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Effect of pharmacist intervention on antibiotic prophylaxis in orthopedic internal fixation: A retrospective study. Res Social Adm Pharm 2023; 19:301-307. [PMID: 36266174 DOI: 10.1016/j.sapharm.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 09/16/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Despite the availability of guidelines and official policies, antibiotic prophylaxis in clean surgery remains suboptimal. OBJECTIVE The aim of this study was to evaluate the clinical effects and cost-effectiveness of pharmacist-led intervention in the perioperative anti-infection prophylaxis of patients undergoing orthopedic internal fixation. METHODS We performed a retrospective analysis based on the medical records of internal fixation surgery in a tertiary hospital from July 2019 to June 2020. Data were divided into two groups based on whether a full-time pharmacist participated in the treatment. The research parameters included use of antibiotics, rationality of medication, postoperative complications, and related cost. To deal with selection bias, propensity score matching method was employed at a ratio of 1:1. Meanwhile, a cost-effectiveness analysis was used to evaluate the impact of pharmacist intervention on antibiotic prevention in internal fixation surgery. RESULTS A total of 537 participants were included in this study. After matching, 236 patients were comparable in each group. During the pharmacist intervention period, less pharmacologic prophylaxis (96.6% vs 100.0%, p = 0.007) and shorter prophylaxis duration (1.60 vs 2.28 days, p < 0.001) were observed. The reasonable rate increased dramatically in usage and dosage (96.6% vs 83.9%, p < 0.001), timing of administration (94.5% vs 78.4%, p < 0.001) and medication duration (64.4% vs 37.7%, p < 0.001). In addition, pharmacist intervention yielded net economic benefits. A remarkable reduction was observed in average length of stay (10.43 vs 11.14 days, p = 0.012), drug cost ($610.57 vs $706.60, p = 0.001) and defined daily doses (2.31 vs 3.27, p < 0.001). The cost-effectiveness ratios, divided drug cost savings by cost of pharmacist time, were 28:1 for drug and 2:1 for antibiotics, respectively. CONCLUSION Pharmacist-driven antibiotic stewardship for orthopedic internal fixation patients improved compliance with peri-procedure antibiotic prophylaxis, and reduced the cost and utilization of antibiotics. This helped to bring significant clinical and economic benefits.
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Ailaney N, Zielinski E, Doll M, Bearman GM, Kates SL, Golladay GJ. Variation in practice for preoperative antibiotic prophylaxis: a survey from an academic tertiary referral center in the United States. Patient Saf Surg 2021; 15:36. [PMID: 34706755 PMCID: PMC8549297 DOI: 10.1186/s13037-021-00308-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 09/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background Antibiotic surgical prophylaxis is a core strategy for prevention of surgical site infections (SSI). Despite best practice guidelines and known efficacy of antibiotic prophylaxis in decreasing SSI risk, there is often wide variation in its use. This study was designed to determine the individual perspectives of perioperative providers at an academic tertiary referral center regarding their knowledge of preoperative antibiotic choice, dosing, and timing. Methods A prospective survey was conducted amongst surgical and anesthesia team members involved in preoperative antibiotic decision making. The survey addressed ten key principles relating to preoperative antibiotic use, including antibiotic choice, timing and rate of infusion, and dosing. The survey was distributed among orthopaedic surgeons, residents, and anesthesia providers at their respective monthly service line meetings between August 2017 to June 2019. The data was stored and analyzed in a Microsoft Excel worksheet. Results A total of 73 providers completed the survey. Twenty-two (30 %) of the providers agreed and 47 (64 %) disagreed that both vancomycin and cefazolin are equally effective for antibiotic prophylaxis. As for antibiotic choice in patients with penicillin allergies, 37 (51 %) agreed with vancomycin, 21 (29 %) agreed with clindamycin, and 15 (21 %) disagreed with both alternatives. When providers were surveyed regarding the appropriateness of standard versus weight adjusted dosing, 67 (92 %) agreed that vancomycin should be weight adjusted and 63 (86 %) agreed that cefazolin should be weight adjusted. Conclusions There is no clear consensus amongst providers for which antibiotic to administer for antibiotic prophylaxis despite existing guidelines. Discrepancy also exists between orthopaedic surgery and anesthesia providers in regards to appropriate antibiotic choice for patients with reported penicillin allergies. Institutions should implement evidence-based protocols for preoperative antibiotic prophylaxis and continue to prospectively monitor compliance in order to identify any inconsistencies that could result in inappropriate antibiotic prophylaxis for patients.
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Affiliation(s)
- Nikhil Ailaney
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, 1200 Broad Street, 9th Floor, VA, 23298, Richmond, USA.
| | - Elizabeth Zielinski
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, VA, 23298, Richmond, USA
| | - Michelle Doll
- Department of Infectious Disease, Virginia Commonwealth University Health, VA, 23298, Richmond, USA
| | - Gonzalo M Bearman
- Department of Infectious Disease, Virginia Commonwealth University Health, VA, 23298, Richmond, USA
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, VA, 23298, Richmond, USA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, VA, 23298, Richmond, USA
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Neuwirth MM, Marche B, Kugler C, Bures D, Sauerland D, Herbrandt S, Ligges U, Mattner F, Otchwemah R. Evidence of the medical and economic benefits of implementing hygiene measures by a prevention link physician in trauma surgery: Study protocol for a biphasic multicenter prospective interventional pre-post cohort study using a structured intervention bundle development and tools of behavior change management. Contemp Clin Trials Commun 2021; 23:100815. [PMID: 34286158 PMCID: PMC8274293 DOI: 10.1016/j.conctc.2021.100815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The German Commission for Hospital Hygiene and Infection Prevention recommends nominating one authorized medical specialist in every medical department as an infection prevention link physician (PLP). It has been roughly described that a PLP serves as a link between the infection prevention team and the respective clinical departments. No detailed evidence about the contribution made by PLPs to the decrease of infection rates is available in Germany. The "HygArzt" project aims to demonstrate the medical and economic benefits of the implementation of hygiene measures by PLP in trauma surgery/orthopedics. METHODS A multicenter interventional pre/post cohort study design was chosen. The study will run for a three-year period, including a pre-, post-, and an intervention phase, in four different hospitals, one of which will serve as pilot. A complex intervention containing evidence-based infection control measures will be developed and implemented by a PLP to proof efficacy. After the successful implementation of the preventive measures in the pilot hospital, the concept will be transposed to the three remaining trauma and orthopedic departments to confirm the transferability and generalizability. To enable the PLPs of the non-pilot departments, a subject-specific training program will be developed based on the study results of the pilot hospital and offered to the PLPs. DISCUSSION Data are intended to provide evidence that and, if so, to which extent the implementation of specific preventive measures by a medical department-specific PLP is possible and results in a reduction of nosocomial infections in orthopedic surgery and traumatology. CONTRIBUTION TO THE LITERATURE The present study describes a novel complex study design to prove the effectiveness of intervention measures for infection prevention. The study design and newly developed methodological approach could serve as a model for similar studies on infection prevention in the future. For the first time, the presented research project "HygArzt" focuses on the implementation of hygiene measures by an infection prevention link physician (PLP) and investigates whether nosocomial infections, especially surgical site infections, can be reduced by the measures implemented. TRIAL REGISTRATION German clinical Trials register DRKS-ID:00013,296. Registered on March 5, 2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013296.
