Perioperative antibiotic prophylaxis: improved compliance and impact on infection rates

Evaluation of the Adherence to Surgical Antibiotic Prophylaxis Recommendations and Associated Factors in a University Hospital: a Cross-sectional Study

BACKGROUND

Surgical antibiotic prophylaxis (SAP) is an important preventive measure, aiming to minimize surgical site infections. However, despite evidence-based guidelines, adherence to SAP protocols remains suboptimal in clinical practice. The aim of this study was to assess the adequacy of SAP in a high-complexity hospital and investigate associated factors.

METHODS

A cross-sectional design was conducted, involving surgeries performed by expert teams in cardiology, urology, neurology, and gastrointestinal. SAP prescriptions were evaluated based on indication, antibiotic choice, dosage, and duration, according to the hospital protocol. Data analysis included descriptive statistics and association tests between protocol adherence and patient demographics, clinical variables, surgical teams, and types of surgeries.

RESULTS

Out of 1,864 surgeries, only 20.7% adhered to SAP protocols. Lower adherence rates were observed for antibiotic choice and duration of prophylaxis. Neurological surgeries exhibited significantly lower adherence, particularly concerning antibiotic choice and duration. Factors associated with non-adherence included elevated preoperative blood glucose levels, prolonged hospitalization, and extended surgical duration. Logistic regression analysis identified surgical teams as significant factors influencing protocol adherence.

CONCLUSION

Despite the relatively high adherence to antibiotic dosage, challenges persist in antibiotic choice and duration adjustment. Poor glycemic control, prolonged surgery and surgical teams were variables associated with innapropriate practice.

Use of prophylactic perioperative antibiotics for lumbar spinal fusions: A nationwide population-based cohort study

BACKGROUND

Perioperative prophylactic antibiotic (PPA) use in spine surgery is known to reduce the rate of surgical site infections. In the past decade, several evidence-based guidelines have been published and surveillance systems to monitor the proper use of antimicrobials had been adapted by many institutes.

OBJECTIVE

To report the trends of PPA prescription in lumbar fusion surgeries nationwide in the Republic of Korea.

METHODS

This is a nationwide registry study. Using the population-based data from the Republic of Korea provided by the Korean Health Insurance Review and Assessment Service, data of all lumbar spinal fusion surgeries performed between 2010 and 2018 in adult patients (age ≥19 years) were reviewed.

RESULTS

The most frequently used antibiotics were first-generation cephalosporins, which accounted for 38.2 % of total PPA prescriptions and were prescribed in 58.96 % of lumbar fusion surgeries. A gradual increase in prescription trends was observed. The second most frequently used PPAs were second-generation cephalosporins, which showed decrease in use from 2016. The frequency of vancomycin prescriptions gradually increased over the observation period and showed an almost four-fold increase in 2018 compared to 2010. First- and second-generation cephalosporins were prescribed less frequently to patients with renal disease.

CONCLUSION

The pattern of PPA use has changed remarkably over the observation period. Furthermore, specific differences in PPA prescriptions were observed among patients with certain co-morbidities.

Adherence to Perioperative Antibiotic Prophylaxis Recommendations and Its Impact on Postoperative Surgical Site Infections

Introduction Surgical site infections (SSIs) are common and carry a significant risk of morbidity and mortality and lead to increased healthcare costs. Perioperative antibiotic prophylaxis decreases the risk of SSIs. There are several guidelines on the use of perioperative antibiotic prophylaxis. The American College of Surgeons (ACS) recommends weight-based antibiotic administration within 60 minutes prior to (two hours for vancomycin/fluoroquinolones) incision and redosing by drug half-life. There are limited data regarding adherence to existing recommendations. Furthermore, there are scarce data on the relationship between adherence to recommendations and the risk of postoperative SSI. Objectives In this study, we aimed to assess the adherence to ACS guidelines for perioperative antimicrobial prophylaxis in the Seattle Children's Hospital (SCH) National Surgical Quality Improvement Program (NSQIP) pediatric cohort and to determine whether adherence to ACS guidelines is associated with a decreased risk of SSI. the secondary objective was to identify risk factors associated with SSI in our patient population. Materials and methods We conducted a secondary analysis of an institutional NSQIP pediatric data cohort between Jan 1, 2012, and Dec 31, 2017. We calculated summary statistics to assess adherence to ACS recommendations and fit a logistic regression model to identify factors associated with the risk of SSI. Patients who did not receive antibiotic prophylaxis were excluded. Results  A total of 6,072 surgeries among 5,532 patients met the inclusion criteria. Adherence was achieved for weight-based dosing in 35% of surgeries, administration prior to the incision in 91%, administration within 60 minutes (two hours for vancomycin/fluoroquinolones) in 86%, correct redosing in 97%, and to all recommendations in 29%. There were no significant associations between any adherence metrics and SSI, although confidence intervals were wide for some metrics. Factors associated with SSI when adherence was met included urgent case status, wound class 2 or 4, the American Society of Anesthesiologists (ASA) class 2-5, and surgery duration. Conclusion There was varying adherence to ACS recommendations on antibiotic prophylaxis in our cohort. More evidence is needed to better understand the effects of adherence to any or all components of the recommendations on SSI. We identified a group of pediatric patients at risk of SSI and a need for further research and targeted interventions.

