utilizing existing resources, in order to achieve a reduction in surgical site infections (SSIs) across a heterogeneous group of 34 urban and rural South African hospitals.

Methods

A pharmacist-driven, prospective audit and feedback strategy involving change management and improvement principles was utilized. This 2.5 year intervention involved a pre-implementation phase to test a PAP guideline and a 'toolkit' at pilot sites. Following antimicrobial stewardship committee and clinician endorsement, the model was introduced in all institutions and a survey of baseline SSI and compliance rates with four process measures (antibiotic choice, dose, administration time and duration) was performed. The post-implementation phase involved audit, intervention and monthly feedback to facilitate improvements in compliance.

Results

For 70 weeks of standardized measurements and feedback, 24 206 surgical cases were reviewed. There was a significant improvement in compliance with all process measures (composite compliance) from 66.8% (95% CI 64.8-68.7) to 83.3% (95% CI 80.8-85.8), representing a 24.7% increase ( P  <   0.0001). The SSI rate decreased by 19.7% from a mean group rate of 2.46 (95% CI 2.18-2.73) pre-intervention to 1.97 post-intervention (95% CI 1.79-2.15) ( P  =   0.0029).

Conclusions

The implementation of process improvement initiatives and principles targeted to institutional needs utilizing pharmacists can effectively improve PAP guideline compliance and sustainable patient outcomes.

Antibiotic prophylaxis adequacy in knee arthroplasty and surgical wound infection: Prospective cohort study

OBJECTIVE

Antibiotic prophylaxis is the most suitable tool for preventing surgical wound infection. This study evaluated adequacy of antibiotic prophylaxis in surgery for knee arthroplasty and its effect on surgical site infection.

MATERIAL AND METHOD

Prospective cohort study. We assessed the degree of adequacy of antibiotic prophylaxis, the causes of non-adequacy, and the effect of non-adequacy on surgical site infection. Incidence of surgical site infection was studied after a maximum incubation period of a year. To assess the effect of prophylaxis non-adequacy on surgical site infection we used the relative risk adjusted with the aid of a logistic regression model.

RESULTS

The study covered a total of 1749 patients. Antibiotic prophylaxis was indicated in all patients and administered in 99.8% of cases, with an overall protocol adequacy of 77.6%. The principal cause of non-compliance was the duration of prescription of the antibiotics (46.5%). Cumulative incidence of surgical site infection was 1.43%. No relationship was found between prophylaxis adequacy and surgical infection (RR=1.15; 95% CI: .31-2.99) (P>.05).

DISCUSSION

Surveillance and infection control programs enable risk factors of infection and improvement measures to be assessed. Monitoring infection rates enables us to reduce their incidence.

CONCLUSIONS

Adequacy of antibiotic prophylaxis was high but could be improved. We did not find a relationship between prophylaxis adequacy and surgical site infection rate.

Appropriateness of Surgical Antibiotic Prophylaxis in Pediatric Patients in Italy

OBJECTIVES

Appropriate use of surgical antibiotic prophylaxis (SAP) reduces intraoperative wound contamination in pediatric surgery, thus minimizing the risk of surgical site infection (SSIs). Conversely, inappropriate use of SAP exposes patients to the risk of antibiotic side effects and contributes to the emergence of antimicrobial resistance. Our aims were to describe SAP administration and to analyze factors associated with nonadherence in pediatric patients.

DESIGN

Descriptive study.

SETTING

Overall, 955 pediatric patients underwent 1,038 surgical procedures.

METHODS

We assessed adherence to SAP international guidelines for surgical procedures performed on children aged <18 years in 2015 in 4 randomly selected hospitals in Calabria (Italy). The clinical records of these patients were retrospectively reviewed.

