An Audit of Perioperative Antimicrobial Prophylaxis: Compliance with the International Guidelines

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Abstract

Objective:

Antimicrobial prophylaxis has been demonstrated to lower the incidence of postoperative infection in nearly all types of surgery. The American Society of Health-System Pharmacists (ASHP) guideline summarizes current data on the appropriate use of antibiotic for surgical prophylaxis. The objective of this study was to assess and audit the use of antibiotics in a tertiary care center according to the recommendation of ASHP guideline.

Methods:

This cross-sectional study was performed using prospective data gathered from April to September 2015 in the surgical wards of Al Zahra Hospital, Isfahan, Iran. Antibiotic indication and choice, dose, dosing interval, route of administration, and timing of first administration and duration of prophylaxis were compared with the ASHP guideline recommendations.

Findings:

A total of 100 patients with the mean age of 49.8 ± 18.2 years were recruited for this study. About 22% of procedures had full compliance with all guideline recommendations. The most frequently encounter noncompliance type were the duration of prophylaxis (14%) and appropriate agent choice (35%). Timing of the initial dose was appropriate in most of the procedures (42%).

Conclusion:

This study revealed that most of the prescribed antibiotics for surgical prophylaxis are not in accordance with standard treatment guideline. The density of antimicrobial use for preoperative antimicrobial prophylaxis is very high. Furthermore, the hospital should develop a formal strategy, including a local guideline for antimicrobial prophylaxis in surgical procedures.

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A Systematic Review of Risk Factors Associated with Surgical Site Infections among Surgical Patients

Ellen Korol, Karissa Johnston, Nathalie Waser … (2013)

Importance Surgical site infection (SSI) complicates 2-5% of surgeries in the United States. Severity of SSI ranges from superficial skin infection to life-threatening conditions such as severe sepsis, and SSIs are responsible for increased morbidity, mortality, and economic burden associated with surgery. Staphylococcus aureus (S. aureus) is a commonly-isolated organism for SSI, and methicillin-resistant S. aureus SSI incidence is increasing globally. Objective The objective of this systematic review was to characterize risk factors for SSI within observational studies describing incidence of SSI in a real-world setting. Evidence Review An initial search identified 328 titles published in 2002-2012; 57 were identified as relevant for data extraction. Extracted information included study design and methodology, reported cumulative incidence and post-surgical time until onset of SSI, and odds ratios and associated variability for all factors considered in univariate and/or multivariable analyses. Findings Median SSI incidence was 3.7%, ranging from 0.1% to 50.4%. Incidence of overall SSI and S. aureus SSI were both highest in tumor-related and transplant surgeries. Median time until SSI onset was 17.0 days, with longer time-to-onset for orthopedic and transplant surgeries. Risk factors consistently identified as associated with SSI included co-morbidities, advanced age, risk indices, patient frailty, and surgery complexity. Thirteen studies considered diabetes as a risk factor in multivariable analysis; 85% found a significant association with SSI, with odds ratios ranging from 1.5-24.3. Longer surgeries were associated with increased SSI risk, with a median odds ratio of 2.3 across 11 studies reporting significant results. Conclusions and Relevance In a broad review of published literature, risk factors for SSI were characterized as describing reduced fitness, patient frailty, surgery duration, and complexity. Recognition of risk factors frequently associated with SSI allows for identification of such patients with the greatest need for optimal preventive measures to be identified and pre-treatment prior to surgery.

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Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections.

Elizabeth Wick, Deborah Hobson, Jennifer L Bennett … (2012)

Surgical site infections (SSI) are a common and costly problem, prolonging hospitalization and increasing readmission. Adherence to well-known infection control process measures has not been associated with substantial reductions in SSI. To date, the global burden of preventable SSI continues to result in patient harm and increased health care costs on a broad scale. We designed a study to evaluate the association between implementation of a surgery-based comprehensive unit-based safety program (CUSP) and postoperative SSI rates. One year of pre- and post-CUSP intervention SSI rates were collected using the high-risk pilot module of the American College of Surgeons National Surgical Quality Improvement Program (July 2009 to July 2011). The CUSP group met monthly and consisted of a multidisciplinary team of front-line providers (eg, surgeons, nurses, operating room technicians, and anesthesiologists) who were directly involved in the care of colorectal surgery patients. Surgical Care Improvement Project process measure compliance was monitored using standard methods from the Centers for Medicare and Medicaid Services. In the 12 months before implementation of the CUSP and interventions, the mean SSI rate was 27.3% (76 of 278 patients). After commencement of interventions, the rate was 18.2% (59 of 324 patients) for the subsequent 12 months--a 33.3% decrease (95% CI, 9-58%; p < 0.05). The interventions included standardization of skin preparation; administration of preoperative chlorhexidine showers; selective elimination of mechanical bowel preparation; warming of patients in the preanesthesia area; adoption of enhanced sterile techniques for skin and fascial closure; addressing previously unrecognized lapses in antibiotic prophylaxis. There was no difference in surgical process measure compliance as measured by the Surgical Care Improvement Project during the same time period. Formation of small groups of front-line providers to address patient harm using local wisdom and existing evidence can improve patient safety. We demonstrate a surgery-based CUSP intervention that might have markedly decreased SSI in a high-risk population. Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

