Association of Duration and Type of Surgical Prophylaxis With Antimicrobial-Associated Adverse Events

Antibiotic prescribing practices and antibiotic use quality indicators in Luang Prabang, Lao PDR: a point prevalence survey in a tertiary care hospital

CONTEXT

The increase and global dissemination of antibiotic resistance limit the use of antibiotics to prevent and treat infections. Implementing antibiotic stewardship programs guided by local data on prescription profiles is a useful strategy to reduce the burden of antibiotic resistance. The aim was to determine the prevalence of antibiotic use and guideline compliance at Luang Prabang provincial hospital, Lao PDR.

METHODS

A point prevalence survey of antibiotics was conducted among hospitalized patients admitted to Luang Prabang hospital (204 beds) in Lao PDR on May 25, 2023. All patients presenting at 8:00 AM were eligible. Sociodemographic data, indications for antibiotic use, and antibiotic prescriptions were collected from medical records using a paper-based questionnaire and entered into an electronic platform following WHO methodology. The prevalence of antibiotic use was determined.

RESULTS

Out of the 102 patients included, 60(58.8%) were undergoing antibiotic treatment, of which 33(55.0%) received combination therapy, and 7(10.5%) had two indications for antibiotic use. The highest prevalence was in the surgical ward (14/15, 93%) followed by general paediatrics (18/27, 67%). Out of the 100 antibiotic prescriptions, 47(47%) were for community-acquired infections, 26(26%) for surgical prophylaxis, 13(13%) for hospital-acquired infections and 5(5%) for medical prophylaxis. Twenty(20%) antibiotics were prescribed for obstetrics and gynaecology prophylaxis, 17(17%) for intra-abdominal infections, and 10(10.0%) for pneumonia treatment as well as bone, and joint infections. The main antibiotics prescribed were ceftriaxone 36(34.6%), metronidazole 18(17.3%), ampicillin 8(7.7%), and gentamicin 8(7.7%). Only 2(3%) samples were sent to the laboratory, one of which showed a positive culture for Escherichia coli Extended Spectrum β-Lactamase. According to the WHO Access Watch and Reserve classification, 55(52.9%) molecules belonged to the Access category, 47(49.1%) to the Watch category, and none to the Reserve category. Only 14.9% of antibiotic prescriptions were fully compliant with current guidelines.

CONCLUSION

This study indicated a significant prevalence of antibiotic use and a very low compliance with guidelines at Luang Prabang provincial hospital, Lao PDR. This highlights an urgent need for comprehensive strategies at all levels to optimize antibiotic use in hospitals, emphasizing diagnostic improvements, and continued research to address the factors driving this excessive antibiotic usage and improve adherence to guidelines.

Duration from start of antibiotic exposure to onset of Clostridioides difficile infection for different antibiotics in a non-outbreak setting

BACKGROUND

Antibiotic treatment is a well-known risk factor for Clostridioides difficile infection (CDI). The time from start of antibiotic exposure to onset of CDI for different antibiotics is sparsely studied. CDI with onset in the community is often treatable without in-hospital care while CDI patients treated in hospital need isolation, resulting in higher costs and infection control measures.

OBJECTIVES

To determine the time from start of antibiotic exposure to onset of healthcare facility-associated CDI for different antibiotics.

METHODS

Time between antibiotic exposure and disease onset was evaluated retrospectively with chart reading in a two-centre Swedish setting. A case was attributed to an antibiotic group if this represented more than 2/3 of total antibiotic exposure 30 days before onset of CDI.

RESULTS

Cephalosporins caused CDI faster (mean 7.6 days), and more often during ongoing antibiotic therapy (81% of the cases) than any other antibiotic group. All other common agents had between 2-3 times longer period between start of exposure to onset of CDI (quinolones more than 3 times).

CONCLUSIONS

The time gap between antibiotic exposure and onset of CDI is markedly different between different antibiotics. Decreased cephalosporin use could delay onset of healthcare facility-associated CDI and limit infections with onset within the hospital. This might decrease costs for inpatient care, need of infection control measures and shortage of beds in the hospital.

Extended-duration antibiotics are not associated with a reduction in surgical site infection in patients with ovarian cancer undergoing cytoreductive surgery with large bowel resection

OBJECTIVE(S)

To evaluate whether extended dosing of antibiotics (ABX) after cytoreductive surgery (CRS) with large bowel resection for advanced ovarian cancer is associated with reduced incidence of surgical site infection (SSI) compared to standard intra-operative dosing and evaluate predictors of SSI.

METHODS

A retrospective single-institution cohort study was performed in patients with stage III/IV ovarian cancer who underwent CRS from 2009 to 2017. Patients were divided into two cohorts: 1) standard intra-operative dosing ABX and 2) extended post-operative ABX. All ABX dosing was at the surgeon's discretion. The impact of antibiotic duration on SSI and other postoperative outcomes was assessed using univariate and multivariable Cox regression models.

RESULTS

In total, 277 patients underwent cytoreductive surgery (CRS) with large bowel resection between 2009 and 2017. Forty-nine percent (n = 137) received standard intra-operative ABX and 50.5% (n = 140) received extended post-operative ABX. Rectosigmoid resection was the most common large bowel resection in the standard ABX (89.9%, n = 124) and extended ABX groups (90.0%, n = 126), respectively. No significant differences existed between age, BMI, hereditary predisposition, or medical comorbidities (p > 0.05). No difference was appreciated in the development of superficial incisional SSI between the standard ABX and extended ABX cohorts (10.9% vs. 12.9%, p = 0.62). Of patients who underwent a transverse colectomy, a larger percentage of patients developed a superficial SSI versus no SSI (21% vs. 6%, p = 0.004).

CONCLUSION(S)

In this retrospective study of patients with advanced ovarian cancer undergoing CRS with LBR, extended post-operative ABX was not associated with reduced SSI, and prolonged administration of antibiotics should be avoided unless clinically indicated.

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

BACKGROUND

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

METHOD

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

RESULT

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

CONCLUSIONS

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

Preventing Surgical Site Infections in the Era of Escalating Antibiotic Resistance and Antibiotic Stewardship

Importance

According to the Centers for Disease Control and Prevention and governing bodies within the American College of Surgeons, the administration of antibiotics as prophylaxis against infection prior to a planned elective procedure is, with rare exception, routinely recommended. The goal of "getting to zero" infections remains a high priority for policymakers, practitioners, and certainly for patients.

Observations

Despite the many advances in surgical technique, skin decontamination, sterile procedure, and enhanced recovery programs, surgical site infections continue to adversely affect procedures as diverse as dental implant surgery, joint arthroplasty, and major abdominal surgery. Although surgical site infection rates are at historically low levels, progress has stalled in recent reporting periods and such infections remain disabling, costly, and occasionally lethal. Stakeholders in the field, including surgeons, infectious diseases specialists, and industry, advocate for strategies emphasizing greater levels of intraoperative sterility or broader-spectrum antibiotic coverage as the most appropriate path forward.

Conclusions and Relevance

The current emphasis on ever-increasing levels of intraoperative sterility and extended-spectrum antibiotic use are not sustainable long-term solutions. Continuing to escalate these approaches may contribute to unintended consequences including antimicrobial resistance. Principles of antimicrobial stewardship and microbiome sciences can be applied to inform a more effective and sustainable approach to infection prevention in the field of surgery.

Additional doses of prophylactic antibiotics post-arthroplasty: Are there any benefits?

Guidelines for prophylactic antibiotic administration in total joint replacement vary considerably in terms of drug, dosage, route of administration and duration of cover. Despite the range of treatment options available, infection remains the most common reason for arthroplasty failure in the decades following a procedure, simultaneously increasing health care costs and lowering patient satisfaction considerably. This work aims to evaluate whether there are benefits to administering further doses of antibiotic post-arthroplasty, in addition to the recommendations of current protocols. We present a review of evidence surrounding infection rates in a variety of prophylactic regimens, and weigh this against further considerations such as cost to the patient and risks of nephrotoxicity. In summary, the available evidence does not suggest a benefit to administering additional doses post-arthroplasty in most cases. However, further doses may benefit those deemed at high risk of infection, or those in areas of high methicillin-resistant Staphylococcus aureus prevalence.

Point Prevalence Survey of Antimicrobial Prescription and Consumption in a Nigerian Tertiary Hospital: A Gateway to the Antimicrobial Stewardship Program

BACKGROUND

Antimicrobial stewardship is an important action plan for curbing the rising trend of antimicrobial resistance (AMR). Surveillance of antimicrobial use and consumption is needed as baseline data and for monitoring the impact of antimicrobial stewardship interventions. The survey was done to understand the burden of AMR, in view of establishing an antimicrobial stewardship program in our hospital.

METHODS

A point prevalence survey (PPS) of antimicrobial use and consumption was conducted on all inpatients admitted before 8.00 am on the days of the survey using a standardized questionnaire. The collected data were entered online into the Global PPS web-based application (www.global-pps.com), for analysis.