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Affiliation(s)
- Meike M. Neuwirth
- Institute of Hygiene, Cologne Merheim Medical Center, University Hospital Witten/Herdecke Cologne, Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
- Witten/Herdecke University, Division of Hygiene and Environmental Medicine, Cologne, Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Benedikt Marche
- Division of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, University Hospital Witten/Herdecke Cologne, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Christiane Kugler
- Institute for Nursing Sciences, Albert-Ludwigs-Universität Freiburg, Breisacher Straße 153, 79110 Freiburg, Germany
| | - Dominik Bures
- Witten/Herdecke University, Faculty of Economics, Chair for Institutional Economics and Health Police, Witten, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Dirk Sauerland
- Witten/Herdecke University, Faculty of Economics, Chair for Institutional Economics and Health Police, Witten, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Swetlana Herbrandt
- TU Dortmund, Center for Statistical Consulting and Analysis, Vogelpothsweg 87, 44227 Dortmund, Vogelpothsweg 87, 44227 Dortmund, Germany
| | - Uwe Ligges
- TU Dortmund, Center for Statistical Consulting and Analysis, Vogelpothsweg 87, 44227 Dortmund, Vogelpothsweg 87, 44227 Dortmund, Germany
| | - Frauke Mattner
- Institute of Hygiene, Cologne Merheim Medical Center, University Hospital Witten/Herdecke Cologne, Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
- Witten/Herdecke University, Division of Hygiene and Environmental Medicine, Cologne, Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Robin Otchwemah
- Institute of Hygiene, Cologne Merheim Medical Center, University Hospital Witten/Herdecke Cologne, Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
- Witten/Herdecke University, Division of Hygiene and Environmental Medicine, Cologne, Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
- Division of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, University Hospital Witten/Herdecke Cologne, Ostmerheimer Str. 200, 51109 Cologne, Germany
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Hassan S, Chan V, Stevens J, Stupans I. Factors that influence adherence to surgical antimicrobial prophylaxis (SAP) guidelines: a systematic review. Syst Rev 2021; 10:29. [PMID: 33453730 PMCID: PMC7811740 DOI: 10.1186/s13643-021-01577-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 01/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite the extensive research that has been conducted to date, practice often differs from established guidelines and will vary between individuals and organisations. It has been noted that the global uptake of local and international surgical antimicrobial prophylaxis (SAP) guidelines is poor with limited research investigating factors that affect guideline adherence. The purpose of this systematic review was to determine the reported barriers and enablers to the adherence of SAP guidelines. METHODS A search of the literature was performed using four electronic databases (CINAHL, EMBASE, PubMed and SCOPUS) for articles published in the English language from January 1998 to December 2018. Articles were included if they were solely related to SAP and discussed the barriers or enablers to SAP guideline adherence. Articles that assessed the adherence to a range of infection control measures or discussed adherence to antibiotic treatment guidelines rather than SAP guidelines were excluded from this review. Barriers and enablers were mapped to the Theoretical Domains Framework (TDF). The Mixed Methods Appraisal Tool was used to assess the quality of included studies. RESULTS A total of 1489 papers were originally retrieved, with 48 papers meeting the eligibility criteria. Barriers and enablers were mapped to 11 out of 14 TDF domains: knowledge, skills, social/professional role and identity, beliefs about capabilities, beliefs about consequences, reinforcement, memory, attention and decision processes, environmental context and resources, social influences, emotion and behavioural regulation. Barriers were further categorised into personal or organisational barriers, while enablers were arranged under commonly trialled interventions. CONCLUSIONS There are numerous factors that can determine the uptake of SAP guidelines. An identification and understanding of these factors at a local level is required to develop tailored interventions to enhance guideline adherence. Interventions, when used in combination, can be considered as a means of improving guideline use.
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Affiliation(s)
- Sarah Hassan
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia.
| | - Vincent Chan
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Julie Stevens
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Ieva Stupans
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
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Assessment of implementation of antibiotic stewardship program in surgical prophylaxis at a secondary care hospital in Ras Al Khaimah, United Arab Emirates. Sci Rep 2021; 11:1042. [PMID: 33441843 PMCID: PMC7806636 DOI: 10.1038/s41598-020-80219-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/17/2020] [Indexed: 02/05/2023] Open
Abstract
Antibiotic overuse is a major factor for causing antibiotic resistance globally. However, only few studies reported the implementation and evaluation of antimicrobial stewardship programs in Gulf Cooperation Council. This study was conducted within 8-months periods to evaluate the effect of the newly implemented antibiotic stewardship program on improving the prescribing practice of surgical antibiotic prophylaxis in a secondary care hospital in the United Arab Emirates by releasing local hospital guidelines. The data of 493 in patients were documented in the predesigned patient profile form and the prescribing practice of surgical antibiotic prophylaxis for clean and clean-contaminant surgical procedures was compared and analyzed two months’ prior (period A) and post (period B) the implementation of antibiotic stewardship program. The 347 patient’s data (PD) were analyzed during period A and 146 PD during period B. The prescription of piperacillin/tazobactam was decreased from 2.4% from all surgical prophylaxis antibiotic orders in period A to 0% in period B. The appropriateness of the antibiotic therapy was found to differ non significantly for the selection of prophylactic antibiotic (p = 0.552) and for the timing of first dose administration (p = 0.061) between A and B periods. The total compliance was decreased non significantly (P = 0.08) from 45.3 to 40.2%. Overall, the guidelines have improved the prescribing practice of antibiotics prior to surgery. However, further improvement can be achieved by initiating educational intervention via cyclic auditing strategy.