RESULTS

Appropriate SAP administration or nonadministration pertained to 754 surgical procedures (72.6%). Surgical antibiotic prophylaxis was administered in 88.5% of 358 procedures with an SAP indication. Adherence to guidelines for appropriate drug choice were followed in 5.7% of cases, for route of administration in 76.7% of cases, for timing in 48.6% of cases, for duration in 14.5% of cases, and for dose in 91.5% of cases, and for all components in only 5 cases (1.6%). Among 680 procedures without SAP indication, 35.7% case patients received antibiotics. Inappropriate administration of antibiotics in procedures without SAP indication was associated with surgical specialty wards (P=.008), ordinary admission (P<.001), head and neck surgical procedures (P=.020), clean surgery (P=.017), and surgical duration (P=.010).

CONCLUSIONS

Discrepancies between SAP guidelines and actual practice behavior more frequently indicate excessive use of antibiotics than underuse. Increased awareness of SAP guidelines is required.

Infect Control Hosp Epidemiol 2017;38:823–831

Violation of prophylactic vancomycin administration timing is a potential risk factor for rate of surgical site infections in cardiac surgery patients: a prospective cohort study

Background

Intensivists and cardiothoracic surgeons are commonly worried about surgical site infections (SSIs) due to increasing length of stay (LOS), costs and mortality. The antimicrobial prophylaxis is one of the most important tools in the prevention of SSIs. The objective of this study was to investigate the relationship between the timing of antimicrobial prophylaxis administration and the rate of SSIs.

Methods

A prospective cohort study was carried out over 1-year period in all consecutive adult patients undergoing elective cardiac surgery. The population was stratified in patients whose antimicrobial prophylaxis administration violated or not the vancomycin timing protocol (i.e., when the first skin incision was performed before the end of vancomycin infusion). To compare SSI rates, the cohort was further stratified in patients at low and high risk of developing SSIs.

Results

Over the study period, 1020 consecutive adult patients underwent cardiac surgery and according to study inclusion criteria, 741 patients were prospectively enrolled. A total of 60 SSIs were identified for an overall infection rate of 8.1%. Vancomycin prophylaxis timing protocol was violated in 305 (41%) out of 741 enrolled patients. SSIs were observed in 3% of patients without violation of the antimicrobial prophylaxis protocol (13/436) compared with 15.4% of patients with a violation of the timing protocol (47/305) (P < 0.0001). Patients at low risk with protocol violation had a higher occurrence of SSIs (P = 0.004) and mortality (P = 0.03) versus patients at low risk without protocol violation. Similarly, patients at high risk with protocol violation had a higher occurrence of SSIs (P < 0.001) and mortality (P < 0.001) versus patients at high risk without protocol violation. The logistic regression analysis showed that internal mammary artery use (P = 0.025), surgical time (P < 0.001), intensive care unit (ICU) LOS (P = 0.002), high risk of developing SSIs (P < 0.001) and protocol violation (P < 0.001) were risk factors for SSI occurrence as well as age (P = 0.003), logistic EuroSCORE (P < 0.001), ICU LOS (P < 0.001), mechanical ventilation time (P < 0.001) and protocol violation (P < 0.001) were risk factors for mortality.

Conclusions

This study showed that violation of the timing of prophylactic vancomycin administration significantly increased the probability of SSIs and mortality from infectious cause in cardiac surgery patients.

Incidence and predictors of surgical site infection in Ethiopia: prospective cohort

BACKGROUND

Surgical site infections are commonest nosocomial infections and responsible for considerable morbidity and mortality as well as increased hospitalizations and treatment cost related to surgical operations. The aim of this study was to determine incidence and predictors of surgical site infections at surgical ward of Hawassa University Referral Hospital, Southern Ethiopia.

METHODS

We performed prospective study involving 105 patients that undergone major surgical procedure at Hawassa University Referral Hospital from March 2 to May 2, 2015. Data were extracted from paper based medical charts, operational and anesthesia note, by direct observation and patients' interview. All patients were followed daily before, during and after operation for 30 days starting from the date of operation. Data were analyzed using Statistical Package for Social Science (SPSS) for window version 20.0 software. Predictors of Surgical site infections were identified using multivariable logistic regression model. P-value less than 0.05 was considered to be statistically significant.