RESULT

Of the 178 patients admitted during the survey period, 50.6% were on one or more antimicrobial agents. All the patients in adult intensive care units were on antibiotics (100%), followed by neonatal intensive care units (83.3%), with the least being adult medical wards (39.4%). Beta-lactam antibiotics were the most frequently prescribed antimicrobial for various infections, especially skin and soft tissue infections, 41.3%, which were the most common diagnoses treated with antibiotics. The infection was mostly community-acquired (81.6%), of which 94.9% were treated empirically. There was no written guideline in existence.

CONCLUSION

The present study revealed a poor prescribing habit because of a high rate of empirical treatment. The need for antimicrobial stewardship cannot be overemphasized as it will help streamline and improve the prescribing pattern.

The devil's in the defaults: An interrupted time-series analysis of the impact of default duration elimination on exposure to fluoroquinolone therapy

OBJECTIVE

To determine whether removal of default duration, embedded in electronic prescription (e-script), influenced antibiotic days of therapy.

DESIGN

Interrupted time-series analysis.

SETTING

The study was conducted across 2 community hospitals, 1 academic hospital, 3 emergency departments, and 86 ambulatory clinics.

PATIENTS

Adults prescribed a fluoroquinolone with a duration <31 days.

INTERVENTIONS

Removal of standard 10-day fluoroquinolone default duration and addition of literature-based duration guidance in the order entry on December 19, 2017. The study period included data for 12 months before and after the intervention.

RESULTS

The study included 35,609 fluoroquinolone e-scripts from the preintervention period and 31,303 fluoroquinolone e-scripts from the postintervention period, accounting for 520,388 cumulative fluoroquinolone DOT. Mean durations before and after the intervention were 7.8 (SD, 4.3) and 7.7 (SD, 4.5), a nonsignificant change. E-scripts with a 10-day duration decreased prior to and after the default removal. The inpatient setting showed a significant 8% drop in 10-day e-scripts after default removal and a reduced median duration by 1 day; 10-day scripts declined nonsignificantly in ED and ambulatory settings. In the ambulatory settings, both 7- and 14-day e-script durations increased after default removal.

CONCLUSION

Removal of default 10-day antibiotic durations did not affect overall mean duration but did shift patterns in prescribing, depending on practice setting. Stewardship interventions must be studied in the context of practice setting. Ambulatory stewardship efforts separate from inpatient programs are needed because interventions cannot be assumed to have similar effects.

Influence of additional prophylactic oral antibiotics during mechanical bowel preparation on surgical site infection in patients receiving colorectal surgery

BACKGROUND

Prophylactic antibiotics (PAs) are standard for preventing surgical site infections (SSIs) post-colorectal surgery. This study aims to compare the effect of additional empiric oral antibiotics (OAs) alongside routine PAs to identify SSI risk factors.

METHODS

A retrospective observatory analysis was conducted from January 2019 to December 2022 at Asan Medical Center, Seoul, Korea. The cohort was divided into two groups: PA given 1 h before surgery and discontinued within 24 h, and OA administered empiric OAs during mechanical bowel preparation in addition to PA.

RESULTS

From a total of 6736 patients, 3482 were in the PA group and 3254 in the OA group. SSI incidence showed no significant intergroup difference (p = 0.374) even after propensity score matching (p = 0.338). The multivariable analysis revealed male sex [odds ratio (OR): 2.153, 95% confidence interval (CI): 1.626-2.852, and p = 0.001], open surgery (OR: 3.335, 95% CI: 2.456-4.528, and p = 0.001), dirty wound (OR: 2.171, 95% CI: 1.256-3.754, and p = 0.006), and an operation time of more than 145 min (OR: 2.110, 95% CI: 1.324-3.365, and p = 0.002) as SSI risk factors. In rectal surgery subgroup, OA demonstrated a protective effect against SSI (OR: 0.613, 95% CI: 0.408-0.922, and p = 0.019) and in laparoscopic approach (OR: 0.626, 95% CI: 0.412-0.952, and p = 0.028).

CONCLUSIONS

OA did not affect SSI incidence in colorectal surgeries. Male sex, open surgery, dirty wounds, and longer operation time were risk factors for SSI. However, for rectal and laparoscopic surgery, OA was a protective factor for SSI.

Assessment of antimicrobial prescribing patterns, guidelines compliance, and appropriateness of antimicrobial prescribing in surgical-practice units: point prevalence survey in Malaysian teaching hospitals

Objectives: This study sought to investigate the quality of antimicrobial prescribing among adult surgical inpatients besides exploring the determinants of non-compliance and inappropriate prescribing to inform stewardship activities. Methods: A cross-sectional point prevalence study employing Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) was conducted in April 2019 at two teaching hospitals in Malaysia. Results: Among 566 surgical inpatients, 44.2% were receiving at least one antimicrobial, for a total of 339 prescriptions. Antimicrobials belonging to the World Health Organization's Watch group were observed in 57.8% of cases. Both hospitals exhibited similar types of antimicrobial treatments prescribed and administration routes. A significant difference in antimicrobial choice was observed between hospitals (p < 0.001). Hospital with electronic prescribing demonstrated better documentation practice (p < 0.001). Guidelines compliance, 32.8% (p = 0.952) and appropriateness, 55.2% (p = 0.561) did not significantly differ. The major contributors of inappropriateness were incorrect duration, (15%) and unnecessary broad-spectrum coverage, (15.6%). Non-compliance and inappropriate prescribing were found to be 2 to 4 times significantly higher with antimicrobial prophylaxis prescription compared to empirical therapy. Conclusion: Antimicrobial stewardship efforts to improve appropriate surgical prescribing are essential. These initiatives should prioritize surgical prophylaxis prescribing, focusing on reducing unnecessarily prolonged use and broad-spectrum antimicrobials, raising awareness among prescribers and promoting proper documentation.

Perioperative Antibiotic Prophylaxis

BACKGROUND

Postoperative surgical site infections (SSI) account for almost 25% of all nosocomial infections in Germany and are a source of increased morbidity and mortality.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed and on national and international guidelines.

RESULTS

The individual risk factors for SSI must be assessed before any surgical procedure. A body-mass index above 30 kg/m2 is associated with an unadjusted risk ratio of 1.35 [1.28; 1.41] for SSI, which rises to 3.29 [2.99; 3.62] if the patient is also immunosuppressed. The risk of SSI is also significantly higher with certain types of procedure. Perioperative antibiotic prophylaxis (PAP) is clearly indicated for operations that carry a high risk of SSI (e.g., colorectal surgery) and for those that involve the implantation of alloplastic material (e.g., hip endoprostheses). PAP can usually be administered with basic antibiotics such as cefazoline. The basic principles of PAP are that it should be given by the anesthesia team in the interval from 60 minutes preoperatively up to shortly before the incision, and that its administration should only be for a short period of time, usually as a single shot. Continuing PAP onward into the postoperative period leads to increased toxicity, bacterial superinfections, and antibiotic resistance.

CONCLUSION

The evidence shows that perioperative antibiotic prophylaxis is a component of a bundle of measures that can help prevent SSI. Strict indications and adherence to the basic principles of PAP are essential for therapeutic success.

Construct validation of machine learning for accurately predicting the risk of postoperative surgical site infection following spine surgery

BACKGROUND

This study aimed to evaluate the risk factors for machine learning (ML) algorithms in predicting postoperative surgical site infection (SSI) following spine surgery.

METHODS

This prospective cohort study included 986 patients who underwent spine surgery at Taizhou People's Hospital Affiliated to Nanjing Medical University from January 2015 to October 2022. Supervised ML algorithms included support vector machine, logistic regression, random forest, XGboost, decision tree, k-nearest neighbour, and naïve Bayes (NB), which were tested and trained to develop a predicting model. The ML model performance was evaluated from the test dataset. We gradually analysed their accuracy, sensitivity, and specificity, as well as the positive predictive value, negative predictive value, and area under the curve.

RESULTS

The rate of SSI was 9.33%. Using a backward stepwise approach, we identified that the remarkable risk factors predicting SSI in the multi-variate Cox regression analysis were age, body mass index, smoking, cerebrospinal fluid leakage, drain duration and pre-operative albumin level. Compared with other ML algorithms, the NB model had the highest performance in seven ML models, with an average area under the curve of 0.95, sensitivity of 0.78, specificity of 0.88, and accuracy of 0.87.

CONCLUSIONS

The NB model in the ML algorithm had excellent calibration and accurately predicted the risk of SSI compared with the existing models, and might serve as an important tool for the early detection and treatment of SSI following spinal infection.

The Practice of Antimicrobial Stewardship in Thoracic Surgery and its Effectiveness

This study examines the effects of the bundle of antimicrobial stewardship measures for prophylactic antibiotics among thoracic surgery patients. A local protocol, based on current guidelines starting from December 2014, was developed by the Infection Control and Thoracic Surgery Teams. The effects of this protocol were assessed by monitoring a total of 1380 patients before and after its implementation from January 1, 2011, to December 31, 2022.