Impact of bodyweight-adjusted antimicrobial prophylaxis on surgical-site infection rates

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.

Antimicrobial Prophylaxis Redosing Reduces Surgical Site Infection Risk in Prolonged Duration Surgery Irrespective of Its Timing

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.

Implementation strategies to reduce surgical site infections: A systematic review

BACKGROUND

Surgical site infections (SSIs) portend high patient morbidity and mortality. Although evidence-based clinical interventions can reduce SSIs, they are not reliably delivered in practice, and data are limited on the best approach to improve adherence.

OBJECTIVE

To summarize implementation strategies aimed at improving adherence to evidence-based interventions that reduce SSIs.

DESIGN

Systematic reviewMethods:We searched PubMed, Embase, CINAHL, the Cochrane Library, the WHO Regional databases, AFROLIB, and Africa-Wide for studies published between January 1990 and December 2015. The Effective Practice and Organization Care (EPOC) criteria were used to identify an acceptable-quality study design. We used structured forms to extract data on implementation strategies and grouped them into an implementation model called the "Four Es" framework (ie, engage, educate, execute, and evaluate).

RESULTS

In total, 125 studies met our inclusion criteria, but only 8 studies met the EPOC criteria, which limited our ability to identify best practices. Most studies used multifaceted strategies to improve adherence with evidence-based interventions. Engagement strategies included multidisciplinary work and strong leadership involvement. Education strategies included various approaches to introduce evidence-based practices to clinicians and patients. Execution strategies standardized the interventions into simple tasks to facilitate uptake. Evaluation strategies assessed adherence with evidence-based interventions and patient outcomes, providing feedback of performance to providers.

CONCLUSIONS

Multifaceted implementation strategies represent the most common approach to facilitating the adoption of evidence-based practices. We believe that this summary of implementation strategies complements existing clinical guidelines and may accelerate efforts to reduce SSIs.

Population Pharmacokinetic Study of Cefazolin Used Prophylactically in Canine Surgery for Susceptibility Testing Breakpoint Determination

This study aimed to determine the population pharmacokinetic (Pop PK) parameters of cefazolin administered prophylactically at 25 mg/kg intravenously (IV) 30 min before surgery in a canine population of 78 dogs and assess whether covariates, such as sex, age, body weight (BW), breed, health status, creatinine level, and surgery time, have an influence on cefazolin disposition. The ultimate goal was to compute PK/PD cut off values and subsequently establish a specific clinical breakpoint (CBP) for the development of an antimicrobial susceptibility test (AST) of cefazolin in dogs according to the VetCAST approach. Two to 11 blood samples were collected from each dog from 5 to 480 min after cefazolin administration. A two-compartment model was selected, and parameterization was in terms of serum clearance (CL), intercompartmental CL(s) (Q) and volume(s) of distribution (V). The percentage of cefazolin binding to serum protein was 36.2 ± 5.3%. Population primary parameter estimates V1, V2, CL, and Q were (typical value ± SE) 0.116 ± 0.013 L/kg, 0.177 ± 0.011 L/kg, 0.0037 ± 0.0002 L/kg/min, and 0.0103 ± 0.0013 L/kg/min, respectively. Cefazolin presented rapid distribution and elimination half-lives (mean ± SE) 4.17 ± 0.77 min and 57.93 ± 3.11 min, respectively. The overall between-subject variability (BSV) for estimated primary parameters ranged from 36 to 42%, and none of the seven explored covariates were able to reduce this variability by an amplitude clinically relevant. By Monte Carlo simulation, the probability of a PK/PD target attainment (here to achieve a free serum concentration exceeding the MIC for 50% of the dosing interval in 90% of dogs) was computed with a dosage of 25 mg/kg administered IV every 6 h for 4 administrations in 24 h. The computed PK/PD cut off value was 2 mg/L. In conclusion, cefazolin administered prophylactically in surgical dogs at 25 mg/kg IV every 6 h was deemed effective against pathogens with a MIC value ≤ 2 mg/L and from a PK/PD perspective, can be recommended in a wide range of canine patient populations with no necessary dose adjustment for special dog subpopulations.

