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      The Global Alliance for Infections in Surgery: defining a model for antimicrobial stewardship—results from an international cross-sectional survey

      research-article
      1 , , 2 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ,   16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 23 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 , 162 , 163 , 164 , 165 , 166 , 167
      World Journal of Emergency Surgery : WJES
      BioMed Central
      Antibiotics, Infections, Surgery, Antimicrobial stewardship

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          Abstract

          Background

          Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world.

          Methods

          A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery.

          Results

          The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4–6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%).

          Conclusion

          The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13017-017-0145-2) contains supplementary material, which is available to authorized users.

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          Most cited references14

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          Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship.

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            Antibiotic stewardship in the intensive care unit

            The rapid emergence and dissemination of antimicrobial-resistant microorganisms in ICUs worldwide constitute a problem of crisis dimensions. The root causes of this problem are multifactorial, but the core issues are clear. The emergence of antibiotic resistance is highly correlated with selective pressure resulting from inappropriate use of these drugs. Appropriate antibiotic stewardship in ICUs includes not only rapid identification and optimal treatment of bacterial infections in these critically ill patients, based on pharmacokinetic-pharmacodynamic characteristics, but also improving our ability to avoid administering unnecessary broad-spectrum antibiotics, shortening the duration of their administration, and reducing the numbers of patients receiving undue antibiotic therapy. Either we will be able to implement such a policy or we and our patients will face an uncontrollable surge of very difficult-to-treat pathogens.
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              How to educate prescribers in antimicrobial stewardship practices