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The effect of change in educational model on surgical antimicrobial prophylaxis. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.759830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Salm L, Marti WR, Stekhoven DJ, Kindler C, Von Strauss M, Mujagic E, Weber WP. Impact of bodyweight-adjusted antimicrobial prophylaxis on surgical-site infection rates. BJS Open 2020; 5:6044705. [PMID: 33688947 PMCID: PMC7944861 DOI: 10.1093/bjsopen/zraa027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/30/2020] [Accepted: 09/19/2020] [Indexed: 12/12/2022] Open
Abstract
Background Antimicrobial prophylaxis (AMP) adjustment according to bodyweight to prevent surgical-site infections (SSI) is controversial. The impact of weight-adjusted AMP dosing on SSI rates was investigated here. Methods Results from a first study of patients undergoing visceral, vascular or trauma operations, and receiving standard AMP, enabled retrospective evaluation of the impact of bodyweight and BMI on SSI rates, and identification of patients eligible for weight-adjusted AMP. In a subsequent observational prospective study, patients weighing at least 80 kg were assigned to receive double-dose AMP. Risk factors for SSI, including ASA classification, duration and type of surgery, wound class, diabetes, weight in kilograms, BMI, age, and AMP dose, were evaluated in multivariable analysis. Results In the first study (3508 patients), bodyweight and BMI significantly correlated with higher rates of all SSI subclasses (both P < 0.001). An 80-kg cut-off identified patients receiving single-dose AMP who were at higher risk of SSI. In the prospective study (2161 patients), 546 patients weighing 80 kg or more who received only single-dose AMP had higher rates of all SSI types than a group of 1615 who received double-dose AMP (odds ratio (OR) 4.40, 95 per cent c.i. 3.18 to 6.23; P < 0.001). In multivariable analysis including 5021 patients from both cohorts, bodyweight (OR 1.01, 1.00 to 1.02; P = 0.008), BMI (OR 1.01, 1.00 to 1.02; P = 0.007) and double-dose AMP (OR 0.33, 0.23 to 0.46; P < 0.001) among other variables were independently associated with SSI rates. Conclusion Double-dose AMP decreases SSI rates in patients weighing 80 kg or more.
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Affiliation(s)
- L Salm
- Department of General Surgery, Kantonsspital Aarau, Aarau, Switzerland
| | | | - D J Stekhoven
- NEXUS Personalized Health Technologies, ETH Zurich, Zurich, Switzerland
| | - C Kindler
- Department of Anaesthesia, Kantonsspital Aarau, Aarau, Switzerland
| | - M Von Strauss
- Department of General Surgery, University Hospital Basle, Basle, Switzerland
| | - E Mujagic
- Department of General Surgery, University Hospital Basle, Basle, Switzerland
| | - W P Weber
- Department of General Surgery, University Hospital Basle, Basle, Switzerland
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Prévost N, Gaultier A, Birgand G, Mocquard J, Terrien N, Rochais E, Dumont R. Compliance with antibiotic prophylaxis guidelines in surgery: Results of a targeted audit in a large-scale region-based French hospital network. Infect Dis Now 2020; 51:170-178. [PMID: 33068683 DOI: 10.1016/j.medmal.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/20/2019] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION While regional monitoring of antibiotic use has decreased since 2011 by 3.2%, in some healthcare facilities a significant increase (+43%) has occurred. The purpose of this study was to assess regional antibiotic prophylaxis (ABP) compliance with national guidelines. MATERIAL AND METHODS In 2015, 26 healthcare facilities, both public and private, were requested to audit five items: utilization of antibiotic prophylaxis, the antimicrobial agent (the molecule) administered, time between injection and incision, initial dose, number of intraoperative and postoperative additional doses. Seven surgical procedures were selected for assessment: appendicectomy (APP), cataract (CAT), cesarean section (CES), colorectal cancer surgery (CCR), hysterectomy (HYS), total hip arthroplasty (THA) and transurethral resection of the prostate (TURP). A statistical analysis of the 2303 records included was carried out. RESULTS The general rate of antibiotic prophylaxis compliance was 64%. The antimicrobial agent used and initial dose were in compliance with the guidelines for 93% and 97.4% of cases respectively, and administration of antibiotic prophylaxis was achieved 60minutes before incision in 77.6% of the records included. Regarding gastrointestinal surgery, amoxicillin/clavulanic acid was used in 32% of patients. In 26% of appendectomy files, administration occurred after incision, and one out of two files showed non-complaint perioperative and postoperative consumption. CONCLUSION Compliance with nationwide ABP guidelines is in need of pronounced improvement, especially with regard to time interval between injection and incision and the molecule prescribed. An action plan based on specific recommendations addressed to each establishment and an updated regionwide ABP protocol are aimed at achieving better and reduced consumption of antimicrobial agents.
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Affiliation(s)
- N Prévost
- Observatoire du médicament, des dispositifs médicaux et de l'innovation thérapeutique (OMEDIT) Pays de la Loire, 85, rue Saint-Jacques, 44093 Nantes, France
| | - A Gaultier
- Réseau Qualirel santé, 85, rue Saint-Jacques, 44093 Nantes, France
| | - G Birgand
- CPias Pays de la Loire, CHU de Nantes, 5, rue Professeur Yves-Boquien, 44093 Nantes, France
| | - J Mocquard
- Observatoire du médicament, des dispositifs médicaux et de l'innovation thérapeutique (OMEDIT) Pays de la Loire, 85, rue Saint-Jacques, 44093 Nantes, France
| | - N Terrien
- Réseau Qualirel santé, 85, rue Saint-Jacques, 44093 Nantes, France
| | - E Rochais
- Observatoire du médicament, des dispositifs médicaux et de l'innovation thérapeutique (OMEDIT) Pays de la Loire, 85, rue Saint-Jacques, 44093 Nantes, France.
