Influence of a 5-year serial infection control and antibiotic stewardship intervention on cardiac surgical site infections

Assessment of the impact of intravenous antibiotics treatment on gut microbiota in patients: Clinical data from pre-and post-cardiac surgery

Background and aims

Surgical site infection is a common complication after surgery. Periprocedural antibiotics are necessary to prescribe for preventing or treating infections. The present study aimed to explore the effect of intravenous antibiotics on gut microbiota and menaquinone biosynthesis in patients, especially in elderly patients undergoing cardiac surgery.

Methods

A total of 388 fecal samples were collected from 154 cardiac surgery patients. The V3-V4 hypervariable region of the bacterial 16S rRNA gene was amplified and sequenced on a MiSeq PE300. The gut microbiota diversity of samples was analyzed in terms of α- and β-diversity at the OTU level. The different groups were classified according to antibiotics in combinations and single antibiotics. PICRUSt2 was used for preliminary prediction of the gut microbiota function for menaquinone biosynthesis.

Results

The intravenously administered antibiotics which are excreted via bile represents the main antibiotics that could disturb the gut microbiota's composition in cardiac surgery patients, especially for elderly patients. The effect of antibiotics on gut microbiota is produced after antibiotics treatments over one week. The recovery of gut microbiota to the state of pre-antibiotics may require over two weeks of antibiotics withdrawal. Sex factor doesn't represent as an influencer in gut microbiota composition. Long-term use of cefoperazone-sulbactam may affect coagulation function.

Conclusions

The composition of the gut microbiota had a significant change post-intravenous antibiotics treatment in cardiac surgery patients. The richness and diversity of gut microbiota are increased in elderly patients.

Impact of individualized feedback letters on adherence to surgical antibiotic prophylaxis guidelines: an interrupted time series study (FEEDBACK-ASAP)

BACKGROUND

Surgical antibiotic prophylaxis (SAP) has been proved to decrease the rate of surgical site infections (SSI), but compliance to SAP guidelines remains suboptimal.

AIM

This study evaluated the impact of periodically sending individualized feedback letters to surgeons and anesthesiologists on their compliance rate to SAP guidelines.

METHODS

A total of 1491 surgeries were evaluated by retrospective chart review during the pre-intervention period and 668 surgeries were evaluated by prospective chart review during the per-intervention period. Finally, 295 letters were sent to 64 surgeons and 45 anesthesiologists. Compliance rate was assessed as an outcome composed of: indication for SAP, choice of antibiotic agent, antibiotic dose, postoperative duration, timing of the preoperative dose and intraoperative redosing. An interrupted time series design was used to assess a difference on compliance rates before and during the intervention period.

FINDINGS

Sending individualized feedback letters to surgeons and anesthesiologists did not significantly improve the overall compliance to local SAP guidelines.

CONCLUSION

Individualized feedback letters could be part of future interventions directed at improving compliance to SAP guidelines, but are likely insufficient by themselves to provide significant results.

Antimicrobial stewardship for surgical antibiotic prophylaxis and surgical site infections: a systematic review

Background Surgical site infections account for 14-17% of all healthcare-associated infections. Antimicrobial stewardship (AMS) are complementary strategies developed to optimize the use of antimicrobials. Aim to evaluate the effectiveness of AMS in promoting adherence to surgical antibiotic prophylaxis protocols in hospitalized patients, reducing surgical site infection rate and cost-benefit ratio. Method This systematic review of randomized clinical trials, non-randomized clinical trials and before and after studies was performed using Pubmed, Cochrane, Web of Science, Scopus, Embase, Google Scholar and ClinicalTrials.gov, in addition to reference lists of included studies. The risk of bias of studies was measured by the ROBINS-I checklist and the quality of the evidence synthesis by GRADE. Results Fourteen before and after design studies were included. In 85.7% of the studies, AMS was effective in increasing adherence to surgical antibiotic prophylaxis protocols and in 28.5%, there was reduction in surgical site infection rate. Three studies evaluated cost-benefit ratio and found a favorable impact. Eight (57%) studies were at risk of moderate bias and six had severe bias. The evaluation of the synthesis of evidence showed quality ranging from low to very low. Conclusion AMS, such as audit, feedback, education, implementation of a protocol, and a computer-assisted decision support methodology, appear to be effective in promoting adherence to surgical antibiotic prophylaxis protocols, reducing surgical site infection rate with a positive economic impact. However, more studies, particularly randomized clinical trials, are needed to improve the level of evidence of available information on AMS in order to favor decision-making.