              Widespread antimicrobial use has compromised its value, leading to a crisis of antimicrobial resistance. A major cause of misuse is insufficient knowledge of prescribing of antimicrobials in many categories of professionals. An important principle of antimicrobial stewardship is avoiding selection pressure in the patient, both on pathogen and commensal by avoiding unnecessary use, choosing the least broad-spectrum antibiotic, adequate doses, a good timing and the shortest possible duration. Up to now, most educational efforts have been targeted at professionals (mostly medical doctors) after their training and at the adult public. In the past few years, progress has been made in educating children. It is now crucial that academia and ministries of Health and Education jointly focus on an adapted undergraduate medical/professional curriculum that teaches all necessary principles of microbiology, infectious diseases and clinical pharmacology, with emphasis on the principles of prudent prescribing.
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                Journal
                World J Emerg Surg
                World J Emerg Surg
                World Journal of Emergency Surgery : WJES
                BioMed Central (London )
                1749-7922
                1 August 2017
                1 August 2017
                2017
                : 12
                : 34
                Affiliations
                [1 ]Department of Surgery, Macerata Hospital, Macerata, Italy
                [2 ]ISNI 0000 0001 1017 3210, GRID grid.7010.6, Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, , Università Politecnica delle Marche, ; Ancona, Italy
                [3 ]Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
                [4 ]ISNI 0000 0004 1757 8431, GRID grid.460094.f, General Surgery Department, , Papa Giovanni XXIII Hospital, ; Bergamo, Italy
                [5 ]ISNI 0000 0004 0634 9246, GRID grid.415666.6, Department of Clinical microbiology, Ampath National Laboratory Services, , Milpark Hospital, ; Johannesburg, South Africa
                [6 ]ISNI 0000 0004 1937 1151, GRID grid.7836.a, Division of Infectious Diseases and HIV Medicine, Department of Medicine, , University of Cape Town, ; Cape town, South Africa
                [7 ]World Alliance against Antibiotics Resistance, Rome, Italy
                [8 ]ISNI 0000 0001 0675 4725, GRID grid.239578.2, Center for Critical Care, Anaesthesiology Institute and Department of Outcomes Research, , Cleveland Clinic, ; Cleveland, OH USA
                [9 ]Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
                [10 ]GRID grid.414614.2, Department of Surgery, , Infermi Hospital, ; Rimini, Italy
                [11 ]ISNI 0000 0004 1759 7093, GRID grid.416290.8, Department of Surgery, , Maggiore Hospital, ; Bologna, Italy
                [12 ]ISNI 0000 0004 1936 9916, GRID grid.412807.8, Department of Surgery, , Vanderbilt University Medical Center, ; Nashville, Tennessee USA
                [13 ]Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, University of Bologna, Bologna, Italy
                [14 ]ISNI 0000 0001 0675 4725, GRID grid.239578.2, Division of Infectious Diseases, , Cleveland Clinic Akron General, ; Akron, OH USA
                [15 ]ISNI 0000 0004 0459 7529, GRID grid.261103.7, Department of Medicine, , Northeast Ohio Medical University, ; Rootstown, OH USA
                [16 ]ISNI 0000 0004 1760 3027, GRID grid.419425.f, , Clinical Epidemiology Unit, IRCCS Policlinico San Matteo Foundation, ; Pavia, Italy
                [17 ]ISNI 0000 0004 1936 8606, GRID grid.26790.3a, Division of Infectious Diseases, Jackson Health System, , University of Miami Miller School of Medicine, ; Miami, FL USA
                [18 ]ISNI 0000 0001 2193 6666, GRID grid.43519.3a, Department of Surgery, College of Medicine and Health Sciences, , UAE University, ; Al-Ain, United Arab Emirates
                [19 ]ISNI 0000 0001 2183 9444, GRID grid.10824.3f, Department of Surgery, College of Health Sciences, , Obafemi Awolowo University, ; Ile-Ife, Nigeria
                [20 ]ISNI 0000 0000 9679 3586, GRID grid.268355.f, Division of Clinical and Administrative Sciences, College of Pharmacy, , Xavier University of Louisiana, ; New Orleans, LA USA