| | - R Dumont
- CHU de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes, France
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Velasco-Arnaiz E, Simó-Nebot S, Ríos-Barnés M, López Ramos MG, Monsonís M, Urrea-Ayala M, Jordan I, Mas-Comas A, Casadevall-Llandrich R, Ormazábal-Kirchner D, Cuadras-Pallejà D, Pérez-Pérez C, Millet-Elizalde M, Sánchez-Ruiz E, Fortuny C, Noguera-Julian A. Benefits of a Pediatric Antimicrobial Stewardship Program in Antimicrobial Use and Quality of Prescriptions in a Referral Children's Hospital. J Pediatr 2020; 225:222-230.e1. [PMID: 32522527 DOI: 10.1016/j.jpeds.2020.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/11/2020] [Accepted: 06/03/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To evaluate the results of the first 24 months of a postprescription review with feedback-based antimicrobial stewardship program in a European referral children's hospital. STUDY DESIGN We performed a pre-post study comparing antimicrobial use between the control (2015-2016) and the intervention periods (2017-2018) expressed in days of therapy/100 days present. Quality of prescriptions was evaluated by quarterly cross-sectional point-prevalence surveys. Length of stay, readmission rates, in-hospital mortality rates, cost of systemic antimicrobial agents, and antimicrobial resistance rates were included as complementary outcomes. RESULTS Total antimicrobial use and antibacterial use significantly decreased during the intervention period (P = .002 and P = .001 respectively), and total antifungal use remained stable. A significant decline in parenteral antimicrobial use was also observed (P < .001). In 8 quarterly point-prevalence surveys (938 prescriptions evaluated), the mean prevalence of use of any antimicrobial among inpatients was 39%. An increasing trend in the rate of optimal prescriptions was observed after the first point-prevalence survey (P = .0898). Nonoptimal prescriptions were more common in surgical than in medical departments, in antibacterial prescriptions with prophylactic intention, and in empirical more than in targeted treatments. No significant differences were observed in terms of mortality or readmission rates. Only minor changes in antimicrobial resistance rates were noted. CONCLUSIONS Our antimicrobial stewardship program safely decreased antimicrobial use and expenditure, and a trend toward improvement in quality of prescription was also observed.
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Affiliation(s)
- Eneritz Velasco-Arnaiz
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain
| | - Silvia Simó-Nebot
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain; Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - María Ríos-Barnés
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain
| | | | - Manuel Monsonís
- Clinical Microbiology Department, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Mireia Urrea-Ayala
- Infection Control Department, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Iolanda Jordan
- Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Pediatric Intensive Care Unit, Sant Joan de Déu Hospital, Barcelona, Spain; Department of Pediatrics, University of Barcelona, Barcelona, Spain; Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Anna Mas-Comas
- Pharmacy Department, Sant Joan de Déu Hospital, Barcelona, Spain
| | | | | | | | | | | | - Emilia Sánchez-Ruiz
- Blanquerna School of Health Science, Ramon Llull University, Barcelona, Spain
| | - Clàudia Fortuny
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain; Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Pediatrics, University of Barcelona, Barcelona, Spain; Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Antoni Noguera-Julian
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain; Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Pediatrics, University of Barcelona, Barcelona, Spain; Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain.
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Snyder E, Mohan C, Michael J, Ross S. Inclusion of surgical antibiotic regimens in pediatric urology publications: A systematic review. J Pediatr Urol 2020; 16:595.e1-595.e7. [PMID: 32641230 DOI: 10.1016/j.jpurol.2020.05.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/27/2020] [Accepted: 05/14/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Perioperative antibiotics prevent infections after surgery. Guidelines for antibiotic use allow the surgeon to balance the risks of adverse events and drug resistance with the benefit of reduced infection rates. However, due to a lack of evidence-based guidelines within pediatric urology, antibiotic practices vary widely. We performed a systematic literature review to investigate when and how authors report their antibiotic usage and infectious outcomes. Our aim was to analyze the available data on perioperative antibiotics and infection rates within pediatric urology. METHODS This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search strategy was devised to identify reports of pediatric urology surgery and use of antibiotics or infectious outcomes. Embase and Medline were queried with no year restrictions with subject heading terms to identify publications on common pediatric urology surgeries. The procedures studied were hypospadias repair, pyeloplasty, orchidopexy, ureteral reimplant, and circumcision. Two independent reviewers screened all titles and abstracts, followed by relevant full texts, for eligibility. Articles were included if the procedure was performed on the majority of study patients, the procedure was performed by urologic surgeons, and the population studied was a pediatric population defined as 0-18 years of age. Case reports, meta-analyses, and editorials were excluded. Data was extracted by one independent reviewer into a preformatted database. Collected data included journal type, date of publication, patient demographics, preoperative and postoperative antibiotic details including regimens, and infection outcomes. The primary outcome was reporting of antibiotic use preoperatively or postoperatively. Secondary outcomes included: reporting of infection, antibiotic class and dosage. Since all studies were diverse, only qualitative analysis was conducted. RESULTS We identified 1483 publications with 297 meeting inclusion criteria. Of these, 9% reported their use of preoperative antibiotics, and 34% reported their use of postoperative antibiotics. Only 6% of studies reported the specific antibiotic class, 15% reported duration, and 1% reported dosage and frequency. Infection outcomes were reported in 58% of studies. Only 57% of studies that reported on infection outcomes described their antibiotics practices. CONCLUSIONS Surgical antibiotic regimens and infection outcomes are infrequently included in pediatric urology studies, limiting the data available for development of evidence-based guidelines. Routine incorporation of antibiotic regimens, infection outcomes and adverse events in the pediatric urology literature will increase our ability to identify indications for antibiotics. Reporting of perioperative antibiotic outcomes in pediatric urology procedures will allow the eventual development of strong evidence-based guidelines.
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Affiliation(s)
- Elizabeth Snyder
- University of North Carolina (UNC) Department of Urology, 101 Manning Dr, Chapel Hill NC, 27514, United States.
| | | | | | - Sherry Ross
- UNC Department of Urology, North Carolina Children's Hospital, United States
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Effectiveness and Sustainability of an Antimicrobial Stewardship Program for Perioperative Prophylaxis in Pediatric Surgery. Pathogens 2020; 9:pathogens9060490. [PMID: 32575542 PMCID: PMC7350339 DOI: 10.3390/pathogens9060490] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/15/2020] [Accepted: 06/17/2020] [Indexed: 11/30/2022] Open
Abstract
Background—Appropriate perioperative antibiotic prophylaxis (PAP) is essential to prevent surgical site infections (SSIs) and to avoid antibiotics misuse. Aim—The aim of this study is to determine the effectiveness and long-term sustainability of an antimicrobial stewardship program (ASP), based on a clinical pathway (CP) and periodic education, to improve adherence to the guidelines for PAP in a tertiary care pediatric surgery center. Methods—We assessed the changes in PAP correctness and its effect on SSIs between the six months before and the 24 months after the implementation of ASP in the Pediatric Surgery Unit of the Department of Women’s and Children’s Health of Padova. The ASP was addressed to all surgeons and anesthesiologists of the Pediatric Surgery Unit. The primary outcome was appropriateness of PAP (agent, timing of the first dose, and duration). SSI rate was the secondary outcome. Results—1771 patients were included in the study and 676 received PAP. The overall correctness of the PAP, in terms of agent, timing, and duration, increased significantly after the CP implementation. What changed most was the PAP discontinuation within 24 h (p < 0.001). Cefazolin was the most used antibiotic, with a significant increase in the post-intervention period (p < 0.001) and with a reduction in the use of other broad-spectrum antibiotics. No variations in the incidence of SSIs were reported in the five periods (p = 0.958). Conclusion—The implementation of an ASP based on CP and education is an effective and sustainable antimicrobial stewardship tool for improving the correct use of PAP.