RESULT

We studied 105 patients. Sixty four patients (61%) were males. The mean age of the patients was 30.85 ± 17.72 years. The mean Body Mass Index (BMI) was 21.6 ± 4 kg/m2. Twenty patients (19.1%) developed surgical site infections. Age greater than 40 years, AOR = 7.7(95% CI [1.610-40.810 p = 0.016,]), preoperative hospital stay more than 7 days, AOR = 22.4(95% CI [4.544-110.780, p = 0.001]), duration of operation more than 1 hour, AOR = 8.01(95% CI [1.562-41.099, p = 0.013]) and administering antimicrobial prophylaxis before 1 hour of operation, AOR = 11.1 (95% CI [1.269-75.639, p = 0.014]) were independent predictors for surgical site infections.

CONCLUSION

Surgical site infection is relatively high.

Impact of monitoring surgical prophylactic antibiotics and a computerized decision support system on antimicrobial use and antimicrobial resistance

BACKGROUND

Monitoring of performance indicators and implementation of a computerized decision support system (CDSS) have been suggested as effective measures to improve quality of care. We conducted this study to evaluate the effect of monitoring of surgical prophylactic antibiotics (SPAs) and the CDSS on the antimicrobial use and resistance rate of major nosocomial pathogens.

METHODS

An interrupted time series with segmented regression analysis in 3 periods (preintervention, SPAs monitoring, and CDSS) was conducted in a tertiary care hospital. Immediate change and change in trends of antimicrobial use density, resistance rate of nosocomial pathogens, and cost of antibiotics in each intervention period were compared with those of the preintervention period.

RESULTS

Compared with the preintervention period, the change in the slope of the total use of antibiotics was -8.71 defined daily dose (DDD) per 1,000 patient days per month (95% confidence interval [CI], -11.43 to -5.98; P < .01) in the SPAs monitoring period and -1.95 DDD per 1,000 patient days per month (95% CI, -2.93 to -0.96; P < .01) in the CDSS period. Use of third-generation cephalosporins and aminoglycosides showed change comparable with that of total antibiotics use, but use of vancomycin and carbapenem was unchanged in the CDSS period. Trends of the proportions of extended-spectrum β-lactamase-producing Escherichia coli, meropenem-resistant Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus have been reversed or decreased in slope in the CDSS period. Length of hospital stay also showed a negative change in slope in the CDSS period.

CONCLUSIONS

Monitoring of SPAs and implementation of the CDSS can be effective measures for antimicrobial stewardship.

Propionibacterium acnes in shoulder surgery: is loss of hair protective for infection?

BACKGROUND

Propionibacterium acnes (P acnes) has been linked to chronic infections in shoulder surgery. It was recently observed during first-time shoulder surgery in healthy patients at a rate between 36% and 56%. Male gender and the anterolateral approach were reported risk factors. Because the skin biology greatly differs, we aimed to correlate skin complaints with P acnes-positive intraoperative cultures from different tissue layer samples in patients undergoing shoulder surgery for the first time.

METHODS

Intraoperative samples (1 skin, 1 superficial, 1 deep tissue, and 1 control sample) from 112 patients (70 men, 42 women; aged 59.2 years) were cultured. The association between the presence of P acnes in the deep or superficial tissue, or both, and 10 items of a validated preoperative questionnaire for skin pathology was explored.

RESULTS

The cultures were positive for P acnes in 38.4% (n = 43) of the cases. Skin samples were positive for P acnes in 8% (n = 9), superficial samples were positive in 23% (n = 26), and deep samples were positive in 30% (n = 34). Self-reported "loss of hair" was significantly negatively associated with the presence of P acnes in the superficial or deep tissue sample (P = .00028).

DISCUSSION

Patients who report having "loss of hair" show fewer P acnes-positive cultures in intraoperative tissue samples taken during open shoulder surgery. Whether this subgroup is at a lesser risk for P acnes infections remains to be substantiated.

LEVEL OF EVIDENCE

Basic Science Study; Microbiology.