                [21 ]ISNI 0000 0000 9075 106X, GRID grid.254567.7, Department of Medicine, Division of Infectious Diseases, , University of South Carolina School of Medicine, ; Columbia, SC USA
                [22 ]ISNI 0000 0004 0419 1043, GRID grid.414177.0, General Surgery Department, , Bakirkoy Dr Sadi Konuk Training and Research Hospital, ; Instanbul, Turkey
                [23 ]ISNI 0000 0000 9375 4688, GRID grid.414556.7, Unit of Prevention and Infection Control, Center of Hospital Epidemiology, , São João Hospital Centre, ; Porto, Portugal
                [24 ]Infection Control Committee, Prontobaby Hospital da Criança, Rio de Janeiro, Brazil
                [25 ]ISNI 0000 0004 0397 9648, GRID grid.412688.1, Department of Surgery, , University Hospital Center, ; Zagreb, Croatia
                [26 ]ISNI 0000 0001 2221 2926, GRID grid.17788.31, Trauma and Acute Care Surgery Unit, , Hadassah Hebrew University Medical Center, ; Jerusalem, Israel
                [27 ]ISNI 000000041936877X, GRID grid.5386.8, Department of Surgery, , Weill Cornell Medicine, ; New York, NY USA
                [28 ]Department of General Surgery, Hospital San Juan de Dios de La Serena, La Serena, Chile
                [29 ]ISNI 0000 0001 2177 007X, GRID grid.415490.d, Academic Department of Surgery, , Queen Elizabeth Hospital, ; Birmingham, UK
                [30 ]Department of Microbiology National Reference Laboratory Cheikh Khalifa Ibn Zaid Hospital, Mohammed 6th University of Health Sciences, Casablanca, Morocco
                [31 ]ISNI 0000 0004 4657 1992, GRID grid.410370.1, Department of Pathology and Laboratory Medicine, , VA Boston HealthCare System, ; Boston, MA USA
                [32 ]ISNI 0000 0004 0367 5222, GRID grid.475010.7, Department of Pathology and Laboratory Medicine, , Boston University School of Medicine, ; Boston, MA USA
                [33 ]ISNI 0000 0000 8816 6945, GRID grid.411048.8, Department of Surgery, , Hospital Clínico Universitario, ; Santiago de Compostela, Spain
                [34 ]ISNI 0000 0004 1760 058X, GRID grid.464574.0, Hospital Epidemiology and Infectious Diseases, , Hospital Universitario Dr Jose Eleuterio Gonzalez, ; Monterrey, Mexico
                [35 ]GRID grid.417007.5, Department of Emergency, , Umberto I Hospital, ; Rome, Italy
                [36 ]ISNI 0000 0004 1781 1790, GRID grid.448741.a, Department of Pharmacology, , Pushpagiri Institute of Medical Sciences and Research Centre, ; Thiruvalla, Kerala India
                [37 ]Department of General Surgery, Kuala Krai Hospital, Kuala Krai, Kelantan Malaysia
                [38 ]ISNI 0000000086837370, GRID grid.214458.e, Division of Acute Care Surgery, Department of Surgery, , University of Michigan, ; Ann Arbor, MI USA
                [39 ]GRID grid.416200.1, , Niguarda Hospital, ; Milano, Italy
                [40 ]Department of General Surgery, Health Sciences University, Samsun Training and Research Hospital, Samsun, Turkey
                [41 ]ISNI 0000 0000 8580 3777, GRID grid.6190.e, Department of Internal Medicine and Infectious Diseases, , University of Cologne, ; Cologne, Germany
                [42 ]ISNI 0000 0000 9792 1228, GRID grid.265021.2, Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, , Tianjin Medical University, ; Tianjin, China
                [43 ]Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
                [44 ]ISNI 0000 0004 1795 3510, GRID grid.418062.9, Department of Digestive Surgery, , Cannes Hospital, ; Cannes, France
                [45 ]ISNI 0000 0004 0626 3303, GRID grid.410566.0, Department of Critical Care Medicine, , Ghent University Hospital, ; Ghent, Belgium
                [46 ]GRID grid.430529.9, School of Pharmacy, Faculty of Medical Sciences, , The University of the West Indies, ; St. Augustine, Trinidad and Tobago
                [47 ]Eric Williams Medical Sciences Complex, Uriah Butler Highway, Champ Fleurs, Trinidad and Tobago
                [48 ]Department of Surgery, Versilia Hospita, Lido di Camaiore, Italy
                [49 ]Department of Surgery, University Hospital of Trauma, Tirana, Albania
                [50 ]GRID grid.444534.6, School of Pharmacy and Biomedicine, , Mongolian National University of Medical Sciences, ; Ulaanbaatar, Mongolia
                [51 ]ISNI 0000 0001 2171 2558, GRID grid.5842.b, Department of Microbiology, Bicêtre Hospital, , Paris-Sud University, ; La Kremlin-Bicêtre, France