Three-Year Point Prevalence Survey of Antimicrobial Use in a Chinese University Hospital

To evaluate the prevalence and quality of antimicrobial prescriptions using a Global Point Prevalence Survey (PPS) tool and help identify targets for improvement of antimicrobial prescribing and inform the development of antimicrobial stewardship activities. Antimicrobial prescriptions for inpatients staying at a hospital overnight were surveyed on one weekday in October 2018, November 2019, and November 2020. Data including basic patient information, antimicrobial drugs, quality evaluation of antimicrobial drug prescription, and the risk factors of nosocomial infection were collected from doctor network workstation. Patient information was anonymized and entered in the PPS Web application by physicians. A total of 720 patients (median age, 62 years) were surveyed. Of them, 246 (34.2%) were prescribed antimicrobials on the survey days. Hospital-wide antimicrobial use had a significantly decreasing trend (P < 0.001). The most commonly prescribed antimicrobial drugs were third-generation cephalosporins (40.5%), followed by quinolones (21.8%) and second-generation cephalosporin (12.5%). In our study, cefoperazone/sulbactam, ceftazidime, and levofloxacin were the most commonly used antimicrobials. The most common indication for antimicrobial use was pneumonia or lower respiratory tract infection (159/321, 49.5%). Antimicrobial for surgical prophylaxis represented 16.2% of the total antibiotic doses. Of those, 67.3% were administered for more than 24 h. The rate of adherence to antibiotic guidelines was 61.4%. The indications for antimicrobials were not documented in 54.5% of the prescriptions. Stop/review date was documented for 36.8% of prescriptions. The PPS tool is useful in identifying targets to enhance the quality of antimicrobial prescriptions to improve the adherence rate in hospitals. This survey can be used as a control to assess the rational application quality of antimicrobial after regular application of antimicrobial intervention.

Beyond SEP-1 Compliance: Assessing the Impact of Antibiotic Overtreatment and Fluid Overload in Suspected Septic Patients

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) developed the Severe Sepsis and Septic Shock Performance Measure bundle (SEP-1) metric to improve sepsis care, but evidence supporting this bundle is limited and harms secondary to compliance have not been investigated.

OBJECTIVE

This study investigates the effect of an emergency department (ED) sepsis quality-improvement (QI) effort to improve CMS SEP-1 compliance, looking specifically at antibiotic overtreatment and harm from fluid resuscitation.

METHODS

This was a retrospective observational study conducted between March and July 2021 with patients for whom a sepsis order set was initiated. The primary outcomes included the number of patients treated with antibiotics who were ultimately deemed nonseptic and the number of patients who developed pulmonary edema, with or without need for positive pressure ventilation (PPV), within 48 h of receiving a 30 mL/kg fluid bolus. Data were collected via nonblinded chart reviews, with a free marginal κ-calculation indicating excellent interrater reliability.

RESULTS

The study cohort included 273 patients, 170 (62.3%) who were ultimately determined to be septic and 103 (37.7%) who were nonseptic. Of the 103 nonseptic patients, 82 (79.6%) received antibiotics in the ED. Of the 121 patients (44.3%) who received a 30 mL/kg bolus, 5 patients (4.1%) developed pulmonary edema and 0 of 121 patients required PPV within 48 h.

CONCLUSIONS

The QI effort led to moderate rates of antibiotic overtreatment and very few patients developed pulmonary edema due to a 30 mL/kg fluid bolus.

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.

Healthcare-associated infections and antimicrobial use in acute care hospitals in Greece, 2022; results of the third point prevalence survey

BACKGROUND

The burden of healthcare-associated infections (HAIs) and the extent of antimicrobial use (AU) are periodically recorded through Point Prevalence Surveys (PPS) in acute care hospitals coordinated by the European Centre for Disease Prevention and Control (ECDC). In previous PPSs, Greece demonstrated increased HAI and AU prevalence: 9% and 54.7% in 2011-2012, and 10% and 55.6% in 2016-2017, respectively. The 2022 PPS aimed to estimate HAIs and AU indicators among inpatients, especially amid the COVID-19 pandemic.

METHODS

A cross-sectional study was conducted in 50 hospitals during October-December 2022, in Greece. Patients admitted before 8.00 a.m. of the survey day were observed. Patients with at least one HAI or receiving at least one antimicrobial agent were included. Data were collected by hospital infection control teams. Hospital and ward-level variables were analysed.

RESULTS

From 9,707 inpatients, 1,175 had at least one HAI (12.1%), and 5,376 were receiving at least one antimicrobial (55.4%). Intensive care unit patients had the highest HAI (45.7%) and AU (71.3%) prevalence. Of the 1,408 recorded HAIs, lower respiratory tract (28.9%), bloodstream (20%), and urinary tract infections (13.1%) were the most common. Among 1,259 isolates, Klebsiella (20.5%) and Acinetobacter (12.8%) were most frequently identified. Resistance to first-level antibiotic markers was 69.3%. Among the 9,003 antimicrobials, piperacillin-tazobactam (10.9%), and meropenem (7.7%) were frequently prescribed. The ratio of broad-spectrum to narrow-spectrum antibiotics was 1.4. As defined by the 2021 WHO AWaRe (Access, Watch, Reserve) classification, restricted classes of Watch and Reserve agents comprised 76.7% of antibiotics. Usual indications were treatment of community-acquired infections (34.6%) and HAIs (22.9%). For surgical prophylaxis, cefoxitin was commonly used (20.2%), and typical courses (75.7%) lasted more than one day. HAI and AU prevalence were positively associated with bed occupancy (p = 0.027) and secondary hospitals (p = 0.014), respectively.

CONCLUSIONS

The 2022 PPS highlighted the increasing trend of HAI prevalence and high AU prevalence in Greece, the emergence of difficult-to-treat pathogens, and the extensive use of broad-spectrum antimicrobials. Strengthening infection control and antimicrobial stewardship programs in hospital settings is essential.

When is vancomycin prophylaxis necessary? Risk factors for MRSA surgical site infection

Background

The 2022 SHEA/IDSA/APIC guidance for surgical site infection (SSI) prevention recommends reserving vancomycin prophylaxis to patients who are methicillin-resistant Staphylococcus aureus (MRSA) colonized. Unfortunately, vancomycin prophylaxis remains common due to the overestimation of MRSA risk and the desire to cover MRSA in patients with certain healthcare-associated characteristics. To optimize vancomycin prophylaxis, we sought to identify risk factors for MRSA SSI.

Methods

This was a single-center, case-control study of patients with a postoperative SSI after undergoing a National Healthcare Safety Network operative procedure over eight years. MRSA SSI cases were compared to non-MRSA SSI controls. Forty-two demographic, medical, and surgical characteristics were evaluated.

Results

Of the 441 patients included, 23 developed MRSA SSIs (rate = 5.2 per 100 SSIs). In the multivariable model, we identified two independent risk factors for MRSA SSI: a history of MRSA colonization or infection (OR, 9.0 [95% CI, 1.9-29.6]) and hip or knee replacement surgery (OR, 3.8 [95% CI, 1.3-9.9]). Hemodialysis, previous hospitalization, and prolonged hospitalization prior to the procedure had no measurable association with odds of MRSA SSI.

Conclusions

Patients with prior MRSA colonization or infection had 9-10 times greater odds of MRSA SSI and patients undergoing hip and knee replacement had 3-4 times greater odds of MRSA SSI. Healthcare-associated characteristics, such as previous hospitalization or hemodialysis, were not associated with MRSA SSI. Our findings support national recommendations to reserve vancomycin prophylaxis for patients who are MRSA colonized, as well as those undergoing hip and knee replacement, in the absence of routine MRSA colonization surveillance.

Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle

In the multimodal strategy context, to implement healthcare-associated infection prevention, bundles are one of the most commonly used methods to adapt guidelines in the local context and transfer best practices into routine clinical care. One of the most important measures to prevent surgical site infections is surgical antibiotic prophylaxis (SAP). This narrative review aims to present a bundle for the correct SAP administration and evaluate the evidence supporting it. Surgical site infection (SSI) prevention guidelines published by the WHO, CDC, NICE, and SHEA/IDSA/APIC/AHA, and the clinical practice guidelines for SAP by ASHP/IDSA/SIS/SHEA, were reviewed. Subsequently, comprehensive searches were also conducted using the PubMed®/MEDLINE and Google Scholar databases, in order to identify further supporting evidence-based documentation. The bundle includes five different measures that may affect proper SAP administration. The measures included may be easily implemented in all hospitals worldwide and are based on minimal drug pharmacokinetics and pharmacodynamics knowledge, which all surgeons should know. Antibiotics for SAP should be prescribed for surgical procedures at high risk for SSIs, such as clean-contaminated and contaminated surgical procedures or for clean surgical procedures where SSIs, even if unlikely, may have devastating consequences, such as in procedures with prosthetic implants. SAP should generally be administered within 60 min before the surgical incision for most antibiotics (including cefazolin). SAP redosing is indicated for surgical procedures exceeding two antibiotic half-lives or for procedures significantly associated with blood loss. In principle, SAP should be discontinued after the surgical procedure. Hospital-based antimicrobial stewardship programmes can optimise the treatment of infections and reduce adverse events associated with antibiotics. In the context of a collaborative and interdisciplinary approach, it is essential to encourage an institutional safety culture in which surgeons are persuaded, rather than compelled, to respect antibiotic prescribing practices. In that context, the proposed bundle contains a set of evidence-based interventions for SAP administration. It is easy to apply, promotes collaboration, and includes measures that can be adequately followed and evaluated in all hospitals worldwide.