Prior inpatient admission increases the risk of post-operative infection in hepatobiliary and pancreatic surgery

BACKGROUND

Hepatobiliary and pancreatic (HPB) operations have a high incidence of post-operative nosocomial infections. The aim of the present study was to determine whether hospitalization up to 1 year before HPB surgery is associated with an increased risk of post-operative infection, surgical-site infection (SSI) and infection resistant to surgical chemoprophylaxis.

METHODS

A retrospective cohort study of patients undergoing HPB surgeries between January 2008 and June 2013 was conducted. A multivariable logistic regression model was used for controlling for potential confounders to determine the association between pre-operative admission and post-operative infection.

RESULTS

Of the 1384 patients who met eligibility criteria, 127 (9.18%) experienced a post-operative infection. Pre-operative hospitalization was independently associated with an increased risk of a post-operative infection [adjusted odds ratio (aOR): 1.61, 95% confidence interval [CI]: 1.06-2.46] and SSI (aOR: 1.79, 95% CI: 1.07-2.97). Pre-operative hospitalization was also associated with an increased risk of post-operative infections resistant to standard pre-operative antibiotics (OR: 2.64, 95% CI: 1.06-6.59) and an increased risk of resistant SSIs (OR: 3.99, 95% CI: 1.25-12.73).

DISCUSSION

Pre-operative hospitalization is associated with an increased incidence of post-operative infections, often with organisms that are resistant to surgical chemoprophylaxis. Patients hospitalized up to 1 year before HPB surgery may benefit from extended spectrum chemoprophylaxis.

Surgical site infection-a population-based study in Australian adults measuring the compliance with and correct timing of appropriate antibiotic prophylaxis

Prophylaxis for surgical site infection (SSI) is often at variance with guidelines, despite the prevalence of SSI and its associated cost, morbidity, and mortality. The CareTrack Australia study, undertaken by a number of the authors, demonstrated that appropriate care (in line with evidence- or consensus-based guidelines) was provided at 38% of eligible SSI healthcare encounters. Here, we report the indicator-level CareTrack Australia findings for SSI prophylaxis. Indicators were extracted from Australian and international clinical guidelines and ratified by clinical experts. A sample designed to be representative of the Australian population was recruited (n=1154). Participants' medical records were reviewed and analysed for compliance with the five SSI indicators. The main outcome measure was the percentage of eligible healthcare encounters with documented compliance with indicators for appropriate SSI prophylaxis. Of the 35,145 CareTrack Australia encounters, 702 (2%) were eligible for scoring against the SSI indicators. Where antibiotics were recommended, compliance was 49% for contaminated surgery, 57% for clean-contaminated surgery and 85% for surgery involving a prosthesis: these fell to 8%, 10% and 14%, respectively (an average of 11%), when currently recommended timing of antibiotic administration was included. Where antibiotics were not indicated, 72% of patients still received them. SSI prophylaxis in our sample was poor; over two-thirds of patients were given antibiotics, whether indicated or not, mainly at the wrong time. There is a need for national agreement on clinical standards, indicators and tools to guide, document and monitor SSI prophylaxis, with both local and national measures to increase and monitor their uptake.

Subinhibitory antibiotic therapy alters recurrent urinary tract infection pathogenesis through modulation of bacterial virulence and host immunity

The capacity of subinhibitory levels of antibiotics to modulate bacterial virulence in vitro has recently been brought to light, raising concerns over the appropriateness of low-dose therapies, including antibiotic prophylaxis for recurrent urinary tract infection management. However, the mechanisms involved and their relevance in influencing pathogenesis have not been investigated. We characterized the ability of antibiotics to modulate virulence in the uropathogens Staphylococcus saprophyticus and Escherichia coli. Several antibiotics were able to induce the expression of adhesins critical to urothelial colonization, resulting in increased biofilm formation, colonization of murine bladders and kidneys, and promotion of intracellular niche formation. Mice receiving subinhibitory ciprofloxacin treatment were also more susceptible to severe infections and frequent recurrences. A ciprofloxacin prophylaxis model revealed this strategy to be ineffective in reducing recurrences and worsened infection by creating larger intracellular reservoirs at higher frequencies. Our study indicates that certain agents used for antibiotic prophylaxis have the potential to complicate infections.