                [52 ]Department of Surgery, John Peter Smith Health Network, Fort Worth, Texas USA
                [53 ]GRID grid.414827.c, Sudan National Public Health Laboratory, , Federal Ministry of Health, ; Khartoum, Sudan
                [54 ]ISNI 0000 0004 0593 1832, GRID grid.415277.2, Department of Medicine, Infectious Disease Division, , King Fahad Medical City, ; Riyadh, Saudi Arabia
                [55 ]ISNI 0000 0004 0458 8737, GRID grid.224260.0, Department of Surgery, , Virginia Commonwealth University, ; Richmond, VA USA
                [56 ]Department of Surgery, Clinica Foianini, Santa Cruz, Bolivia
                [57 ]Department of Abdominal Surgery, Vladimir City Clinical Hospital of Emergency Medicine, Vladimir, Russia
                [58 ]Department of Surgery, Bharati Vidyapeeth Deemed University Medical College and Hospital, Sangli, Maharashtra India
                [59 ]ISNI 0000000103426662, GRID grid.10251.37, Department of General Surgery, Mansoura Faculty of Medicine, , Mansoura University, ; Mansoura, Egypt
                [60 ]GRID grid.414012.2, Sixth Department of Internal Medicine, , Hygeia General Hospital, ; Athens, Greece
                [61 ]ISNI 0000 0001 2155 0800, GRID grid.5216.0, Second Department of Surgery, , Aretaieion University Hospital, National and Kapodistrian University of Athens, ; Athens, Greece
                [62 ]ISNI 0000 0001 2369 4728, GRID grid.20515.33, Center for Global Health, Mito Kyodo General Hospital, , University of Tsukuba, ; Mito, Ibaraki Japan
                [63 ]University Department for Tumours, Sestre Milosrrdnice UHC, Zagreb, Croatia
                [64 ]ISNI 0000 0001 2177 007X, GRID grid.415490.d, General and Upper GI Surgery, , Queen Elizabeth Hospital, ; Birmingham, UK
                [65 ]Peruvian Navy Medical Center, Lima, Peru
                [66 ]ISNI 0000 0001 2198 9354, GRID grid.415169.e, Department of Gastrointestinal Surgery, , Santa Casa Hospital, ; Campo Grande, Brazil
                [67 ]ISNI 0000 0001 0723 4123, GRID grid.16463.36, Trauma and Trauma ICU, Inkosi Albert Luthuli Central Hospital and Department of Surgery, , University of KwaZulu-Natal, ; Durban, South Africa
                [68 ]ISNI 0000 0000 8584 9230, GRID grid.411067.5, Department of General and Thoracic Surgery, , University Hospital Giessen, ; Giessen, Germany
                [69 ]GRID grid.440525.2, Department of Surgery, Faculty of Medicine, , University of Parakou, ; BP 123 Parakou, Benin
                [70 ]ISNI 0000000109457005, GRID grid.4793.9, Fourth Surgical Department, General Hospital G. Papanikolaou, Medical School, , Aristotle University of Thessaloniki, ; Thessaloniki, Greece
                [71 ]ISNI 0000 0001 1498 7262, GRID grid.412176.7, Department of General Surgery, , Erzincan University, Faculty of Medicine, ; Erzincan, Turkey
                [72 ]Department of Pharmacy, Lebanese, International University, Beirut, Lebanon
                [73 ]ISNI 0000 0001 2174 8913, GRID grid.412888.f, Drug Applied Research Center, , Tabriz University of Medical Sciences, ; Tabriz, Iran
                [74 ]ISNI 0000 0004 1936 9801, GRID grid.22903.3a, Division of Infectious Diseases, , American University of Beirut, ; Beirut, Lebanon
                [75 ]ISNI 0000 0004 1936 8972, GRID grid.25879.31, Department of Surgery Philadelphia VA Medical Center, Perelman School of Medicine, , University of Pennsylvania, ; Philadelphia, PA USA
                [76 ]GRID grid.415285.f, Department of Microbiology, , Gandhi Medical College, ; Bhopal, India
                [77 ]ISNI 0000 0001 2166 9385, GRID grid.7149.b, , Clinic for Emergency Surgery, Medical Faculty University of Belgrade, ; Belgrade, Serbia
                [78 ]ISNI 0000 0001 2162 9631, GRID grid.5522.0, Third Department of General Surgery, , Jagiellonian University Medical College, ; Krakow, Poland
                [79 ]Department of Abdominal Surgery, Regional Hospital of Tienen, Tienen, Belgium
                [80 ]ISNI 0000 0004 1772 5665, GRID grid.416132.3, Department of Internal Medicine, , Royal Hospital, ; Muscat, Oman
                [81 ]Department of Emergency Surgery, City Hospital, Mozyr, Belarus
                [82 ]ISNI 0000 0004 0620 0548, GRID grid.11194.3c, Department of Pharmacology and Therapeutics, College of Health Sciences, , Makerere University, ; Kampala, Uganda