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Pough K, Bhakta R, Maples H, Honeycutt M, Vijayan V. Evaluation of Pediatric Surgical Site Infections Associated with Colorectal Surgeries at an Academic Children's Hospital. Healthcare (Basel) 2020; 8:healthcare8020091. [PMID: 32283686 PMCID: PMC7348892 DOI: 10.3390/healthcare8020091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/04/2020] [Accepted: 04/05/2020] [Indexed: 01/22/2023] Open
Abstract
Appropriate use of antibiotic prophylaxis (AP) is a key measure for the prevention of surgical site infections (SSI) in colorectal surgeries; however, despite the presence of national and international guidelines, compliance with AP recommendations remains low. The purpose of this study is to evaluate compliance with recommendations for the use of AP in children undergoing colorectal surgeries and to evaluate the effectiveness of antibiotics in the prevention of SSI. We collected demographic and clinical characteristics of patients who underwent colorectal surgeries, as well as microbiological and antimicrobial susceptibility data for patients who developed SSI. AP data were collected and compared with national guidelines. Antibiotic dosing and duration were most frequently in concordance with national guidelines, while antibiotic timing and selection had the lowest rates of compliance. Twelve of the 192 colorectal procedures evaluated resulted in SSI. Only 2 of the 12 children with SSI received appropriate AP for all four categories evaluated. Eight cases that resulted in SSI were due to organisms not covered by the recommended AP. We identified multiple areas for the improvement of AP in children undergoing colorectal surgery. A multidisciplinary approach to development of standardized protocols, educational interventions, and EHR-based algorithms may facilitate or improve appropriate AP use.
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Affiliation(s)
- Kimberly Pough
- Department of Pharmacy Practice, Arkansas Children’s Hospital, Little Rock, AR 72202, USA;
- Department of Pharmacy Practice, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA
- Correspondence:
| | - Rima Bhakta
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Holly Maples
- Department of Pharmacy Practice, Arkansas Children’s Hospital, Little Rock, AR 72202, USA;
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Michele Honeycutt
- Department of Infection Prevention and Hospital Epidemiology, Arkansas Children’s Hospital, Little Rock, AR 72202, USA;
| | - Vini Vijayan
- Division of Infectious Diseases, Department of Pediatrics, Valley Children’s Hospital, Madera, CA 93636, USA;
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Shadmehr MB, Alaeen Z, Baniasadi S. Adherence to American Society of Health‐System Pharmacists guidelines for antibiotic prophylaxis in thoracic surgery: a prospective observational study. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Mohammad Behgam Shadmehr
- Tracheal Diseases Research Center National Research Institute of Tuberculosis and Lung Diseases Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Zeinab Alaeen
- Department of Clinical Pharmacy Faculty of Pharmacy Pharmaceutical Sciences Branch Islamic Azad University Tehran Iran
| | - Shadi Baniasadi
- Tracheal Diseases Research Center National Research Institute of Tuberculosis and Lung Diseases Shahid Beheshti University of Medical Sciences Tehran Iran
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Cassidy MR, Rosenkranz P, Macht RD, Talutis S, McAneny D. The I COUGH Multidisciplinary Perioperative Pulmonary Care Program: One Decade of Experience. Jt Comm J Qual Patient Saf 2020; 46:241-249. [PMID: 32122711 DOI: 10.1016/j.jcjq.2020.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/14/2020] [Accepted: 01/23/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Surgical quality improvement programs can provide meaningful benefits for patient outcomes, but sustainability of initial success is rarely described. In response to data that revealed a greater than predicted likelihood of postoperative pulmonary complications in one hospital, the study team designed a standardized program to improve care. This study offers a long-term perspective of the effort, including special challenges and lessons learned about sustaining success. METHODS A before-after study was conducted at an academic safety-net hospital. A multidisciplinary team developed tactics to reduce pulmonary complications, designated by the acronym I COUGH: Incentive spirometry, Coughing/deep breathing, Oral care, Understanding (education), Getting out of bed, and Head of bed elevation. Clinical practices were audited and compared to actual and risk-adjusted pulmonary outcomes. RESULTS Improvements in compliance with the I COUGH elements were initially promising, but baseline behaviors eventually returned. Adverse outcomes have inversely correlated with process adherence in "sawtooth" patterns. Rejuvenation efforts have successively extended beyond the literal principles of the acronym to foster broader institutional commitment to perioperative pulmonary care, restoring favorable trends in both process and outcomes. A more comprehensive I COUGH program now extends beyond the acronym, applying numerous concepts to support the original program. CONCLUSION I COUGH, a standardized perioperative pulmonary care program, initially improved performance and reduced pulmonary complications. However, loss of early program momentum corresponded with a return to baseline outcomes. Fortunately, an overall favorable trend has resulted from a coordinated rededication to I COUGH that requires steadfast commitment and creative responses to numerous cultural barriers.
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Donà D, Barbieri E, Daverio M, Lundin R, Giaquinto C, Zaoutis T, Sharland M. Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review. Antimicrob Resist Infect Control 2020; 9:3. [PMID: 31911831 PMCID: PMC6942341 DOI: 10.1186/s13756-019-0659-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.