Antibiotics are the mainstay treatment for bacterial infections; however, evidence is emerging that argues these agents may have off-target effects if sublethal concentrations are present. Most studies have focused on changes occurring in vitro, leaving questions regarding the clinical relevance in vivo. We utilized a murine urinary tract infection model to explore the potential impact of low-dose antibiotics on pathogenesis. Using this model, we showed that subinhibitory antibiotics prime uropathogens for adherence and invasion of murine urothelial tissues. These changes in initial colonization promoted the establishment of chronic infection. Furthermore, treatment of chronically infected mice with subtherapeutic ciprofloxacin served to exacerbate infection. A part of these changes was thought to be due to suppression of mucosal immunity, as demonstrated through reductions in cytokine secretion and migration of leukocytes into the urinary tract. This work identifies novel risk factors associated with antibiotic therapy when dosing strategies fall below subtherapeutic levels.

Successful Implementation of a Window for Routine Antimicrobial Prophylaxis Shorter than That of the World Health Organization Standard

Objective.

To evaluate the feasibility of implementation of the refined window for routine antimicrobial prophylaxis (RAP) of 30-74 minutes before skin incision compared to the World Health Organization (WHO) standard of 0-60 minutes.

Design.

Prospective study on timing of routine antimicrobial prophylaxis in 2 different time periods.

Setting.

Tertiary referral university hospital with 30,000 surgical procedures per year.

Methods.

In all consecutive vascular, visceral, and trauma procedures, the timing was prospectively recorded during a first time period of 2 years (A; baseline) and a second period of 1 year (B; after intervention). An intensive intervention program was initiated after baseline. The primary outcome parameter was timing; the secondary outcome parameter was surgical site infection (SSI) rate in the subgroup of patients undergoing cholecystectomy/colon resection.

Results.

During baseline time period A (3,836 procedures), RAP was administered 30–74 minutes before skin incision in 1,750 (41.0%) procedures; during time period B (1,537 procedures), it was administered in 914 (56.0%; P < .001). The subgroup analysis did not reveal a significant difference in SSI rate.

Conclusions.

This bundle of interventions resulted in a statistically significant improvement of timing of RAP even at a shortened window compared to the WHO standard.

Reinforcing good practice: Implementation of guidelines at hospital G. Pini

INTRODUCTION

Surgical site infections (SSIs) in orthopaedic surgery are a demanding complication for the patient and in terms of economics. Many guidelines (GLs) are available on antibiotic prophylaxis as an effective preventive measure; however, these GLs are often ignored in practice. A surveillance study of SSIs in arthroplasty, promoted by the Italian Study Group of Hospital Hygiene of the Italian Society of Public Health (SitI), showed a high percentage of non-adherence to GLs on antibiotic prophylaxis.

OBJECTIVES

The purpose of this study was to review the existing GLs, share them within the hospital and then monitor their implementation.

MATERIALS AND METHODS

Information and training are considered to be great tools for implementation and sharing of GLs, which leads to significant improvements in clinical practice. A multidisciplinary team comprising infectious disease specialists, orthopaedic surgeons, nurse epidemiologists and public health specialists was established at the G. Pini Hospital in Milan to revise GLs, and to organise educational events for their implementation, sharing and dissemination. A checklist was devised for monitoring purposes.

RESULTS

GLs were presented to orthopaedic surgeons and nurse coordinators during two educational events. Meetings were organised in each unit to present the results of the surveillance of SSIs in arthroplasty and to discuss the reasons why the prophylaxis regimens adopted were not consistent with GLs. It was emphasised that the most important issue, on which there is consensus in the scientific literature, was related to the duration of prophylaxis beyond 24h. The review process for GLs was presented and pocket-sized GLs were given to surgeons. The importance of documenting on medical record any deviations from the GLs was emphasised.