                [83 ]ISNI 0000 0004 0647 3378, GRID grid.412480.b, Department of Internal Medicine, , Seoul National University Bundang Hospital, ; Seongnam, Republic of Korea
                [84 ]ISNI 0000 0004 0639 0054, GRID grid.412040.3, Department of Internal Medicine, , National Cheng Kung University Hospital, ; Tainan, Taiwan
                [85 ]ISNI 0000 0004 0372 2033, GRID grid.258799.8, Department of Primary Care and Emergency Medicine, , Kyoto University Graduate School of Medicine, ; Kyoto, Japan
                [86 ]Department of Surgery n. 2, Higher educational institutions of Ukraine Bukovina State Medical University, Chernivtci City, Ukraine
                [87 ]ISNI 0000 0004 1936 9609, GRID grid.21613.37, Section of Critical Care Medicine and Section of Infectious Diseases, Department of Medicine, Medical Microbiology and Pharmacology/Therapeutics, , University of Manitoba, ; Winnipeg, MB Canada
                [88 ]ISNI 0000 0004 0633 6808, GRID grid.414410.4, , Hospital Central Dr Ignacio Morones Prieto, ; San Luis Potosi, Mexico
                [89 ]ISNI 0000 0001 2168 186X, GRID grid.134563.6, Department of Surgery, Division of Trauma, , University of Arizona, ; Tucson, AZ USA
                [90 ]ISNI 0000 0004 0470 5454, GRID grid.15444.30, Department of Surgery, , Yonsei University College of Medicine, ; Seoul, South Korea
                [91 ]GRID grid.449754.f, , Texas Tech University, Health Sciences Center School of Pharmacy, ; Abilene, TX USA
                [92 ]Abdominal Center, University Hospital Meilahti, Helsinki, Finland
                [93 ]ISNI 0000 0001 2314 964X, GRID grid.41156.37, Department of Surgery, Inling Hospital, , Nanjing University School of Medicine, ; Nanjing, China
                [94 ]ISNI 0000 0001 2355 7002, GRID grid.4367.6, Division of Infectious Diseases, Division of Emergency Medicine, , Washington University School of Medicine, ; St. Louis, MO USA
                [95 ]ISNI 0000 0004 1937 1135, GRID grid.11951.3d, Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, , University of the Witwatersrand, ; Johannesburg, South Africa
                [96 ]ISNI 0000 0001 2289 5077, GRID grid.412213.7, Department of Surgery, , Universidad Nacional de Asuncion, ; Asuncion, Paraguay
                [97 ]ISNI 0000 0000 9024 6397, GRID grid.412581.b, Department for Traumatology and Orthopedic Surgery, Cologne Merheim Medical Center (CMMC), , University of Witten/Herdecke (UW/H), ; Cologne, Germany
                [98 ]ISNI 0000 0001 2162 9631, GRID grid.5522.0, Second Department of General Surgery, , Jagiellonian University Medical College, ; Krakow, Poland
                [99 ]ISNI 0000 0000 8914 5257, GRID grid.12984.36, Health Research Program, Institute of Economic and Social Research, , University of Zambia, ; Lusaka, Zambia
                [100 ]GRID grid.477264.4, , Clinical Research Center, Fundacion Valle del Lili, ; Cali, Colombia
                [101 ]GRID grid.417374.2, First Department of Surgery, , Tzaneion General Hospital, ; Piraeus, Greece
                [102 ]Service of General Surgery, Hospital Complex of Jaén, Jaén, Spain
                [103 ]ISNI 0000 0004 1771 1642, GRID grid.412572.7, Department of Surgery, , Post-Graduate Institute of Medical Sciences, ; Rohtak, India
                [104 ]Servicio de Anestesia y Reanimación, Hospital Universitario La Paz Madrid, Madrid, Spain
                [105 ]ISNI 0000 0004 0500 5353, GRID grid.412963.b, Department of Surgery, Radiology, , University Hospital of the West Indies, ; Kingston, Jamaica
                [106 ]GRID grid.415696.9, Infectious Diseases Division, Department of Medicine, , Prince Mohamed Bin Abdulaziz Hospital, Ministry of Health, ; Riyadh, Saudi Arabia
                [107 ]ISNI 0000 0004 1936 8227, GRID grid.25073.33, Departments of Medicine, Clinical Epidemiology and Biostatistics, and Pathology and Molecular Medicine, , McMaster University, ; Hamilton, ON Canada
                [108 ]Second Surgical Clinic, Emergency Hospital of Craiova, Craiova, Romania
                [109 ]Department of Microbiology, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
                [110 ]Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
                [111 ]Department of Surgery, Onandjokwe Hospital, Ondangwa, Namibia
                [112 ]ISNI 0000 0004 1936 9094, GRID grid.40263.33, Infectious Diseases Division, , Warren Alpert Medical School of Brown University, Rhode Island Hospital, ; Providence, RI USA