Noncompliance with surgical antimicrobial prophylaxis guidelines: A Jordanian experience in cesarean deliveries

BACKGROUND

Surgical site infections are common, especially in developing countries. Nevertheless, up to 60% of surgical site infections can be prevented with appropriate perioperative care, which includes among other measures using suitable surgical antimicrobial prophylaxis (SAP).

METHODS

After a short interview with patients and retrospective review of medical charts, compliance with 6 SAP parameters was assessed for appropriateness; those parameters are indication, choice, dose, time of administration, intraoperative redosing interval, and duration of prophylaxis in 1,173 operations.

RESULTS

Overall compliance was poor; nevertheless, certain components showed high compliance rates, such as indication and choice of antibiotics. The most frequent error noted was extended administration of prophylactic antibiotics, which was observed in 88.2% of the study population. Emergency operations were associated with a lower risk of noncompliance in administering the correct dose at the correct time (odds ratio, 0.63; 95% confidence interval, 0.47-0.83 and odds ratio, 0.21; 95% confidence interval, 0.14-0.3, respectively). On the other hand, women who underwent an emergency operation were associated with a 6-fold higher risk of receiving prophylactic therapy following surgery.

CONCLUSIONS

The present study demonstrated the existence of a surprisingly low level of overall compliance with the hospital-adapted SAP guidelines. Factors implicated in noncompliance were investigated, and the present results create a starting point to improve the current practice.

Does surgical site infection after Caesarean section in Polish hospitals reflect high-quality patient care or poor postdischarge surveillance? Results from a 3-year multicenter study

BACKGROUND

Caesarean sections (CSs) are associated with a high infection risk. Surgical site infection (SSI) incidence is among the markers of effectiveness of infection prevention efforts. The aim of this study was to analyze risk factors for SSI, incidence, and microbiology in patients who underwent CS.

METHODS

The study was conducted during 2013-2015 using active infection surveillance in 5 Polish hospitals according to the European Centre for Disease Prevention and Control surveillance network known as HAI-Net. For each procedure, the following data were registered: age, American Society of Anesthesiologists score, procedure time, elective or emergency procedure, use of perioperative antibiotic prophylaxis, microbiology, the treatment used, and other information.

RESULTS

SSI incidence was 0.5% and significant differences were noted among hospitals (between 0.1% and 1.8%), for different American Society of Anesthesiologists scales (between 0.2% and 4.8%) and different values of standardized SSI risk index (between 0.0% and 0.8%). In 3.1% of procedures, with no antibiotic prophylaxis, SSI risk was significantly higher. Deep infections dominated: 61.5% with superficial infections in only approximately 30% of cases and 2.6% of infections were detected postdischarge without readmissions.

CONCLUSIONS

Results showed high incidence of SSI in Poland without perioperative antibiotic prophylaxis, and secondly, ineffective surveillance according to CS status, considering outpatient obstetric care. Without postdischarge surveillance, it is not possible to recognize the epidemiologic situation, and further, to set priorities and needs when it comes to infection prophylaxis, especially because such low incidence may indicate no need for improvement in infection control.

Appropriateness of Surgical Antibiotic Prophylaxis in Pediatric Patients in Italy

OBJECTIVES

Appropriate use of surgical antibiotic prophylaxis (SAP) reduces intraoperative wound contamination in pediatric surgery, thus minimizing the risk of surgical site infection (SSIs). Conversely, inappropriate use of SAP exposes patients to the risk of antibiotic side effects and contributes to the emergence of antimicrobial resistance. Our aims were to describe SAP administration and to analyze factors associated with nonadherence in pediatric patients.