CONCLUSIONS

Any changes in behaviour in clinical practice must be monitored and evaluated regularly. The monitoring of GLs in terms of correct choice of drug, timing of administration and duration of prophylaxis is made using a special checklist on a representative sample of medical records.

Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue?

BACKGROUND

Propionibacterium acnes has been linked to chronic infections in shoulder surgery. Whether the bacterium is a contaminant or commensal of the deep tissue is unclear. We aimed to assess P. acnes in intraoperative samples of different tissue layers in patients undergoing first-time shoulder surgery.

METHODS

In 118 consecutive patients (mean age, 59.2 years; 75 men, 43 women), intraoperative samples were correlated to preoperative subacromial injection, the type of surgical approach, and gender. One skin, one superficial, one deep tissue, and one test sample were cultured for each patient.

RESULTS

The cultures were positive for P. acnes in 36.4% (n = 43) of cases. Subacromial injection was not associated with bacterial growth rates (P = .88 for P. acnes; P = .20 for bacteria other than P. acnes; P = .85 for the anterolateral approach; P = .92 for the deltopectoral approach; P = .56 for men; P = .51 for women). Skin samples were positive for P. acnes in 8.5% (n = 10), superficial samples were positive in 7.6% (n = 9), deep samples were positive in 13.6% (n = 16), and both samples (superficial and deep) were positive in 15.3% (n = 18) of cases (P < .0001). P. acnes was detected in the anterolateral approach in 27.1% (n = 32) of cases and in the deltopectoral approach in 9.3% (n = 11) of cases (P = .01; relative risk, 1.93; 95% confidence interval, 1.08-3.43). Thirty-five of the P. acnes-positive patients were men (81.4%), and 8 patients were women (18.6%; P = .001; relative risk, 2.51; 95% confidence interval, 1.28-4.90).

DISCUSSION

P. acnes was detected in more than one third of patients undergoing first-time shoulder surgery. Preoperative subacromial injection was not associated with bacterial growth. P. acnes was observed more frequently in the deep tissues than in the superficial tissues. The relative risk for obtaining a positive P. acnes culture was 2-fold greater for the anterolateral approach than for the deltopectoral approach, and the risk was 2.5-fold greater for men.

Upcoming rules and benchmarks concerning the monitoring of and the payment for surgical infections

There has been a good deal of dialogue about pay for performance and linking outcomes with reimbursement, especially given the recent national health care legislation. Many such concerns are caused by upcoming changes that have been outlined in the Affordable Care Act. This article discusses these upcoming changes and reviews some of the literature that supports them, specifically those related to surgical infections. Likewise, the lack of support for some of these changes in the academic literature is discussed. Finally, some of the proposed key benchmarks and the methodologies behind the design of those benchmarks are discussed.

The economics and timing of preoperative antibiotics for orthopaedic procedures

BACKGROUND

The efficacy of antibiotics in preventing surgical site infections (SSIs) depends on the timing of administration relative to the start of surgery. However, currently, both the timing of and recommendations for administration vary substantially.

AIM

To determine how the economic value from the hospital perspective of preoperative antibiotics varies with the timing of administration for orthopaedic procedures.

METHODS

Computational decision and operational models were developed from the hospital perspective. Baseline analyses looked at current timing of administration, while additional analyses varied the timing of administration, compliance with recommended guidelines, and the goal time-interval.

FINDINGS

Beginning antibiotic administration within 0-30 min prior to surgery resulted in the lowest costs and SSIs. Operationally, linking to a pre-surgical activity, administering antibiotics prior to incision but after anaesthesia-ready time was optimal, as 92.1% of the time, antibiotics were administered in the optimal time-interval (0-30 min prior to incision). Improving administration compliance from 80% to 90% for this pre-surgical activity results in cost savings of $447 per year for a hospital performing 100 orthopaedic operations a year.

CONCLUSION

This study quantifies the potential cost-savings when antibiotic administration timing is improved, which in turn can guide the amount hospitals should invest to address this issue.