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Affiliation(s)
- D. Donà
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
- Pediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
- Fondazione Penta ONLUS, Padua, Italy
| | - E. Barbieri
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
| | - M. Daverio
- Pediatric intensive care unit, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - R. Lundin
- Fondazione Penta ONLUS, Padua, Italy
| | - C. Giaquinto
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
- Fondazione Penta ONLUS, Padua, Italy
| | - T. Zaoutis
- Fondazione Penta ONLUS, Padua, Italy
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - M. Sharland
- Pediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
- Fondazione Penta ONLUS, Padua, Italy
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Bertschi D, Weber WP, Zeindler J, Stekhoven D, Mechera R, Salm L, Kralijevic M, Soysal SD, von Strauss M, Mujagic E, Marti WR. Antimicrobial Prophylaxis Redosing Reduces Surgical Site Infection Risk in Prolonged Duration Surgery Irrespective of Its Timing. World J Surg 2019; 43:2420-2425. [PMID: 31292675 DOI: 10.1007/s00268-019-05075-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Long-duration surgery requires repeated administration of antimicrobial prophylaxis (amp). Amp "redosing" reduces incidence of surgical site infections (SSI) but is frequently omitted. Clinical relevance of redosing timing needs to be investigated. Here, we evaluated the effects of compliance with amp redosing and its timing on SSI incidence in prolonged duration surgery. METHODS Data from >9000 patients undergoing visceral, trauma, or vascular surgery with elective or emergency treatment in two tertiary referral Swiss hospitals were analyzed. All patients had to receive amp preoperatively and redosing, if indicated. Antibiotics used were cefuroxime (1.5 or 3 g, if weight >80 kg), or cefuroxime and metronidazole (1.5 and 0.5 g, or 3 and 1 g doses, if weight >80 kg). Alternatively, in cases of known or suspected allergies, vancomycin (1 g), gentamicin (4 mg/Kg), and metronidazole or clindamycin (300 mg) with or without ciprofloxacin (400 mg) were used. Association of defined parameters, including wound class, ASA scores, and duration of operation, with SSI incidence was explored. RESULTS In the whole cohort, SSI incidence significantly correlated with duration of surgery (ρ = 0.73, p = 0.031). In 593 patients undergoing >240 min long interventions, duration of surgery was the only parameter significantly (p < 0.001) associated with increased SSI risk, whereas wound class, ASA scores, treatment areas, and emergency versus elective hospital entry were not. Redosing significantly reduced SSI incidence as shown by multivariate analysis (OR 0.60, 95% CI 0.37-0.96, p = 0.034), but exact timing had no significant impact. CONCLUSIONS Long-duration surgery associates with higher SSI incidence. Irrespective of its exact timing, amp redosing significantly decreases SSI risk.
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Affiliation(s)
- Daniela Bertschi
- Department of Visceral Surgery, Kantonsspital Chur, Chur, Switzerland
| | - Walter P Weber
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Jasmin Zeindler
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Daniel Stekhoven
- NEXUS Personalized Health Technologies, ETH Zurich, Zurich, Switzerland
| | - Robert Mechera
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Lilian Salm
- Department of Visceral Surgery, Kantonsspital Aarau, Chirurgieaarau, Bahnhofstrasse 24, 5000, Aarau, Switzerland
| | - Marco Kralijevic
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Savas D Soysal
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Marco von Strauss
- Department of Visceral Surgery, Kantonsspital Aarau, Chirurgieaarau, Bahnhofstrasse 24, 5000, Aarau, Switzerland
| | - Edin Mujagic
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Walter R Marti
- Department of Visceral Surgery, Kantonsspital Aarau, Chirurgieaarau, Bahnhofstrasse 24, 5000, Aarau, Switzerland.
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The timing and redosing of perioperative antimicrobial prophylaxis in Greek children. Infect Control Hosp Epidemiol 2019; 40:1318-1319. [PMID: 31526403 DOI: 10.1017/ice.2019.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Effects of an antimicrobial stewardship intervention on perioperative antibiotic prophylaxis in pediatrics. Antimicrob Resist Infect Control 2019; 8:13. [PMID: 30675340 PMCID: PMC6334390 DOI: 10.1186/s13756-019-0464-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/03/2019] [Indexed: 11/13/2022] Open
Abstract
Purpose This study aims to determine the effectiveness of an Antimicrobial Stewardship Program based on a Clinical Pathway (CP) to improve appropriateness in perioperative antibiotic prophylaxis (PAP). Materials and methods This pre-post quasi-experimental study was conducted in a 12 month period (six months before and six months after CP implementation), in a tertiary Pediatric Surgical Centre. All patients from 1 month to 15 years of age receiving one or more surgical procedures were eligible for inclusion. PAP was defined appropriate according to clinical practice guidelines. Results Seven hundred sixty-six children were included in the study, 394 in pre-intervention and 372 in post-intervention. After CP implementation, there was an increase in appropriate PAP administration, as well as in the selection of the appropriate antibiotic for prophylaxis, both for monotherapy (p = 0.02) and combination therapy (p = 0.004). Even the duration of prophylaxis decreased during the post-intervention period, with an increase of correct PAP discontinuation from 45.1 to 66.7% (p < 0.001). Despite the greater use of narrow-spectrum antibiotic for fewer days, there was no increase in treatment failures (10/394 (2.5%) pre vs 7/372 (1.9%) post, p = 0.54). Conclusions CPs can be a useful tool to improve the choice of antibiotic and the duration of PAP in pediatric patients.
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Conaty O, Gaughan L, Downey C, Carolan N, Brophy MJ, Kavanagh R, McNamara DAA, Smyth E, Burns K, Fitzpatrick F. An interdisciplinary approach to improve surgical antimicrobial prophylaxis. Int J Health Care Qual Assur 2018; 31:162-172. [PMID: 29504869 DOI: 10.1108/ijhcqa-05-2017-0078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this paper is to improve surgical antimicrobial prophylaxis (SAP) prescribing in orthopaedic surgery using the model for improvement framework. Design/methodology/approach Orthopaedic patients receiving joint replacements, hip fracture repairs or open-reduction internal-fixation procedures were included. Antimicrobial(s); dose, time of administration and duration of SAP were evaluated for appropriateness based on the local SAP guidelines. After baseline data collection, a driver diagram was constructed with interventions devised for plan-do-study-act cycles. Data were fed back weekly using a point prevalence design (PPD). Interventions included SAP guideline changes, reminders and tools to support key messages. Findings SAP in 168 orthopaedic surgeries from 15 June 2016 to 31 January 2017 was studied. Prescribing appropriateness improved from 20 to 78 per cent. Junior doctor changeover necessitated additional education and reminders. Practical implications Due to constant staff changeover; continuous data collection, communication, education and reminders are essential to ensure continuous compliance with clinical guidance. Patients with hip fractures are difficult to weigh, requiring weight estimation for weight-based antimicrobial dosing. Unintended consequences of interventions included the necessity to change pre-operative workflow to accommodate reconstitution time of additional antimicrobials and inadvertent continuation of new antimicrobials post-operatively. Originality/value Rather than perform the traditional retrospective focused audit, we established a prospective, continuous, interventional quality improvement (QI) project focusing on internal processes within the control of the project team with rapid cyclical changes and interventions. The weekly PPD was pragmatic and enabled the QI project to be sustained with no additional resources.