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Adherence to International Antimicrobial Prophylaxis Guidelines in Cardiac Surgery: A Jordanian Study Demonstrates Need for Quality Improvement

Nairooz H. Al-Momany, Amal G. Al-Bakri, Zeid M. Makahleh … (2009)

BACKGROUND: Antimicrobial prophylaxis in cardiac surgery has been demonstrated to lower the incidence of surgical site infection (SSI). Inappropriate antimicrobial prophylaxis, such as inappropriate selection of the antimicrobial agent or inappropriate dosing regimen, can increase the prevalence of antibiotic resistant strains, prolong hospital stay, cause adverse reactions, and negatively affect an institution's pharmacy budget for antibiotics. In developing countries such as Jordan, where the role of clinical pharmacists is still in its primary stages, the first step in establishing an organized clinical pharmacy service is the evaluation of current practice to determine the need for improvement. OBJECTIVES: To assess the degree of adherence to international guidelines for antimicrobial prophylaxis practice in cardiac surgery performed at Queen Alia Heart Institute (QAHI) in Amman, Jordan, as part of an attempt to determine opportunities for clinical pharmacist intervention. METHODS: For a total of 236 patients who were admitted for cardiac surgery to QAHI the only official referral hospital for cardiac patients in Jordan between November 19, 2006, and January 22, 2007, the antimicrobial prophylaxis indication, choice, duration, dose, dosing interval, and timing appropriateness were assessed against 3 international guidelines using a pre-tested, structured clinical data collection form that was completed by 2 of the authors who work at QAHI. The study design was prospective. All patients who were scheduled for surgery were monitored daily during their inpatient stay until discharge and then were tracked in the outpatient clinic for 2 months following surgery. Data regarding antimicrobial prophylaxis indication, choice, duration, dose, dosing interval, and timing appropriateness were collected during the patient's inpatient stay; data collection was performed periodically thereafter as data became available until the end of the 2-month follow-up. The 3 guidelines agreed that (a) antimicrobial prophylaxis should be given to all patients undergoing cardiac surgeries; (b) the first- or second-generation cephalosporins (cefazolin or cefuroxime) are the antibiotics of choice, and vancomycin use is reserved for cases of allergy to betalactams or if presumed or known methicillin-resistant Staphylococcus aureus (MRSA) colonization is present; (c) the timing of the first dose should be within 60 minutes prior to the skin incision; and (d) the duration of antimicrobial prophylaxis should not be longer than 48 hours. RESULTS: Adherence to all antimicrobial prophylaxis guidelines was not achieved for any study patients. For the 6 evaluated criteria, (1) indication: in 100% of patients the appropriate decision was made to use antimicrobial prophylaxis in concordance with guidelines; (2) choice: only 1.7% of patients received the antibiotic of choice; (3) duration: 39.4% of patients received antimicrobial prophylaxis for a total duration of 48 hours or less in concordance with guidelines, and for 58.9% of patients, duration was longer than recommended; (4) dose: 27.9% of patients received an appropriate dose; (5) dosing interval: only 13.0% of patients received an appropriate dosing interval, and none of the doses of antimicrobial prophylaxis used at induction of anesthesia was repeated in operations that lasted longer than the half-life of the antibiotic used; and (6) timing: 99.1% of patients received antimicrobial prophylaxis dose within 60 minutes prior to skin incision as recommended by guidelines, but 97.0% of patients received an unnecessary midnight dose of intravenous antibiotic the night before surgery. CONCLUSIONS: Study findings indicate that adherence to international guidelines for antimicrobial prophylaxis is far from optimal in QAHI, leading to the inappropriate administration of many antibiotics. Developing local hospital guidelines, as well as giving the clinical.

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Author and article information

Journal

Journal ID (nlm-ta): J Res Pharm Pract

Journal ID (iso-abbrev): J Res Pharm Pract

Journal ID (publisher-id): JRPP

Title: Journal of Research in Pharmacy Practice

Publisher: Medknow Publications & Media Pvt Ltd (India )

ISSN (Print): 2319-9644

ISSN (Electronic): 2279-042X

Publication date (Print): Apr-Jun 2017

Volume: 6

Issue: 2

Pages: 126-129

Affiliations

[1 ]Department of Clinical Pharmacy and Pharmacy Practice, Isfahan University of Medical Sciences, Isfahan, Iran

[2 ]Faculty of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran

[3 ]Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Author notes

Address for correspondence: Dr. Sarah Mousavi, E-mail: s.mousavi@ 123456pharm.mui.ac.ir

Article

Publisher ID: JRPP-6-126

DOI: 10.4103/jrpp.JRPP_16_164

PMC ID: 5463548

PubMed ID: 28616437

SO-VID: d2fc6419-b1d9-4786-bfa4-4ef9d93f014b

License:

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

An Audit of Perioperative Antimicrobial Prophylaxis: Compliance with the International Guidelines

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Abstract

Objective:

Methods:

Findings:

Conclusion:

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International Journal of Applied Technology in Medical Sciences

Most cited references 16

A Systematic Review of Risk Factors Associated with Surgical Site Infections among Surgical Patients

Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections.

Adherence to International Antimicrobial Prophylaxis Guidelines in Cardiac Surgery: A Jordanian Study Demonstrates Need for Quality Improvement

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