Improving prediction of surgical site infection risk with multilevel modeling

Background

Surgical site infection (SSI) surveillance is a key factor in the elaboration of strategies to reduce SSI occurrence and in providing surgeons with appropriate data feedback (risk indicators, clinical prediction rule).

Aim

To improve the predictive performance of an individual-based SSI risk model by considering a multilevel hierarchical structure.

Patients and Methods

Data were collected anonymously by the French SSI active surveillance system in 2011. An SSI diagnosis was made by the surgical teams and infection control practitioners following standardized criteria. A random 20% sample comprising 151 hospitals, 502 wards and 62280 patients was used. Three-level (patient, ward, hospital) hierarchical logistic regression models were initially performed. Parameters were estimated using the simulation-based Markov Chain Monte Carlo procedure.

Results

A total of 623 SSI were diagnosed (1%). The hospital level was discarded from the analysis as it did not contribute to variability of SSI occurrence (p  = 0.32). Established individual risk factors (patient history, surgical procedure and hospitalization characteristics) were identified. A significant heterogeneity in SSI occurrence between wards was found (median odds ratio [MOR] 3.59, 95% credibility interval [CI] 3.03 to 4.33) after adjusting for patient-level variables. The effects of the follow-up duration varied between wards (p<10⁻⁹), with an increased heterogeneity when follow-up was <15 days (MOR 6.92, 95% CI 5.31 to 9.07]). The final two-level model significantly improved the discriminative accuracy compared to the single level reference model (p<10⁻⁹), with an area under the ROC curve of 0.84.

Conclusion

This study sheds new light on the respective contribution of patient-, ward- and hospital-levels to SSI occurrence and demonstrates the significant impact of the ward level over and above risk factors present at patient level (i.e., independently from patient case-mix).

Adherence of surgeons to antimicrobial prophylaxis guidelines in a tertiary general hospital in a rapidly developing country

Objectives. To assess the standard practice of care of surgeons regarding surgical antibiotic prophylaxis, to identify gaps, and to set recommendations. Methods. A retrospective analysis of data obtained from different surgical units in a single center in Qatar over a 3-month period in 2012. A total of 101 patients who underwent surgery and followed regimes for surgical prophylaxis as per hospital guidelines were included in the study. Results. The overall use of antibiotic was 89%, whereas the current practice did not match the recommended hospital protocols in 53.5% of cases. Prolonged antibiotics use (59.3%) was the commonest reason for nonadherence followed by the use of an alternative antibiotic to that recommended in the protocol (31.5%) and no prophylaxis was used in 9.2% of cases. The rate of compliance was significantly higher among clean surgery than clean contaminated group (P = 0.03). Forty-four percent of clean and 65% of clean-contaminated procedures showed noncompliance with the recommended surgical antimicrobial prophylaxis hospital guidelines. Conclusion. Lack of adherence to hospital protocols is not uncommon. This finding remains a challenge to encourage clinicians to follow hospital guidelines appropriately and to consistently apply the surgical antibiotic prophylaxis. The role of clinical pharmacist may facilitate this process across all surgical disciplines.

Construction and validation of an instrument for assessment of the nursing diagnosis, risk for infection, in patients following cardiac surgery

PURPOSE

To construct and validate a data collection instrument (DCI), and a corresponding instructional guide, for assessment of the nursing diagnosis, risk for infection, in patients following cardiac surgery.

METHODS

Construction of conceptual and operational definitions for risk factors based on literature, content validation by experts, and clinical validation by clinical nurses.

FINDINGS

There were significant internal consistency and reproducibility in the content validation. In the clinical validation, agreement among nurses was higher than 70% for all risk factors.

CONCLUSIONS

The DCI was constructed and validated.

IMPLICATIONS FOR NURSING PRACTICE

This DCI could be used for assessment of adult patients after cardiac surgeries worldwide because of its detailed cues for risk factors, which facilitate clinical reasoning and diagnostic judgment.