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Affiliation(s)
- Oisín Conaty
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Pollmann AS, Bailey JG, Davis PJB, Johnson PM. Antibiotic use among older adults on an acute care general surgery service. Can J Surg 2017; 60:388-393. [PMID: 28930045 DOI: 10.1503/cjs.004317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Antibiotics play an important role in the treatment of many surgical diseases that affect older adults, and the potential for inappropriate use of these drugs is high. Our objective was to describe antibiotic use among older adults admitted to an acute care surgery service at a tertiary care teaching hospital. METHODS Detailed data regarding diagnosis, comorbidities, surgery and antibiotic use were retrospectively collected for patients 70 years and older admitted to an acute care surgery service. We evaluated antibiotic use (perioperative prophylaxis and treatment) for appropriateness based on published guidelines. RESULTS During the study period 453 patients were admitted to the acute care surgery service, and 229 underwent surgery. The most common diagnoses were small bowel obstruction (27.2%) and acute cholecystitis (11.0%). In total 251 nonelective abdominal operations were performed, and perioperative antibiotic prophylaxis was appropriate in 49.5% of cases. The most common prophylaxis errors were incorrect timing (15.5%) and incorrect dose (12.4%). Overall 206 patients received treatment with antibiotics for their underlying disease process, and 44.2% received appropriate first-line drug therapy. The most common therapeutic errors were administration of second- or third-line antibiotics without indication (37.9%) and use of antibiotics when not indicated (12.1%). There was considerable variation in the duration of treatment for patients with the same diagnoses. CONCLUSION Inappropriate antibiotic use was common among older patients admitted to an acute care surgery service. Quality improvement initiatives are needed to ensure patients receive optimal care in this complex hospital environment.
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Affiliation(s)
- André S Pollmann
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Pollmann, Bailey, Davis, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Bailey, Davis, Johnson)
| | - Jon G Bailey
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Pollmann, Bailey, Davis, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Bailey, Davis, Johnson)
| | - Philip J B Davis
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Pollmann, Bailey, Davis, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Bailey, Davis, Johnson)
| | - Paul M Johnson
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Pollmann, Bailey, Davis, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Bailey, Davis, Johnson)
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Duclos G, Zieleskiewicz L, Leone M. Antimicrobial prophylaxis is critical for preventing surgical site infection. J Thorac Dis 2017; 9:2826-2828. [PMID: 29221249 DOI: 10.21037/jtd.2017.08.81] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Gary Duclos
- Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation, Hôpital Nord, Marseille, France
| | - Laurent Zieleskiewicz
- Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation, Hôpital Nord, Marseille, France
| | - Marc Leone
- Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation, Hôpital Nord, Marseille, France
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Readmission After Gynecologic Surgery: A Comparison of Procedures for Benign and Malignant Indications. Obstet Gynecol 2017; 130:285-295. [PMID: 28697106 DOI: 10.1097/aog.0000000000002141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare 30-day postsurgical readmission rates and associated risk factors for readmission among women undergoing gynecologic surgery for benign and malignant conditions. METHODS In a retrospective cohort study, we identified patients after surgery for benign and malignant gynecologic conditions in the National Surgical Quality Improvement Program database between January 1, 2011, and December 31, 2012. Data collected included surgical factors, perioperative characteristics, surgical complications, and 30-day readmissions. The primary study outcome was readmission rates after gynecologic surgery for benign and oncologic conditions. Secondary study outcomes were risk factors associated with readmission among gynecologic surgeries performed for benign and oncologic conditions. RESULTS Approximately 3% (1,444/46,718) compared with 8.2% (623/7,641) of patients who underwent gynecologic surgery for benign and malignant indications, respectively, were readmitted (P<.01). Compared with patients with benign surgical indications, those with uterine cancer (readmission rate 6.6%; odds ratio [OR] 2.21, 95% CI 1.95-2.51), ovarian cancer (readmission rate 10.9%; OR 3.82, 95% CI 3.29-4.45), and cervical cancer (readmission rate 10.1%; OR 3.51, 95% CI 2.71-4.53) were more likely to be readmitted. In multivariable models, independent risk factors for readmission for gynecologic cancer surgery included worse preoperative conditions (OR 1.49, 95% CI 1.17-1.90) and major complications (OR 17.84, 95% CI 14.19-22.43). In comparison, independent risk factors for readmission after surgery for benign indications included comorbid conditions (OR 1.36, 95% CI 1.18-1.57), operative time (15-59 minutes: referent; 60 minutes or greater: 1.37, 95% CI 1.14-1.63) and major complications (OR 53.91, 95% CI 46.98-61.85). CONCLUSION Among gynecologic surgeries, those performed for oncologic indications were associated with readmission rates 2.8 times that of surgeries performed for benign indications. In adjusted models, worse preoperative conditions and surgical complications remained independent risk factors associated with the higher rate of readmission among patients with gynecologic cancer.
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Mueck KM, Putnam LR, Anderson KT, Lally KP, Tsao K, Kao LS. Does compliance with antibiotic prophylaxis in pediatric simple appendicitis matter? J Surg Res 2017; 216:1-8. [DOI: 10.1016/j.jss.2017.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/31/2017] [Accepted: 04/11/2017] [Indexed: 12/17/2022]
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Simonds VW, Garroutte EM, Buchwald D. Health Literacy and Informed Consent Materials: Designed for Documentation, Not Comprehension of Health Research. JOURNAL OF HEALTH COMMUNICATION 2017; 22:682-691. [PMID: 28759329 PMCID: PMC6155979 DOI: 10.1080/10810730.2017.1341565] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Minority populations with health disparities are underrepresented in research designed to address those disparities. One way to improve minority representation is to use community-based participatory methods to overcome barriers to research participation, beginning with the informed consent process. Relevant barriers to participation include lack of individual or community awareness or acceptance of research processes and purposes. These barriers are associated with limited health literacy. To inform recommendations for an improved consent process, we examined 97 consent documents and 10 associated Institutional Review Board websites to determine their health literacy demands and degree of adherence to principles of community-based research. We assessed the reading level of consent documents and obtained global measures of their health literacy demand by using the Suitability and Comprehensibility Assessment of Materials instrument. Although these documents were deemed suitable as medical forms, their readability levels were inappropriate, and they were unsuitable for educating potential participants about research purposes. We also assessed consent forms and Institutional Review Board policies for endorsement of community-based participatory principles, finding that very few acknowledged or adhered to such principles. To improve comprehension of consent documents, we recommend restructuring them as educational materials that adhere to current health literacy guidelines.