                [113 ]ISNI 0000000086837370, GRID grid.214458.e, Department of Surgery, , University of Michigan, ; Ann Arbor, MI USA
                [114 ]Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
                [115 ]ISNI 0000 0004 0517 2741, GRID grid.418653.d, , Clinic for General Surgery, Clinical Centre, ; Nis, Serbia
                [116 ]Center of Anti-Infective Research and Development, Hartford, CT USA
                [117 ]ISNI 0000 0004 0411 3985, GRID grid.460946.9, Department of Surgery, , King Abdullah University Hospital, ; Irbid, Jordan
                [118 ]ISNI 0000 0001 2295 7397, GRID grid.8271.c, Department of Surgery and Critical Care, , Universidad del Valle, Fundación Valle del Lili, ; Cali, Colombia
                [119 ]ISNI 0000 0001 1503 7226, GRID grid.5808.5, Intensive Care Medicine Department, , Centro Hospitalar São João, University of Porto, ; Porto, Portugal
                [120 ]GRID grid.461024.5, Department of Microbiology, , Grande International Hospital, ; Dhapasi, Kathmandu, Nepal
                [121 ]ISNI 0000 0004 0576 9812, GRID grid.419014.9, Department of Surgery, , Santa Casa de Sao Paulo School of Medical Sciences, ; São Paulo, Brazil
                [122 ]ISNI 0000 0001 1216 0093, GRID grid.412700.0, Department of General and Emergency Surgery, , University Hospital Kraków, ; Kraków, Poland
                [123 ]ISNI 0000 0001 0723 2494, GRID grid.411087.b, Department of Surgery, , University of Campinas, ; Campinas, Brazil
                [124 ]ISNI 0000 0001 0698 4037, GRID grid.416850.e, Laboratory of Clinical Microbiology, Department of Infectious Diseases, , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, ; Mexico City, Mexico
                [125 ]ISNI 0000 0004 0622 4662, GRID grid.411449.d, Fourth Department of Internal Medicine and Infectious Diseases Unit, , National and Kapodstrian University-Medical School, Attikon University General Hospital, ; Athens, Greece
                [126 ]John Farman Intensive Care Unit, University Hospitals, NHS Foundation Trust, Cambridge, UK
                [127 ]Infectious and Tropical Diseases Department, University Hospital of Nancy, and EA 4360 APEMAC, Lorraine University, Nancy, France
                [128 ]Department of General and Emergency Surgery, Riga East University Hospital ‘Gailezers’, Riga, Latvia
                [129 ]ISNI 0000 0004 0465 2778, GRID grid.461067.2, Department of Trauma, , Hospital Santo Tomas, ; Panama, Panama
                [130 ]ISNI 0000 0001 2113 8111, GRID grid.7445.2, National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, , Imperial College London, ; Hammersmith Campus, London, UK
                [131 ]Emergency Post-operative Department, Otavio de Freitas Hospital and Hosvaldo Cruz Hospital, Recife, Brazil
                [132 ]Department of General Surgery, Jesenice General Hospital, Jesenice, Slovenia
                [133 ]ISNI 0000 0001 2157 2938, GRID grid.17063.33, Trauma and Acute Care Service, St Michael’s Hospital, , University of Toronto, ; Toronto, Canada
                [134 ]ISNI 0000 0000 9320 7537, GRID grid.1003.2, Burns, Trauma and Critical Care Research Centre, , The University of Queensland, ; Brisbane, Queensland Australia
                [135 ]ISNI 0000 0001 2168 1229, GRID grid.9224.d, Unidad Clínica Intercentros de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío-IBiS and Departamento de Medicina, , Universidad de Sevilla, ; Seville, Spain
                [136 ]ISNI 0000 0001 0726 0380, GRID grid.35371.33, General Surgery Department, , Medical University, University Hospital St George, ; Plovdiv, Bulgaria
                [137 ]GRID grid.414766.6, , JPS Health Network, ; Texas, TX USA
                [138 ]Hospital Center Tondela Viseu, Tondela, Portugal
                [139 ]ISNI 0000 0001 1011 3808, GRID grid.255464.4, Department of Aeromedical Services for Emergency and Trauma Care, , Ehime University Graduate School of Medicine, ; Ehime, Japan
                [140 ]ISNI 0000 0004 1936 9932, GRID grid.412587.d, Department of Surgery, , University of Virginia Health System, ; Charlottesville, VA USA
                [141 ]ISNI 0000 0004 1937 0722, GRID grid.11899.38, Department of Surgery, , University of Sao Paulo, ; Ribeirao Preto, Brazil