Guideline concordance and antibiotic-associated adverse events between Veterans administration and non-Veterans administration dental settings: a retrospective cohort study

Background: Antibiotics prescribed as infection prophylaxis prior to dental procedures have the potential for serious adverse drug events (ADEs). However, the extent to which guideline concordance and different dental settings are associated with ADEs from antibiotic prophylaxis is unknown. Aim: The purpose was to assess guideline concordance and antibiotic-associated ADEs and whether it differs by VA and non-VA settings. Methods: Retrospective cohort study of antibiotic prophylaxis prescribed to adults with cardiac conditions or prosthetic joints from 2015 to 2017. Multivariable logistic regression models were fit to assess the impact of ADEs, guideline concordance and dental setting. An interaction term of concordance and dental setting evaluated whether the relationship between ADEs and concordance differed by setting. Results: From 2015 to 2017, 61,124 patients with antibiotic prophylaxis were identified with 62 (0.1%) having an ADE. Of those with guideline concordance, 18 (0.09%) had an ADE while 44 (0.1%) of those with a discordant antibiotic had an ADE (unadjusted OR: 0.84, 95% CI: 0.49-1.45). Adjusted analyses showed that guideline concordance was not associated with ADEs (OR: 0.78, 95% CI: 0.25-2.46), and this relationship did not differ by dental setting (Wald χ^2 p-value for interaction = 0.601). Conclusion: Antibiotic-associated ADEs did not differ by setting or guideline concordance.

A Randomized, Open-Label, Non-inferiority Clinical Trial Assessing 7 Versus 14 Days of Antimicrobial Therapy for Severe Multidrug-Resistant Gram-Negative Bacterial Infections: The OPTIMISE Trial Protocol

INTRODUCTION

Shorter courses of antimicrobials have been shown to be non-inferior to longer, "traditional" duration of therapies, including for some severe healthcare-associated infections, with a few exceptions. However, evidence is lacking regarding shorter regimes against severe infections by multidrug-resistant Gram-negative bacteria (MDR-GNB), which are often caused by distinct strains and commonly treated with second-line antimicrobials. In the duratiOn of theraPy in severe infecTIons by MultIdrug-reSistant gram-nEgative bacteria (OPTIMISE) trial, we aim to assess the non-inferiority of 7-day versus 14-day antimicrobial therapy in critically ill patients with severe infections caused by MDR-GNB.

METHODS

This is a randomized, multicenter, open-label, parallel controlled trial to assess the non-inferiority of 7-day versus 14-day of adequate antimicrobial therapy for intensive care unit (ICU)-acquired severe infections by MDR-GNB. Adult patients with severe infections by MDR-GNB initiated after 48 h of ICU admission are screened for eligibility. Patients are eligible if they proved to be hemodynamically stable and without fever for at least 48 h on the 7th day of adequate antimicrobial therapy. After consenting, patients are 1:1 randomized to discontinue antimicrobial therapy on the 7th (± 1) day or to continue for a total of 14th (± 1) days.

PLANNED OUTCOMES

The primary outcome is treatment failure, defined as death or relapse of infection within 28 days after randomization. Non-inferiority will be achieved if the upper edge of the two-tailed 95% confidence interval of the difference between the clinical failure rate in the 7-day and the 14-day group is not higher than 10%.

CONCLUSION

The OPTIMISE trial is the first randomized controlled trial specifically designed to assess the duration of antimicrobial therapy in patients with severe infections by MDR-GNB.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05210387. Registered on 27 January 2022. Seven Versus 14 Days of Antibiotic Therapy for Multidrug-resistant Gram-negative Bacilli Infections (OPTIMISE).

Suboptimal antimicrobial discharge prescriptions at a tertiary referral children's hospital

Objective

To determine the rate of and factors associated with suboptimal discharge antimicrobial prescribing at a tertiary referral children's hospital.

Design

Retrospective cohort.

Setting

Tertiary referral children's hospital.

Population

All enteral antimicrobial discharge prescriptions at Lucile Packard Children's Hospital Stanford from January 1st, 2021 through December 31st, 2021.

Method

All enteral discharge antimicrobials are routinely evaluated by our antimicrobial stewardship program within 48 hours of hospital discharge. Antimicrobials are determined to be optimal or suboptimal by an antimicrobial stewardship pharmacist after evaluating the prescribed choice of antimicrobial, dose, duration, dosing frequency, and formulation. The rate and factors associated with suboptimal antimicrobial discharge prescribing were evaluated.

Results

Of 2,593 antimicrobial prescriptions ordered at discharge, 19.7% were suboptimal. Suboptimal prescriptions were due to incorrect duration (72.2%), dose (31.0%), dose frequency (23.3%), drug choice (6.5%), or formulation (5.7%). In total, 87.2% of antimicrobials for perioperative prophylaxis and 13.5% of treatment antimicrobials were suboptimal. Antimicrobials with the highest rate of suboptimal prescriptions were amoxicillin-clavulanate (40.7%), clindamycin (36.6%), and cephalexin (36.6%).

Conclusion

Suboptimal antimicrobial discharge prescriptions are common and present an opportunity for antimicrobial stewardship programs during hospital transition of care. Factors associated with suboptimal prescriptions differ by antimicrobial and prescribed indication, indicating that multiple stewardship interventions may be needed to improve prescribing.

Using antibiotics wisely

PURPOSE OF REVIEW

This review will describe role of shorter antibiotic therapies, early switch from intravenous to oral therapy, and artificial intelligence in infectious diseases.

RECENT FINDINGS

There is evidence that shorter courses of antibiotics are noninferior to standard durations of therapy. This has been demonstrated with Enterobacterales bacteremia that can be treated with 7 days of therapy, community acquired pneumonia with 3 days and ventilator associated pneumonia with just 7 days of antibiotic therapy. The conversion from intravenous to oral therapy in treating bacteremia, endocarditis and bone and joint infections is safe and effective and reduces line complications and costs. Also, for clean surgical procedures only one dose of antibiotic is needed, but it should be the most effective antibiotic which is cefazolin. This means avoiding clindamycin, removing penicillin allergies where possible for improved outcomes. Finally, the role of artificial intelligence to incorporate into using antibiotics wisely is rapidly emerging but is still in early stages.

SUMMARY

In using antibiotics wisely, targeting such as durations of therapy and conversion from intravenous antibiotic therapy to oral are low hanging fruit. The future of artificial intelligence could automate a lot of this work and is exciting but needs to be proven.

VIDEO ABSTRACT

http://links.lww.com/COID/A50.

Resuscitation and Preparation of the Emergency General Surgery Patient

Traditionally, the workflow surrounding a general surgery patient allows for a period of evaluation and optimization of underlying medical issues to allow for risk modification; however, in the emergency, this optimization period is largely condensed because of its time-dependent nature. Because the lack of optimization can lead to complications, the ability to rapidly resuscitate the patient, proceed to procedural intervention to control the situation, and manage common medical comorbidities is paramount. This article provides an overview on these subjects.

Clostridioides difficile infection in neurosurgical patients in a national centre over 10 years: less common but associated with longer hospital stays

BACKGROUND

Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated (HA) diarrhoea, contributing to patient morbidity and prolonged length-of-stay (LOS). We retrospectively assessed CDI over a decade in a national neurosurgical centre, with a multi-disciplinary approach to CDI surveillance and antimicrobial stewardship, by comparing CDI patients with other patient groups.

METHODS

Data on CDI in neurosurgical inpatients between January 2012 and December 2021 were collated. Disease-specific variables were compared to other inpatients with CDI. Rates per 10,000 bed days used were calculated. Patient-specific differences were compared with neurosurgical patients without CDI. CDI rates by patient group were explored using odds ratio (OR) and χ2 analyses. Negative binomial regression was used to investigate CDI rates over time.

RESULTS

Of 50 neurosurgical patients with CDI, all were HA; the average age was 53 years (standard deviation (SD) 16.3 years), 49 were first-episode CDI, and three had severe CDI. The majority (76.7%) had received recent antimicrobials. Compared with non-neurosurgical CDI patients, neurosurgical CDI rates differed significantly (1.9 versus 3.6 per 10,000 bed days used, p < 0.05), neurosurgical patients were younger (p ≤ 0.01), C. difficile testing was more likely to be requested by neurosurgeons (OR 2.4; p ≤ 0.01), and the proportion of severe CDI was higher (6% versus 2%, OR 3.0, p = 0.07, confidence interval (CI) 0.54 to 11.3). Within the neurosurgical cohort, CDI patients had an average LOS four times that of other patients (CI 15.2 to 35.1; p < 0.01) and were older (53.5 versus 47.8 years, CI 0.1 to 11 years; p < 0.05). Only one CDI outbreak was linked to neurosurgical patients.