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Affiliation(s)
- Vanessa Watts Simonds
- a Department of Health and Human Development , Montana State University , Bozeman , Montana , USA
| | | | - Dedra Buchwald
- c Initiative for Research and Education to Advance Community Health , Washington State University , Seattle , Washington , USA
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Garcell HG, Arias AV, Sandoval CP, Valle Gamboa ME, Sado AB, Alfonso Serrano RN. Impact of a focused antimicrobial stewardship program in adherence to antibiotic prophylaxis and antimicrobial consumption in appendectomies. J Infect Public Health 2017; 10:415-420. [DOI: 10.1016/j.jiph.2016.06.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/17/2016] [Accepted: 06/24/2016] [Indexed: 10/21/2022] Open
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Improving antibiotic prophylaxis in gastrointestinal surgery patients: A quality improvement project. Ann Med Surg (Lond) 2017; 20:6-12. [PMID: 28663796 PMCID: PMC5480815 DOI: 10.1016/j.amsu.2017.06.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 06/05/2017] [Accepted: 06/11/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND A surgical site infection (SSI) is a frequent complication following gastrointestinal surgery, but the careful selection and administration of prophylactic antibiotics can reduce the risk. The aim of this study was to develop a package of interventions that could be used to improve surgical antibiotic prophylaxis (SAP) at our institution. METHODS A pre-post quality improvement project at a private hospital in Saudi Arabia was conducted between January 2014 until July 2016. A multidisciplinary team was assembled to identify and overcome barriers that were responsible for patients receiving suboptimal antibiotic prophylaxis. Patients were included if they had undergone surgery on their appendix, colon, rectum, or small intestine. Compliance with use of an adapted order form, as well as appropriate antibiotic selection, dosing, timing, and timing of re-dosing, were measured. Data on the rates of SSI before and after the intervention were also obtained. RESULTS Of the 269 patients included in the study, 161 (61.5%) had appendix surgery, 86 (32.8%) had colorectal surgery, and 15 (5.7%) had small bowel surgery. The surgery was performed laparoscopically in 218 (83.5%) of patients. Utilization of the adapted order form increased from 1.8% to 92.0% following the intervention (p < 0.001). Compliance with a bundle of appropriate antibiotic selection, dosing and timing improved from 47.3% to 82.2% after the intervention (p < 0.001). Additionally, there was a non-statistically significant reduction in SSI rate (9.1% vs 5.1%; p = 0.27). CONCLUSIONS Our quality improvement intervention was successful in improving SAP for patients undergoing gastrointestinal surgery at our institution.
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Putnam LR, Ostovar-Kermani TG, Le Blanc A, Anderson KT, Holzmann-Pazgal G, Lally KP, Tsao K. Surgical site infection reporting: more than meets the agar. J Pediatr Surg 2017; 52:156-160. [PMID: 27863822 DOI: 10.1016/j.jpedsurg.2016.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 10/20/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Surgical site infection (SSI) rate in pediatric appendicitis is a commonly used hospital quality metric. We hypothesized that surveillance of organ-space SSI (OSI) using cultures alone would fail to capture many clinically-important events. METHODS A prospective, multidisciplinary surveillance program recorded 30-day SSI and hospital length of stay (LOS) for patients <18years undergoing appendectomy for perforated appendicitis from 2012 to 2015. Standardized treatment pathways were utilized, and OSI was identified by imaging and/or bacterial cultures. RESULTS Four hundred ten appendectomies for perforated appendicitis were performed, and a total of 84 OSIs (20.5%) were diagnosed with imaging. Positive cultures were obtained for 39 (46%) OSIs, whereas 45 (54%) had imaging only. Compared to the mean LOS for patients without OSI (5.2±2.9days), LOS for patients with OSI and positive cultures (13.7±5.4days) or with OSI without cultures (10.4±3.7days) was significantly longer (both p<0.001). The OSI rate identified by positive cultures alone was 9.5%, whereas the clinically-relevant OSI rate was 20.5%. CONCLUSIONS Using positive cultures alone to capture OSI would have identified less than half of clinically-important infections. Utilizing clinically-relevant SSI is an appropriate metric for comparing hospital quality but requires agreed upon standards for diagnosis and reporting. LEVEL OF EVIDENCE II. TYPE OF STUDY Diagnostic study.
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Affiliation(s)
- Luke R Putnam
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - Tiffany G Ostovar-Kermani
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - Andrea Le Blanc
- Children's Memorial Hermann Hospital, Houston, TX; Department of Infectious Diseases, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Kathryn T Anderson
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - Galit Holzmann-Pazgal
- Children's Memorial Hermann Hospital, Houston, TX; Department of Infectious Diseases, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Kevin P Lally
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX.
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Evaluation of a disease state management guideline for urinary tract infection. Int J Antimicrob Agents 2016; 47:451-6. [PMID: 27211208 DOI: 10.1016/j.ijantimicag.2016.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 03/21/2016] [Accepted: 03/23/2016] [Indexed: 11/20/2022]
Abstract
A urinary tract infection (UTI) disease state management guideline, including risk-based antimicrobial recommendations, Foley catheter management and transitions of care, was implemented. This study evaluated the outcomes associated with implementation of the guideline. A retrospective study was conducted between 1 July 2013 and 30 September 2013 (pre-implementation) and between 1 July 2014 and 30 September 2014 (post-implementation). Symptomatic patients treated for UTI within 24 h with an identified pathogen were included. Risk-based patient groups were community-acquired UTI, healthcare-associated UTI, or extended-spectrum β-lactamase (ESBL) history in prior 12 months. Recommended antimicrobials were ceftriaxone, cefepime ± vancomycin, or doripenem ± vancomycin, respectively. Given the low post-implementation guideline adherence, pre- and post-groups were combined to evaluate potential guideline value. Length of stay (LOS) decreased when guidelines were followed [5 (IQR 4-7) days vs. 6 (IQR 4-8) days; P = 0.03] or appropriate therapy (according to in vitro susceptibilities) was given [5 (IQR 4-7) days vs. 6 (IQR 4-9) days; P = 0.03]. Those receiving guideline-recommended antimicrobials were more likely to have appropriate therapy within 24 h (84.4% vs. 64.2%; P <0.001). On multivariate analysis, intensive care unit (ICU) admission and admission from home were associated with longer and shorter LOS, respectively. Despite less than anticipated adherence, these data suggest that the established disease state management guideline can improve outcomes in patients admitted with UTI.
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