                [142 ]Unit of Hospital Pharmacy, Macerata Hospital, Macerata, Italy
                [143 ]ISNI 0000 0004 1767 2903, GRID grid.415131.3, Department of Pharmacology, , Postgraduate Institute of Medical Education and Research, ; Chandigarh, India
                [144 ]GRID grid.240988.f, Department of General Surgery, , Tan Tock Seng Hospital, ; Tan Tock Seng, Singapore
                [145 ]ISNI 0000 0004 1936 9932, GRID grid.412587.d, Office of Hospital Epidemiology/Infection Prevention and Control, , University of Virginia Health System, ; Charlottesville, VA USA
                [146 ]ISNI 0000 0004 1937 1127, GRID grid.412434.4, Department of Surgery, Faculty of Medicine, , Thammasat University Hospital, Thammasat University, ; Pathum Thani, Thailand
                [147 ]ISNI 0000 0004 0627 2891, GRID grid.412835.9, Department of Gastrointestinal Surgery, , Stavanger University Hospital, ; Stavanger, Norway
                [148 ]ISNI 0000 0004 1936 7443, GRID grid.7914.b, Department of Clinical Medicine, , University of Bergen, ; Bergen, Norway
                [149 ]Department of Emergency Surgery and Critical Care, Centro Medico Imbanaco, Cali, Colombia
                [150 ]ISNI 0000 0001 2166 9094, GRID grid.412519.a, Department of Surgery, School of Medicine, , Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), ; Porto Alegre, Brazil
                [151 ]Department of Surgery, North Estonia Medical Center, Tallinn, Estonia
                [152 ]Department of Molecular Biology, Tran Hung Dao Hospital, No 1, Tran Hung Dao Street, Hai Ba Trung Dist, Hanoi, Vietnam
                [153 ]Department of Infectious Diseases, John Peter Smith Health Network, Fort Worth, Texas USA
                [154 ]ISNI 0000 0001 0941 3192, GRID grid.8142.f, Institute of Infectious Diseases, , Catholic University, ; Rome, Italy
                [155 ]ISNI 0000 0000 9100 9940, GRID grid.411798.2, First Department of Surgery—Department of Abdominal, Thoracic Surgery and Traumatology, , General University Hospital, ; Prague, Czech Republic
                [156 ]ISNI 0000 0000 8988 2476, GRID grid.11598.34, Department of Surgery, , Medical University of Graz, ; Graz, Austria
                [157 ]ISNI 0000 0004 0444 9382, GRID grid.10417.33, Department of Surgery, , Radboud University Nijmegen Medical Center, ; Nijmegen, The Netherlands
                [158 ]ISNI 0000 0001 0663 9479, GRID grid.9679.1, Department of Surgery, , Medical School University of Pécs, ; Pécs, Hungary
                [159 ]ISNI 0000 0001 2165 8627, GRID grid.8664.c, Department of Urology, Pediatric Urology and Andrology, , Medical Faculty of the Justus Liebig University Giessen, ; Giessen, Germany
                [160 ]ISNI 0000 0004 1759 700X, GRID grid.13402.34, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, , The First Affilliated Hospital, Zhejiang University, ; Zhejiang, China
                [161 ]ISNI 0000 0004 1756 1461, GRID grid.454210.6, Trauma and Emergency Surgery Department, , Chang Gung Memorial Hospital, ; Taoyuan City, Taiwan
                [162 ]ISNI 0000 0004 0522 8258, GRID grid.413303.6, Department of Antibiotics and Infection Control, , Rudolfstiftung Hospital, ; Vienna, Austria
                [163 ]Infection Control Unit, Angers University, CHU d’Angers, Angers, France
                [164 ]ISNI 0000 0004 1936 8606, GRID grid.26790.3a, Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, , University of Miami, ; Miami, FL USA
                [165 ]ISNI 0000 0004 1936 9000, GRID grid.21925.3d, Department of Surgery, , University of Pittsburgh, ; Pittsburgh, PA USA
                [166 ]ISNI 0000 0004 0435 165X, GRID grid.16872.3a, , VU University Medical Center, ; Amsterdam, The Netherlands
                [167 ]Department of General Surgery, Maggiore Hospital, Parma, Italy
                Article
                145
                10.1186/s13017-017-0145-2
                5540347
                28775763
                805e231d-ad91-40f6-86be-04b2e9fa57cb
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 19 May 2017
                : 24 July 2017
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2017

                Surgery
                antibiotics,infections,surgery,antimicrobial stewardship
                Surgery
                antibiotics, infections, surgery, antimicrobial stewardship

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