CONCLUSION

CDI in neurosurgery patients differed from the wider hospital, with greater awareness of CDI testing. Longer LOS impacted bed utilisation with limited capacity. Robust surveillance supports proactive antimicrobial stewardship programmes in this vulnerable population.

How standardised are antibiotic regimens in otologic surgery?

BACKGROUND

Within otologic surgery, a paucity of well-controlled studies assessing the use of systemic antibiotic to reduce surgical site infections exists. Moreover, discrepancies in wound classification of procedures challenge consensus in antimicrobial prescribing patterns. We sought to compare surgeons from two different health systems to examine how surgeons' prescribing habits compared to practice guidelines for numerous otologic procedures.

METHODS

An online questionnaire was distributed to 33 Canadian and 32 Austrian surgeons who regularly perform otologic surgery. Current systemic antibiotic prescribing habits for cochlear implantation, cholesteatoma surgery, stapes surgery, and tympanoplasty ± ossiculoplasty were collected.

RESULTS

Eighteen of 33 (54.5%) Canadian surgeons provided responses, while 18 of 32 (56.3%) of Austrian surgeons answered. Clear consistency with clinical practice guidelines exists for pre-operative antibiotics use in cochlear implant surgery and infected cholesteatoma surgery. However, for stapes surgery and tympanoplasty ± ossiculoplasty, consensus is lacking for both pre- and post-operative antibiotic prescribing habits. Notable differences between the two countries include post-operative antibiotics for cochlear implant surgery (Austria: 36.4%, Canada: 71.4%) and uninfected cholesteatoma surgery (Austria: 33.3%, Canada: 77.8%). Across all procedures, both induction and post-operative antibiotic administration was not significantly associated with surgeon seniority when stratified by five-year increments.

CONCLUSION

The lack of consensus among each country's otologic surgeons underscores the uncertainty in wound classification and thus, adherence to clinical practice guidelines.

Impact of a Pharmacist-Conducted Preoperative Beta-Lactam Allergy Assessment on Perioperative Cefazolin Prescribing

Background: Cefazolin is guideline recommended for perioperative prophylaxis in orthopedic surgery. Despite its unique R1 side chain, cefazolin is often avoided in patients with beta-lactam allergy with concern for cross reactivity. Objectives: The primary outcome was the percentage of patients who received cefazolin perioperatively. Secondary outcomes included the percentage of patients with a beta-lactam allergy clarified following the telephone interview and clinical outcomes including acute kidney injury, surgical site infection, Clostridioides difficile infection, and re-admission at 30 and 90 days. Methods: This single-center, quasi-experimental study evaluated a pilot program in which a pharmacist phoned patients > 18 years of age with a scheduled orthopedic surgery and a documented beta-lactam allergy to assess their allergy preoperatively. Recommendations to use cefazolin were based on an algorithm. Patients were divided into pre- and post-intervention cohorts. Results: A total of 832 patients were screened for inclusion with 135 and 66 patients included in the pre- and post-intervention cohorts. No significant difference was identified in the primary outcome. In the post-intervention cohort, 62% had a beta-lactam reaction updated in the electronic medical record. Those with a beta-lactam allergy delabeled or made less severe were numerically more likely to receive cefazolin than those with an unchanged reaction or a reaction made more severe (95.2% vs 68% vs 65%). There were no differences in clinical outcomes between groups. Conclusion: A pharmacist-conducted preoperative beta-lactam allergy interview in adult patients undergoing elective orthopedic surgery improved beta-lactam allergy documentation but, did not result in increased utilization of cefazolin.

Preoperative oral antibiotic administration in patients undergoing curative resection with stoma creation for colorectal cancer: effectiveness in preventing surgical site infection and the possibility of peristomal candidiasis induced by enterobacterial alteration

AIM

There are many reports that preoperative oral antibiotics (OAs) are effective in preventing surgical site infections (SSIs) in colorectal surgery. However, there is no consensus on the optimal dose of OAs. In this study, we investigated the efficacy of OAs in preventing SSIs and the possibility that OAs induce enterobacterial alteration in the intestinal tract.

METHOD

We performed a retrospective cross-sectional analysis of 389 patients who underwent R0 resection and stoma creation for colorectal cancer in our department between 2009 and 2020. We focused on the incidence of peristomal candidiasis (PSC) as an indicator of enterobacterial alteration and used kanamycin (KM) and metronidazole (MNZ) as the OAs. A low-dose group received 1000 mg/day of both KM and MNZ, and a high-dose group received 2000 mg/day of both KM and MNZ.

RESULTS

SSI occurred in 60 of the 389 cases (15.4%). Regardless of stoma type, SSI was significantly more common in the non-OA group, while PSC was significantly less common. When examined by OA dose, the incidence of SSI was not significantly different between the low-dose and high-dose groups. However, PSC was significantly more common in the high-dose group than in the non-OA and low-dose groups. Analysis of bacterial and fungal levels in stool samples showed that bacterial levels after OAs were significantly lower than before OAs, while fungal levels increased.

CONCLUSION

OAs significantly reduce SSI in colorectal cancer surgery. However, excess OAs were significantly associated with the occurrence of PSC without contributing to further reduction in SSI.

Antimicrobial prophylaxis with teicoplanin plus gentamicin in primary total joint arthroplasty

Objectives: To compare prosthetic joint infection (PJI) and acute kidney injury (AKI) rates among cohorts before and after changing our hospital's antimicrobial prophylactic regimen from cefuroxime to teicoplanin plus gentamicin. Methods: We retrospectively studied all patients undergoing primary total joint arthroplasty at our hospital 18 months pre- and post-implementation of the change in practice. All deep infections identified during follow-up were assessed against the European Bone and Joint Infection Society (EBJIS) definitions for PJI. Survival analysis using Cox regression was employed to adjust for differences in baseline characteristics and compare the risk of PJI between the groups. AKIs were identified using pathology records and categorized according to the KDIGO (Kidney Disease - Improving Global Outcomes) criteria. AKI rates were calculated for the pre- and post-intervention periods. Results: Of 1994 evaluable patients, 1114 (55.9 %) received cefuroxime only (pre-intervention group) and 880 (44.1 %) patients received teicoplanin plus gentamicin (post-intervention group). The overall rate of PJI in our study was 1.50 % (30 of 1994), with a lower PJI rate in the post-intervention group (0.57 %; 5 of 880) compared with the pre-intervention group (2.24 %; 25 of 1114). A corresponding risk reduction for PJI of 75.2 % (95 % CI of 35.2-90.5; p = 0 .004) was seen in the post-intervention group, which was most pronounced for early-onset and delayed infections due to coagulase-negative staphylococci (CoNS) and cefuroxime-resistant Enterobacteriaceae. Significantly higher AKI rates were seen in the post-intervention group; however, 84 % of cases (32 of 38) were stage 1, and there were no differences in the rate of stage-2 or -3 AKI. Conclusions: Teicoplanin plus gentamicin was associated with a significant reduction in PJI rates compared with cefuroxime. Increases in stage-1 AKI were seen with teicoplanin plus gentamicin.

Impact of the Five-Year Intervention of an Antimicrobial Stewardship Program on the Optimal Selection of Surgical Prophylaxis in a Hospital without Antibiotic Prescription Restrictions in Costa Rica: A Retrospective Study

This study aims to characterize the impact of the implementation of an antimicrobial stewardship program (AMS) on the optimal selection of surgical antibiotic prophylaxis in adult patients. This is a retrospective quasi-experimental study that compared the selection and duration of antibiotics for all surgical prophylaxis prescriptions over six months, both before (pre-AMS) and after a five-year intervention of AMS (post-AMS). In addition, data related to the consumption of antibiotics, adverse drug reactions, and surgical site infections throughout the years of the intervention were analyzed. The rate of appropriate selection of antibiotic prophylaxis in surgical procedures improved to 80% during the post-AMS period. The percentage of optimal duration increased from 69.1% (N = 1598) in the pre-AMS period to 78.0% (N = 841) in the post-AMS period (p < 0.001). The consumption of ceftriaxone significantly decreased, while the use of cefazolin increased more than nine times. No severe adverse reactions or increases in surgical site infections were detected after the intervention. The implementation of an AMS in the surgical ward demonstrated a trend towards a positive overall impact on the selection and duration of prophylactic antibiotics for surgery, with positive results also observed in other variables associated with the prescription of these antibiotics.

Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action

Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.