DESIGN

Descriptive study.

SETTING

Overall, 955 pediatric patients underwent 1,038 surgical procedures.

METHODS

We assessed adherence to SAP international guidelines for surgical procedures performed on children aged <18 years in 2015 in 4 randomly selected hospitals in Calabria (Italy). The clinical records of these patients were retrospectively reviewed.

RESULTS

Appropriate SAP administration or nonadministration pertained to 754 surgical procedures (72.6%). Surgical antibiotic prophylaxis was administered in 88.5% of 358 procedures with an SAP indication. Adherence to guidelines for appropriate drug choice were followed in 5.7% of cases, for route of administration in 76.7% of cases, for timing in 48.6% of cases, for duration in 14.5% of cases, and for dose in 91.5% of cases, and for all components in only 5 cases (1.6%). Among 680 procedures without SAP indication, 35.7% case patients received antibiotics. Inappropriate administration of antibiotics in procedures without SAP indication was associated with surgical specialty wards (P=.008), ordinary admission (P<.001), head and neck surgical procedures (P=.020), clean surgery (P=.017), and surgical duration (P=.010).

CONCLUSIONS

Discrepancies between SAP guidelines and actual practice behavior more frequently indicate excessive use of antibiotics than underuse. Increased awareness of SAP guidelines is required.

Infect Control Hosp Epidemiol 2017;38:823–831

Antimicrobial Prophylaxis in Instrumented Spinal Fusion Surgery: A Comparative Analysis of 24-Hour and 72-Hour Dosages

Study Design

Prospective study.

Purpose

To compare the efficacy of 24-hour and 72-hour antibiotic prophylaxis in preventing surgical site infections (SSIs).

Overview of Literature

Antimicrobial prophylaxis in surgical practice has become a universally accepted protocol for minimizing postoperative complications related to infections. Although prophylaxis is an accepted practice, a debate exists with regard to the antibiotic type and its administration duration for various surgical procedures.

Methods

Our institute is a tertiary care hospital with more than 100 spinal surgeries per year for various spine disorders in the department of orthopedics. We conducted this prospective study in our department from June 2012 to January 2015. A total of 326 patients were enrolled in this study, with 156 patients in the 72-hour antibiotic prophylaxis group (group A) and 170 patients in the 24-hour group (group B). Cefazolin was the antibiotic used in both groups. Two surgeons were involved in conducting all the spinal procedures. Our study compared SSIs among patients undergoing instrumented spinal fusion.

Results

The overall rate of SSIs was 1.8% with no statistical difference between the two groups.

Conclusions

The 24-hour antimicrobial prophylaxis is as effective as the 72-hour dosage in instrumented spinal fusion surgery.

Compliance of Perioperative Antibiotic Dosing and Surgical Site Infection Rate in Office-Based Elective Surgery

BACKGROUND

A best practice goal to reduce surgical site infection includes administration of antibiotics in the ideal preoperative window. This article evaluates an office surgical suite antibiotic administration rate and compares it with the timing of a local hospital treating a similar patient population. The hypothesis was that similar or better compliance and surgical site infection rates can be achieved in the office-based suite.

METHODS

A total of 277 office-based surgeries were analyzed for antibiotic administration time before incision and their corresponding surgical site infection rate.

RESULTS

Our facility administered timely prophylactic antibiotics in 96% of cases with a surgical site infection rate of 0.36%. This rate was significantly lower than a reported rate of 3.7%.

CONCLUSION

Low infection rates with high antibiotic administration rate suggest that compliance with best possible practice protocols is possible in the outpatient setting.

May the drain be a way in for microbes in surgical infections?

BACKGROUND

Surgical site infection (SSI) is among the most frequent hospital-acquired infections occurring in surgical patients and leads to increased morbidity, mortality, and costs. We aimed to identify risk factors for SSI in patients undergoing surgical procedures, with a particular attention to the use of drains.

METHODS

This study includes all patients undergoing abdominal surgical procedures in 2 surgical wards in a teaching hospital in central Italy. Collected data included patient's demographic and clinical characteristics, procedure characteristics, administration of perioperative antibiotic prophylaxis, and microorganism isolated. The outcome of interest was SSI.