Antibiotic Stewardship Interventions Improve Choice of Antibiotic Prophylaxis in Total Joint Arthroplasty in Patients with Reported Penicillin Allergies

BACKGROUND

Most patients who report a penicillin allergy can tolerate cefazolin, the preferred prophylaxis in a total joint arthroplasty (TJA). Regardless, patients with a reported penicillin allergy are less likely to receive first-line perioperative antibiotics as a result of inaccurate penicillin allergy documentation and misconceptions regarding cross-reactivity between penicillin and cephalosporins. The over-reporting of penicillin allergies and the safety of cephalosporins in patients with reported penicillin allergies have been well established throughout the evidence [13].

QUESTIONS/PURPOSES

The study sought to answer two questions: (1) Do antibiotic stewardship interventions improve adherence to appropriate prophylactic antibiotic usage in patients with a documented penicillin allergy undergoing primary TJA? (2) What is the risk of allergic or adverse reactions secondary to cefazolin use in patients with a documented penicillin allergy?

METHODS

This was a single-center, retrospective study of orthopaedic patients older than 18 years who underwent a primary elective TJA at a 261-bed community hospital. The study had two periods: the preintervention period ran from March 1, 2017 to August 30, 2017 and the postintervention period was from March 1, 2019 to August 30, 2019. A total of 396 patients with a history of a documented penicillin allergy underwent a THA or TKA during the study periods. After reviewing every fourth patient with a history of a documented penicillin allergy who met study inclusion criteria and excluding those patients who had a codocumented cephalosporin allergy, a total of 180 patients with a documented penicillin allergy were evaluated (90 patients in the preintervention group and 90 patients in the postintervention group). To answer our first study question, regarding whether antibiotic stewardship interventions improve adherence to appropriate prophylactic antibiotic usage in patients with a documented penicillin allergy undergoing primary TJA, we evaluated appropriate antibiotic usage pre- and postintervention. To answer our second study question, concerning the risk of allergic or adverse reactions secondary to cefazolin use in patients with a documented penicillin allergy, we reviewed signs of allergic reactions in patients who received cefazolin for a primary TJA and had a documented penicillin allergy.

RESULTS

Postintervention antibiotic use was more appropriate (91% [82 of 90] versus 54% [49 of 90], risk ratio 1.67 [95% confidence interval 1.37 to 2.04]; p < 0.01), particularly in patients with nonsevere allergy (preintervention: 47% [36 of 76] versus postintervention: 96% [76 of 79]; p < 0.01). No patients had signs of an allergic reaction related to cefazolin, including eight patients with severe penicillin allergy.

CONCLUSION

A multifaceted antibiotic stewardship intervention increased the appropriateness of antibiotic prophylaxis in elective primary TJA. Patients with nonsevere penicillin allergies, even those reporting hives or local swelling, tolerated cefazolin. Antibiotic stewardship interventions can be implemented across institutions to expand cephalosporin use in patients with a reported penicillin allergy within orthopaedic TJA patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Bugs and Drugs: Collaboration Between Infection Prevention and Antibiotic Stewardship

Overall goals of antibiotic stewardship and infection prevention programs are to improve patient safety as it pertains to risk of infection or multidrug-resistant organism (MDRO) acquisition. Although the focus of day-to-day activities may differ, the themes of surveillance, education, clinician engagement, and multidisciplinary interactions are prevalent in both programs. Synergistic work between programs has yielded benefits in prevention of MDROs, surgical site infections, Clostridioides difficile infection, and reducing inappropriate testing and treatment for asymptomatic bacteriuria. Collaboration between programs can help maximize resources and minimize redundant work to keep issues related to bugs and drugs at bay.

Perioperative Infections after Open Abdominal Aortic Aneurysm Repair Lead to Increased Risk of Subsequent Complications

BACKGROUND

Patients undergoing open abdominal aortic aneurysm (AAA) repair are at risk of perioperative infections that can lead to subsequent complications. Our goal was to understand how an initial infectious complication influences the risk of subsequent complications in this cohort of patients.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012), we evaluated the relationship between 3 index infectious complications after open elective AAA repair (pneumonia, deep/organ surgical site infection [SSI], and urinary tract infection [UTI]) and subsequent complications. We used 5:1 propensity matching and calculated propensity score to experience to establish matching cohorts for each index complication. This score was based on preoperative variables and number of event-free days.