The Use of Oral Antibiotics After Total Joint Arthroplasty: A Critical Analysis Review

» There is conflicting and insufficient evidence that extended oral antibiotic (EOA) therapy prevents infection in high-risk patients undergoing primary total joint arthroplasty (TJA), limiting recommendation for or against the practice.» In the case of aseptic revision TJA, the evidence is also conflicting and limited by underlying confounders, preventing recommendation for use of EOA.» There is fair evidence that use of EOA after debridement antibiotic therapy and implant retention of the prosthesis prolongs infection-free survival, but randomized controlled trials are needed. On the other hand, there is strong evidence that patients undergoing 2-stage revision should receive a period of suppressive oral antibiotics after the second stage.» The optimal duration of EOA in primary TJA, aseptic revision, and debridement antibiotic therapy and implant retention of the prosthesis is unknown. However, there is strong evidence that 3 months of EOA suppression may be appropriate after reimplantation as part of 2-stage exchange arthroplasty.» Complications secondary to EOA are reported to be between 0% and 13.7%, yet are inconsistently reported and poorly defined. The risks associated with antibiotic use, including development of antimicrobial resistance, must be weighed against a possible decrease in infection rate.

Efficacy of Polyhexamethylene Biguanide in Reducing Post-Operative Infections: A Systematic Review and Meta-Analysis

Background: Post-operative infections are a substantial cause of morbidity and mortality worldwide. Polyhexamethylene biguanide (PHMB) is an antimicrobial agent that has been used in various surgical settings to prevent infections. However, the literature on its efficacy in reducing post-operative infections remains unclear. Materials and Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of PHMB in reducing post-operative infections. The risk of bias and methodologic quality of the included studies were also assessed. Results: The systematic review included nine RCTs, and eight were included in the meta-analysis that showed that the use of PHMB was associated with a reduction in the rate of post-operative infections. The overall effect size was statistically significant, with moderate heterogeneity across the included studies (log Peto's odds ratio [OR], -0.890; 95% confidence interval [CI], -1.411 to -0.369; I2 = 41.89%). However, the diversity in the application of PHMB and the potential influence of other factors, such as adherence to infection prevention protocols and organizational-level variables, underscore the need for further primary studies. Conclusions: Polyhexamethylene biguanide appears to be a promising intervention for reducing post-operative infections. However, more high-quality, well-designed RCTs are needed to confirm these findings and to explore the most effective ways to use PHMB within specific infection prevention bundles. Future research should also aim to control for potential confounding factors to provide a more comprehensive understanding of the efficacy of PHMB in reducing post-operative infections.

Association Between Antibiotic Redosing Before Incision and Risk of Incisional Site Infection in Children With Appendicitis

OBJECTIVE

To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis.

BACKGROUND

Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision.

METHODS

This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events.

RESULTS

A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P <0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity.

CONCLUSIONS

Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic.

A Systematic Review on Postoperative Antibiotic Prophylaxis after Pediatric and Adult Male Urethral Reconstruction

In the era of antibiotic overuse and increasing antibiotic resistance, there is a gap in evidence regarding antibiotic stewardship, and in particular, perioperative antibiotic prophylaxis after urethral reconstruction. The aim of this systematic review was to evaluate the effectiveness and relevance of postoperative antibiotic prophylaxis after male pediatric and adult urethral reconstruction. An online search of MEDLINE database via PubMed was performed. The systematic review was registered in PROSPERO (CRD42022348555) and was conducted according to the PRISMA guidelines and AMSTAR 2 checklist. A narrative synthesis of included studies was performed. After the screening of 1176 publications, six studies regarding antibiotic prophylaxis after hypospadias reconstruction and two studies regarding antibiotic prophylaxis after urethroplasty in adults were eligible to be included in the systematic review. All but one of the studies on hypospadias repair showed no benefit from postoperative antibiotic prophylaxis. The level of evidence on postoperative antibiotic prophylaxis after urethroplasty in adults is low. Neither of the two studies included in the review showed a benefit from antibiotic use. Postoperative prophylaxis after hypospadias repair is not effective in preventing urinary tract infections and wound infections. It seems that the use of postoperative prophylaxis after urethroplasty in adults is also not beneficial, but there is a high need for high-quality scientific data.

Antibiotic prescribing to inpatients in Limpopo, South Africa: a multicentre point-prevalence survey

BACKGROUND

Electronic continuous surveillance databases are ideal for monitoring antibiotic use (ABU) in hospitalised patients for antibiotic stewardship programmes (ASP). However, such databases are scarce in low-resource settings. Point prevalence surveys (PPS) are viable alternatives. This report describes ABU and identifies ASP implementation improvement areas in Limpopo Province, South Africa.

METHODS

This cross-sectional descriptive study extracted patient-level ABU data from patients' files using a modified global PPS tool. Data were collected between September and November 2021 at five regional hospitals in Limpopo Province, South Africa. All patients in the wards before 8 a.m. on study days with an antibiotic prescription were included. Antibiotic use was stratified by Anatomic Therapeutic Chemical and Access, Watch, Reserve classifications and presented as frequencies and proportions with 95% confidence intervals (CI). Associations between categorical variables were assessed using the chi-square test. Cramér's V was used to assess the strength of these associations.

RESULTS

Of 804 inpatients surveyed, 261 (32.5%) (95% CI 29.2-35.7) were prescribed 416 antibiotics, 137 were female (52.5%) and 198 adults (75.9%). One hundred and twenty-two (46.7%) patients received one antibiotic, 47.5% (124/261) received two, and 5.7% (15/261) received three or more antibiotics. The intensive care units had a higher ABU (68.6%, 35/51) compared to medical (31.3%, 120/384) and surgical (28.5%, 105/369) wards (p = 0.005, Cramér's V = 0.2). Lower respiratory tract infection (27.4%, 104/379), skin and soft tissue infections (SST) (23.5%, 89/379), and obstetrics and gynaecology prophylaxis (14.0%, 53/379) were the common diagnoses for antibiotic prescriptions. The three most prescribed antibiotic classes were imidazoles (21.9%, 91/416), third-generation cephalosporins (20.7%, 86/416) and combination penicillin (18.5%, 79/416). Access antibiotics accounted for 70.2% (292/416) of prescriptions and Watch antibiotics for 29.6% (123/416) (p = 0.110, Cramér's V = 0.1). Reasons for prescribing and treatment plans were documented in 64.9% (270/416) (95% CI 60.3-69.5) and 21.4% (89/416) (95% CI 17.3-25.3) of prescriptions, respectively.

CONCLUSIONS

The study serves as a baseline for ABU surveillance at the five regional hospitals in Limpopo Province. Lack of documentation indicates poor prescribing practices; ASP should address gaps by deploying evidence-based, multifaceted and stepwise interventions.

Potent antibacterial activity in surgical wounds with local administration of D-PLEX100

Despite significant advances in infection control guidelines and practices, surgical site infections remain a substantial cause of morbidity, prolonged hospitalization, and mortality. The most effective component of SSI reduction strategies is the preoperative administration of intravenous antibiotics; however, systemic antibiotics drug exposure diminishes rapidly and may result in insufficient prophylactic activity against susceptible and resistant SSI pathogens at the wound. D-PLEX100 (D-PLEX) is an antibiotic-releasing drug (doxycycline) that is supplied as a sterile powder for paste reconstitution with sterile saline. D-PLEX paste is administered locally into the incision site along the entire length of soft tissue and sternal bone wound surfaces prior to skin closure. A single D-PLEX administration is intended for 30 days of constant antimicrobial prophylaxis in the prevention of incisional SSIs. We evaluated D-PLEX minimal bactericidal concentration (MBC) against a panel of bacteria that is prevalent in the abdominal wall and sternal surgical procedures including doxycycline susceptible and resistant strains. D-PLEX in vivo efficacy was assessed in incisional infection rabbit models (abdominal wall and sternal) challenged with a similar bacterial panel. The D-PLEX drug exposure profile was determined by in vitro release assay, and in vivo by quantitative pharmacokinetic parameters of local and systemic doxycycline concentrations released from D-PLEX after local administration in incisional rabbit models. Analyses of pathogens and variations in antibiotic resistance from wound isolates were determined from patients who participated in a previously reported prospective randomized trial that assessed the SSI rate in D-PLEX plus standard of care (SOC) versus SOC alone in colorectal resection surgery. The D-PLEX MBC values demonstrated >3- Log10 reduction in all the organisms tested relative to untreated controls, including doxycycline-resistant bacteria (i.e., Methicillin-resistant Staphylococcus aureus (MRSA), K. pneumoniae, and P. aeruginosa). In vivo, D-PLEX significantly reduced the bacterial loads in all the bacteria tested in both animal models (p=0.0001) with a marked impact observed in E. Coli (>6.5 Log10 reduction). D-PLEX exhibited a zero-order release kinetics profile in vitro for 30 days (R2 = 0.971) and the matched in vivo release profile indicated a constant local release of protein-unbound doxycycline for 30 days at 3-5 mcg/mL with significantly lower (>3 orders of magnitudes) systemic levels. In colorectal surgery patients, where significant SSI reduction was observed, analysis of the positive cultures in the overall population indicated similar pathogen diversity and antibiotic resistance rates in both treatment arms. However, almost all the patients with positive culture in the SOC arm were adjudicated as SSI (94%) compared to only 28% in the D-PLEX arm. The SSI-adjudicated D-PLEX patients also exhibited lower resistance rates to the SOC antibiotics and to MDRs compared to patients in the SOC arm. Thus, D-PLEX provides safe and effective prophylaxis activity against the most prevalent SSI pathogens including doxycycline-susceptible and resistant bacteria. Our findings suggest that D-PLEX is a promising addition to SSI prophylactic bundles and may address the gaps in current SSI prophylaxis. D-PLEX is now evaluated in Phase 3 clinical trial.