FINDINGS

A total of 872 abdominal surgery procedures were surveyed during the study period. Drains were placed in 37.0% of cases. SSI rate was 6.4% globally and 13.6% among the patients with drains, versus 2.4% in those without a drain (P < .001). In 72.1% of cases antibiotic prophylaxis was administered. The logistic regression analysis (P < .001) shown insertion of a drain (odds ratio [OR], 5.14; 95% confidence interval [CI], 2.63-10.08), prolonged surgery (OR, 1.98; 95% CI, 1.09-3.59), and American Society of Anesthesiologists score equal to 3 (OR, 6.13; 95% CI, 2.33-16.11) as independent risk factors for SSI, whereas antibiotic prophylaxis was protective (OR, 0.53; 95% CI, 0.29-0.99).

CONCLUSION

This study revealed surgical drains as a risk factor for SSI, pointing out the need of a clearer understanding of drain role in the dynamics of SSI occurrence, with the purpose of decreasing infection risk through targeted preventive interventions.

Surgical site infection-a population-based study in Australian adults measuring the compliance with and correct timing of appropriate antibiotic prophylaxis

Prophylaxis for surgical site infection (SSI) is often at variance with guidelines, despite the prevalence of SSI and its associated cost, morbidity, and mortality. The CareTrack Australia study, undertaken by a number of the authors, demonstrated that appropriate care (in line with evidence- or consensus-based guidelines) was provided at 38% of eligible SSI healthcare encounters. Here, we report the indicator-level CareTrack Australia findings for SSI prophylaxis. Indicators were extracted from Australian and international clinical guidelines and ratified by clinical experts. A sample designed to be representative of the Australian population was recruited (n=1154). Participants' medical records were reviewed and analysed for compliance with the five SSI indicators. The main outcome measure was the percentage of eligible healthcare encounters with documented compliance with indicators for appropriate SSI prophylaxis. Of the 35,145 CareTrack Australia encounters, 702 (2%) were eligible for scoring against the SSI indicators. Where antibiotics were recommended, compliance was 49% for contaminated surgery, 57% for clean-contaminated surgery and 85% for surgery involving a prosthesis: these fell to 8%, 10% and 14%, respectively (an average of 11%), when currently recommended timing of antibiotic administration was included. Where antibiotics were not indicated, 72% of patients still received them. SSI prophylaxis in our sample was poor; over two-thirds of patients were given antibiotics, whether indicated or not, mainly at the wrong time. There is a need for national agreement on clinical standards, indicators and tools to guide, document and monitor SSI prophylaxis, with both local and national measures to increase and monitor their uptake.

Catheter-associated urinary tract infection: Role of the setting of catheter insertion

BACKGROUND

This study aimed to describe the epidemiology of catheter-associated urinary tract infections (CAUTIs) in patients admitted to a surgical ward in Central Italy and to analyze the associated risk factors.

METHODS

An active surveillance program for CAUTI was carried out in patients catheterized for at least 48 hours. Place of catheter insertion (operating room, hospital ward, cystoscopy room, emergency care unit), indication for catheterization and its duration, among other risk factors were monitored until discharge. Antibiotic resistance profiles of isolates were analyzed.

RESULTS

There were 641 catheterized patients monitored for CAUTI onset. Of these, 40 (6.2%) developed a CAUTI (rates were 15.1/1,000 catheter days, 95% confidence interval [CI], 11.9-22.6; 8.7/1,000 patient days, 95% CI, 6.9-13.1). Patients with CAUTI were older (P < .05) and their durations of hospitalization and catheterization were both longer compared with those who were not affected (P < .05). Catheterization >4 days (odds ratio [OR] = 8.21; 95% CI, 3.79-17.73; P < .05) and place of catheter insertion different from the operating room (OR = 7.9; 95% CI, 2.83-22.08; P < .05, for catheters placed in the ward) were associated with CAUTI. Among the micro-organisms isolated in CAUTIs, the most common were Pseudomonas aeruginosa (41.5%), Klebsiella pneumoniae (19.5%), and Escherichia coli (12.2%); 82.5% of them were resistant to different classes of antibiotics.

CONCLUSION

These results highlight the role played by the setting of catheter insertion in CAUTIs onset, therefore reflecting the importance of hand hygiene and proper aseptic insertion techniques as crucial determinants in CAUTIs prevention.