RESULTS

There were 3,991 patients who were identified to have undergone elective open AAA repair in the ACS-NSQIP database. Postoperative index pneumonia was associated with increased risk of unplanned intubation (28.6% vs. 3.5%; odds ratio [OR], 10.9; 95% confidence interval [CI]: 6.7-17.5; P < 0.001), prolonged ventilation (38.5% vs. 6.7%; OR, 8.7; 95% CI: 5.9-13.0; P < 0.001), sepsis (14.3% vs. 3.3%; OR, 4.8; 95% CI: 2.8-8.4; P < 0.001), acute renal failure (9.9% vs. 2.1%; OR, 5.1; 95% CI: 2.6-9.9; P < 0.001), deep vein thrombosis (DVT) (3.8% vs. 1.4%; OR, 2.7; 95% CI: 1.1-7.0; P = 0.035), and mortality (7.1% vs. 3.0%; OR, 2.5; 95% CI: 1.3-4.9; P = 0.009). Postoperative index UTI was associated with increased risk of sepsis (21.4% vs. 0%; OR, 49.2; 95% CI: 14.5-166.8; P < 0.001), pneumonia (10.7% vs. 2.9%; OR, 4.0; 95% CI: 1.8-8.6; P = 0.001), DVT (3.6% vs. 0.4%; OR, 10.0; 95% CI: 1.8-55.5; P = 0.008), and mortality (5.4% vs. 1.8%; OR, 3.0; 95% CI: 1.1-8.5; P = 0.02). Finally, postoperative index deep/organ SSI increased the risk of pneumonia (13.0% vs. 0.9%; OR, 16.7; 95% CI: 1.6-168.2; P = 0.017), prolonged ventilation (21.7% vs. 0.9%; OR, 30.8; 95% CI: 3.4-279.4; P = 0.002), and sepsis (13.0% vs. 0.9%; OR, 16.7; 95% CI: 1.6-168.2; P = 0.017).

CONCLUSIONS

A postoperative nosocomial infection after open AAA repair is significantly more likely to lead to serious subsequent complications. Prevention and early identification of infectious index complications and subsequent complications could allow for interventions that could decrease morbidity and mortality.

Impact of an Infection Control and Antimicrobial Stewardship Program on Solid Organ Transplantation and Hepatobiliary Surgical Site Infections

OBJECTIVE

The goal of this long-term quasi-experimental retrospective study was to assess the impact of a 5-year serial infection control and antimicrobial stewardship intervention on surgical site infections (SSIs).

METHODS

This study was conducted in a tertiary-care public teaching institution over a 5-year period from January 2010 to December 2014. All patients undergoing hepatobiliary surgery and liver, kidney, pancreas, and simultaneous pancreas–kidney transplantation were included. Outcomes were compared between a preintervention group (2010–2011) and a postintervention group (2012–2014).

RESULTS

A total of 1,424 procedures averaged an overall SSI rate of 11.2%. After implementation of the interventions, a decrease of 52.8% in SSI rates from 17.4% to 8.2% was observed (P<.001; odds ratio [OR], 2.1; 95% confidence interval [CI], 1.5–2.9). An overall significant decrease >50% (relative rate; P<.001) was observed in superficial incisional and organ-space infections between pre- and postintervention groups. In addition, a 54.9% decrease from 19.7% to 8.9% (P<.001; OR, 2.2; 95% CI, 1.4–3.5) and a 51.6% decrease from 15.5% to 7.5% (P=.001; OR, 2.2; 95% CI, 1.4–3.5) were observed for SSI rates in hepatobiliary surgery and solid organ transplantation, respectively. The antimicrobial stewardship intervention increased overall conformity to the internal surgical prophylaxis protocol by 15.2% (absolute rate) from 45.1% to 60.3% (P<.003; 95% CI, 5.4–24.9).

CONCLUSIONS

A long-term serial infection control and antimicrobial stewardship intervention decreased SSIs among patients undergoing hepatobiliary surgery and liver, kidney, pancreas, and simultaneous pancreas–kidney transplantation.

Infect Control Hosp Epidemiol 2016;1468–1474