A microbial consortium alters intestinal Pseudomonadota and antimicrobial resistance genes in individuals with recurrent Clostridioides difficile infection

Intestinal colonization with pathogens and antimicrobial-resistant organisms (AROs) is associated with increased risk of infection. Fecal microbiota transplant (FMT) has successfully been used to cure recurrent Clostridioides difficile infection (rCDI) and to decolonize intestinal AROs. However, FMT has significant practical barriers to safe and broad implementation. Microbial consortia represent a novel strategy for ARO and pathogen decolonization, with practical and safety advantages over FMT. We undertook an investigator-initiated analysis of stool samples collected from previous interventional studies of a microbial consortium, microbial ecosystem therapeutic (MET-2), and FMT for rCDI before and after treatment. Our aim was to assess whether MET-2 was associated with decreased Pseudomonadota (Proteobacteria) and antimicrobial resistance gene (ARG) burden with similar effects to FMT. Participants were selected for inclusion if baseline stool had Pseudomonadota relative abundance ≥10%. Pre- and post-treatment Pseudomonadota relative abundance, total ARGs, and obligate anaerobe and butyrate-producer relative abundances were determined by shotgun metagenomic sequencing. MET-2 administration had similar effects to FMT on microbiome outcomes. The median Pseudomonadota relative abundance decreased by four logs after MET-2 treatment, a greater decrease than that observed after FMT. Total ARGs decreased, while beneficial obligate anaerobe and butyrate-producer relative abundances increased. The observed microbiome response remained stable over 4 months post-administration for all outcomes. IMPORTANCE Overgrowth of intestinal pathogens and AROs is associated with increased risk of infection. With the rise in antimicrobial resistance, new therapeutic strategies that decrease pathogen and ARO colonization in the gut are needed. We evaluated whether a microbial consortium had similar effects to FMT on Pseudomonadota abundances and ARGs as well as obligate anaerobes and beneficial butyrate producers in individuals with high Pseudomonadota relative abundance at baseline. This study provides support for a randomized, controlled clinical trial of microbial consortia (such as MET-2) for ARO decolonization and anaerobe repletion.

Effect of single versus multiple prophylactic antibiotic doses on prosthetic joint infections following primary total hip arthroplasty in patients with osteoarthritis at public and private hospitals in Denmark: protocol for a nationwide cross-over, cluster randomised, non-inferiority trial [The Pro-Hip-Quality Trial]

INTRODUCTION

A feared complication after total hip arthroplasty (THA) is prosthetic joint infection (PJI), associated with high morbidity and mortality. Prophylactic antibiotics can reduce the risk of PJI. However, there is no consensus on the dosages and current recommendations are based on a low evidence level. The objective is to compare the effect of a single versus multiple doses of prophylactic antibiotics administered within 24 hours on PJI.

METHODS AND ANALYSIS

The study is designed as a cross-over, cluster randomised, non-inferiority trial. All clinical centres use both antibiotic practices (1 year of each intervention). All Danish orthopaedic surgery departments will be involved: Based on quality databases, 2-year cohorts of approximately 20 000 primary THAs conducted at 39 public and private hospitals, will be included.

INCLUSION CRITERIA

age ≥18 years, all indications for THA except patients operated due to acute or sequelae from proximal femoral or pelvic fractures or bone tumour or metastasis. The primary outcome is PJI within 90 days after primary THA. Secondary outcomes include (1) serious adverse events, (2) potential PJI, (3) length of hospitalisation stay, (4) cardiovascular events, (5) hospital-treated infections, (6) community-based antibiotic use, (7) opioid use and (8) use of acetaminophen and non-steroidal anti-inflammatory drugs. All outcome measures will be extracted from national databases. Analyses will be based on the intention-to-treat population. Non-inferiority will be shown if the upper limit of the two-sided 95% CI for the OR is less than 1.32 for the single dose as compared with multiple doses. The results will establish best practice on antibiotic prophylaxis dosages in the future.

ETHICS AND DISSEMINATION

This study has been approved by Committees on Health Research Ethics for The Capital Region of Denmark (21069108) and The Danish Medicines Agency (2021091723). All results will be presented in peer-reviewed medical journals and international conferences.

TRIAL REGISTRATION NUMBER

NCT05530551.

Prophylactic antibiotics for massive endoprostheses in orthopaedic oncology

The recently published Prophylactic Antibiotic Regimens In Tumor Surgery (PARITY) trial found no benefit in extending antibiotic prophylaxis from 24 hours to five days after endoprosthetic reconstruction for lower limb bone tumours. PARITY is the first randomized controlled trial in orthopaedic oncology and is a huge step forward in understanding antibiotic prophylaxis. However, significant gaps remain, including questions around antibiotic choice, particularly in the UK, where cephalosporins are avoided due to concerns of Clostridioides difficile infection. We present a review of the evidence for antibiotic choice, dosing, and timing, and a brief description of PARITY, its implication for practice, and the remaining gaps in our understanding.

A Multidisciplinary Approach to Improvements in Perioperative Antibiotic Prophylaxis at a Military Treatment Facility

INTRODUCTION

Surgical site infections complicate 2%-5% of surgeries. According to the Centers for Disease Control and Prevention, half of all surgical site infections are preventable. Adherence to published recommendations regarding perioperative antibiotic administration decreases the incidence of surgical site infections. Members of the Department of Anesthesia noticed casual observations of inaccurate prescribing of antibiotics at our institution, Brooke Army Medical Center, and approached the Antimicrobial Stewardship Program to collaborate on this issue.

MATERIALS AND METHODS

A team of anesthesiologists, clinical pharmacists, and infectious disease specialists collaborated with the Department of Surgery to improve this effort as part of a multiyear project from 2018 to 2021. We first assessed adherence to recommended perioperative antibiotic use to establish a baseline and next, noticing gaps, created a project with the goal to improve compliance to >90% across surveyed measures. Our key interventions included educational initiatives, creation of facility-specific guidelines, peer benchmarking, updating order sets, interdisciplinary collaboration, creation of intraoperative reminders and visual aids, and tailored presentations to selected services.

RESULTS

Of 292 charts (2.3% of cases from January to October 2018) reviewed pre-intervention, compliance rates were 84% for antibiotic choice, 92% for dose, 65% for redosing, and 71% for postoperative administration. Of doses, 100% were timed correctly, and thus, this variable was not targeted. Post-intervention, our review of 387 charts (10% of cases from May to November 2020) showed no change in correct antibiotic choice (84%) and statistical improvement to 96% for correct dose, 95% for correct redosing, and 85% for correct postoperative administration (P < .05 for all).

CONCLUSIONS

Our multidisciplinary approach of collaboration with multiple departments, creating guidelines and providing feedback, improved compliance with perioperative antibiotic administration recommendations.

Effect of an E-Prescription Intervention on the Adherence to Surgical Chemoprophylaxis Duration in Cardiac Surgery: A Single Centre Experience

In our hospital, adherence to the guidelines for peri-operative antimicrobial prophylaxis (PAP) is suboptimal, with overly long courses being common. This practice does not offer any incremental benefit, and it only adds to the burden of antimicrobial consumption, promotes the emergence of antimicrobial resistance, and it is associated with adverse events. Our objective was to study the effect of an electronic reminder on the adherence to each element of PAP after cardiac surgery. We conducted a single center, before and after intervention, prospective cohort study from 1 June 2014 to 30 September 2017. The intervention consisted of a reminder of the hospital guidelines when ordering PAP through the hospital information system. The primary outcome was adherence to the suggested duration of PAP, while secondary outcomes included adherence to the other elements of PAP and incidence of surgical site infections (SSI). We have studied 1080 operations (400 pre-intervention and 680 post-intervention). Adherence to the appropriate duration of PAP increased significantly after the intervention [PRE 4.0% (16/399) vs. POST 15.4% (105/680), chi-square p < 0.001]; however, it remained inappropriately low. Factors associated with inappropriate duration of PAP were pre-operative hospitalization for <3 days, and duration of operation >4 h, while there were significant differences between the chief surgeons. Unexpectedly, the rate of SSIs increased significantly during the study (PRE 2.8% (11/400) vs. POST 5.9% (40/680), chi-square p < 0.019). The implemented intervention achieved a relative increase in adherence to the guideline-recommended PAP duration; however, adherence was still unacceptably low and further efforts to improve adherence are needed.

Prevalence, Microbiological Profile, and Risk Factors of Surgical Site Infections in Saudi Patients with Colorectal Cancer

Background

Resection surgery in patients with colorectal cancer (CRC) patients is associated with potential complications, including surgical site infection (SSI).

Objectives

To estimate the prevalence rate of SSI, identify the common pathogens responsible for SSI, and determine potential risk factors for SSI development in a cohort from Saudi Arabia.

Materials and Methods

Patients with CRC who underwent bowel resection surgery at King Abdulaziz Medical City, Riyadh, between January 01, 2016, and December 31, 2019, were retrospectively included. Demographics, comorbidities, surgical procedure data, and the results of preoperative laboratory tests were retrospectively collected from medical records through the health information system. The study population was divided into two groups: those who developed SSI and those who did not.

Results

A total of 92 patients with CRC who underwent resection surgery were included, of which 54 (58.7%) were males. The median age was 65 (IQR 55.5-75.0) years. SSI was observed in 25 (27.2%) patients. The most frequently isolated organisms were Escherichia coli and Pseudomonas aeruginosa, followed by Klebsiella pneumoniae, vancomycin-sensitive Enterococcus faecium, and methicillin-resistant Staphylococcus aureus. Three E. coli isolates were producers of extended-spectrum beta-lactamases, and two K. pneumoniae isolates exhibited a multidrug resistance profile. Low preoperative serum albumin level was identified as a significant independent risk factor for developing SSI (AOR = 0.853, 95% CI = 0.748-0.973, P = 0.0181).

Conclusion

The study found a notable prevalence of SSI among the included patients. Gram-negative bacteria were more involved in SSI events and were also associated with drug-resistance patterns. Gut microbiota bacteria were most commonly involved in SSIs. Low preoperative serum albumin levels predicted the development of postoperative SSI, and thus its close monitoring and management before surgery could reduce the SSIs.

Impact of Perioperative Prophylaxis With Enterococcus Activity on Risk of Surgical-Site Infection After Pancreas Transplantation

Surgical-site infection (SSI) is the most common early infectious complication after pancreas transplantation (PT). Although SSI has been shown to worsen outcomes, little data exist to guide optimal choices in perioperative prophylaxis.

Methods

We performed a retrospective cohort study of PT recipients from 2010-2020 to examine the effect of perioperative antibiotic prophylaxis with Enterococcus coverage. Enterococcus coverage included antibiotics that would be active for penicillin-susceptible Enterococcus isolates. The primary outcome was SSI within 30 d of transplantation, and secondary outcomes were Clostridioides difficile infection (CDI) and a composite of pancreas allograft failure or death. Outcomes were analyzed by multivariable Cox regression.

Results

Of 477 PT recipients, 217 (45.5%) received perioperative prophylaxis with Enterococcus coverage. Eighty-seven recipients (18.2%) developed an SSI after a median of 15 d from transplantation. In multivariable Cox regression analysis, perioperative Enterococcus prophylaxis was associated with reduced risk of SSI (hazard ratio [HR] 0.58; 95% confidence interval [CI], 0.35-0.96; P = 0.034). Anastomotic leak was also significantly associated with elevated risk of SSI (HR 13.95; 95% CI, 8.72-22.32; P < 0.001). Overall, 90-d CDI was 7.4%, with no difference between prophylaxis groups (P = 0.680). SSI was associated with pancreas allograft failure or death, even after adjusting for clinical factors (HR 1.94; 95% CI, 1.16-3.23; P = 0.011).

Conclusions

Perioperative prophylaxis with Enterococcus coverage was associated with reduced risk of 30-d SSI but did not seem to influence risk of 90-d CDI after PT. This difference may be because of the use of beta-lactam/beta-lactamase inhibitor combinations, which provide better activity against enteric organisms such as Enterococcus and anaerobes compared with cephalosporin. Risk of SSI was also related to anastomotic leak from surgery, and SSI itself was associated with subsequent risk of a poor outcome. Measures to mitigate or prevent early complications are warranted.

Adherence to Antimicrobial Prophylaxis Guidelines for Elective Surgeries Across 825 US Hospitals, 2019-2020

BACKGROUND

There are limited US data assessing adherence to surgical antimicrobial prophylaxis guidelines, particularly across a large, nationwide sample. Moreover, commonly prescribed inappropriate antimicrobial prophylaxis regimens remain unknown, hindering improvement initiatives.

METHODS

We conducted a retrospective cohort study of adults who underwent elective craniotomy, hip replacement, knee replacement, spinal procedure, or hernia repair in 2019-2020 at hospitals in the PINC AI (Premier) Healthcare Database. We evaluated adherence of prophylaxis regimens, with respect to antimicrobial agents endorsed in the American Society of Health-System Pharmacist guidelines, accounting for patient antibiotic allergy and methicillin-resistant Staphylococcus aureus colonization status. We used multivariable logistic regression with random effects by hospital to evaluate associations between patient, procedural, and hospital characteristics and guideline adherence.

RESULTS

Across 825 hospitals and 521 091 inpatient elective surgeries, 308 760 (59%) were adherent to prophylaxis guidelines. In adjusted analysis, adherence varied significantly by US Census division (adjusted OR [aOR] range: .61-1.61) and was significantly lower in 2020 compared with 2019 (aOR: .92; 95% CI: .91-.94; P < .001). The most common reason for nonadherence was unnecessary vancomycin use. In a post hoc analysis, controlling for patient age, comorbidities, other nephrotoxic agent use, and patient and procedure characteristics, patients receiving cefazolin plus vancomycin had 19% higher odds of acute kidney injury (AKI) compared with patients receiving cefazolin alone (aOR: 1.19; 95% CI: 1.11-1.27; P < .001).

CONCLUSIONS

Adherence to antimicrobial prophylaxis guidelines remains suboptimal, largely driven by unnecessary vancomycin use, which may increase the risk of AKI. Adherence decreased in the first year of the COVID-19 pandemic.

Alterations of gut microbiome following gastrointestinal surgical procedures and their potential complications

Intestinal microorganisms play a crucial role in shaping the host immunity and maintaining homeostasis. Nevertheless, alterations in gut bacterial composition may occur and these alterations have been linked with the pathogenesis of several diseases. In surgical practice, studies revealed that the microbiome of patients undergoing surgery changes and several post-operative complications seem to be associated with the gut microbiota composition. In this review, we aim to provide an overview of gut microbiota (GM) in surgical disease. We refer to several studies which describe alterations of GM in patients undergoing different types of surgery, we focus on the impacts of peri-operative interventions on GM and the role of GM in development of post-operative complications, such as anastomotic leak. The review aims to enhance comprehension regarding the correlation between GM and surgical procedures based in the current knowledge. However, preoperative and postoperative synthesis of GM needs to be further examined in future studies, so that GM-targeted measures could be assessed and the different surgery complications could be reduced.

Preoperative Prophylactic Antibiotics in Mandibular Fractures and Surgical Site Infection

BACKGROUND

Compared with other facial fractures, mandibular fractures have the highest rate of postsurgical site infection. There is strong evidence to suggest that postoperative antibiotics do not reduce rates of surgical site infections (SSIs) regardless of duration. However, there are conflicting data in the literature regarding the role of prophylactic preoperative antibiotics in reducing rates of SSIs. This study reviews the rate of infections in patients who underwent mandibular fracture repair who received a course of preoperative prophylactic antibiotics compared with those who received no or 1 dose of perioperative antibiotics.

METHODS

Adult patients who underwent mandibular fracture repair at Prisma Health Richland between 2014 and 2019 were included in the study. A retrospective cohort review was conducted to determine the rate of SSI, comparing 2 groups of patients who underwent mandibular fracture repair. Patients who received more than 1 dose of scheduled antibiotics before surgery were compared with those who did not receive any antibiotic treatment before surgery or received only a single dose of antibiotics within 1 hour of incision time (perioperative antibiotics). The primary outcome was the rate of SSI between the 2 groups of patients.

RESULTS

There were 183 patients who received more than 1 dose of scheduled antibiotics before surgery and 35 patients who received a single dose of perioperative antibiotics or did not receive any antibiotics. The rate of SSI was not significantly different in the preoperative prophylactic antibiotics group (29.3%) compared with the patients who received a single perioperative dose or no antibiotics (25.0%).

CONCLUSION

Extended regimens of preoperative prophylactic antibiotics beyond a single dose at time of surgery do not reduce SSIs after surgical repair in mandibular fractures.

Six Long-Standing Questions about Antibiotic Prophylaxis in Surgery

Surgical site infections (SSIs) are the most common adverse event occurring in surgical patients. Optimal prevention of SSIs requires the bundled integration of a variety of measures before, during, and after surgery. Surgical antibiotic prophylaxis (SAP) is an effective measure for preventing SSIs. It aims to counteract the inevitable introduction of bacteria that colonize skin or mucosa into the surgical site during the intervention. This document aims to guide surgeons in appropriate administration of SAP by addressing six key questions. The expert panel identifies a list of principles in response to these questions that every surgeon around the world should always respect in administering SAP.