Appropriate use of antimicrobial prophylaxis: an observational study in 21 surgical wards

BACKGROUND

Surveillance of Surgical Site Infections (SSI) in 2010 found 39 % compliance with hospital guidelines in Piedmont (Italy). The aim of the study was to estimate the appropriate use of antimicrobial prophylaxis and compliance with hospitals guidelines in surgical wards.

METHODS

This survey study took place in 21 surgery wards of 4 public hospitals. Forms were completed by public health resident doctors together with a medical ward referent and infection control nurses. 15 consecutive surgical procedures were randomly chosen from each ward. A total of 320 cases were analyzed. The study period was from July 2012 to January 2013. Data were collected using a survey form. A final score variable from 0 to 4 was given to each case. The results were compared with hospital and international guidelines. Data were analyzed using Epi-Info software.

RESULTS

Of the 320 cases collected, 63 were excluded; of the remaining 257 cases, 56.4 % of the procedures were appropriate (score 4), 15.2 % were acceptable and 28.4 % were not acceptable. The study found an unjustified continuation of antimicrobial prophylaxis in 17.1 % of the 257 cases, an unjustified re-start of antimicrobial therapy in 9.7 % and a re-dosing omission in 7.8 %.

CONCLUSIONS

The study demonstrated critical problems in antimicrobial prophylaxis management in surgical wards due to a lack of compliance between hospitals and national guidelines, a shortage of specific and updated recommendations for some surgical interventions and incorrect local specific procedures. Coordination between local and national recommendations, strengthening of evidence based decisions and continuous sharing of policy updates are needed.

Factors Affecting Surgical Site Infection Rates in Hepatobiliary Surgery

BACKGROUND

There are several studies regarding risk factors affecting surgical site infections (SSIs); nevertheless, there are an insufficient number of studies focusing on risk factors for SSI in hepatobiliary (HPB) surgery. In this study, we aimed to determine risk factors related to HPB surgery.

METHODS

A total of 1,418 patients were included in this study, all of whom underwent hepatobiliary system surgery in a five-year period between January 2005 and December 2009. Demographic data, patient- and surgery-related risk factors, and laboratory parameters were analyzed retrospectively from a database maintained prospectively.

RESULTS

The overall incidence of SSI was 3.94% for HPB surgery. In multivariable analysis, blood transfusion (OR: 20.9), the presence of surgical drains (OR: 10.7), a pre-operative hospital stay of more than eight days (OR: 8.1), diabetes mellitus (OR: 6.2), chronic obstructive pulmonary disease (OR: 6.127), inappropriate antimicrobial prophylaxis (OR: 6), obesity (OR: 3.2), the presence of an external-internal biliary drainage catheter (OR: 2), and a direct bilirubin concentrations more than 15 mg/dL (OR: 1.4) were determined as independent risk factors related to SSI. E.coli and Enterococcus spp. were the pathogens isolated most commonly in SSIs.

CONCLUSIONS

Most of the independent risk factors for hepatobiliary system surgery are similar to those for other general abdominal surgical procedures. The presence of an external-internal biliary drainage catheter and direct bilirubin concentrations higher than 15 mg/dL were found to be specific risk factors for HPB surgery.

Fighting surgical site infections in small animals: are we getting anywhere?

A diverse array of pathogen-related, patient-related, and caretaker-related issues influence risk and prevention of surgical site infections (SSIs). The entire surgical team involved in health care settings in which surgical procedures are performed play a pivotal role in the prevention of SSIs. In this article, current knowledge of SSI risk factors and prevention methods is reviewed. Although new avenues that can be explored in the prevention of SSIs in veterinary medicine are described, the main conclusion drawn is that the best method for prevention of SSI is to adhere to what we already know.

Evaluation of the appropriate perioperative antibiotic prophylaxis in Italy

BACKGROUND

The appropriate use of antibiotics prophylaxis in the prevention and reduction in the incidence of surgical site infection is widespread. This study evaluates the appropriateness of the prescription of antibiotics prophylaxis prior to surgery amongst hospitalized patients in the geographic area of Avellino, Caserta, and Naples (Italy) and the factors associated with a poor adherence.

METHODS

A sample of 382 patients admitted to 23 surgical wards and undergoing surgery in five hospitals were randomly selected.

RESULTS

Perioperative antibiotic prophylaxis was appropriate in 18.1% of cases. The multivariate logistic regression analysis showed that patients with hypoalbuminemia, with a clinical infection, with a wound clean were more likely to receive an appropriate antibiotic prophylaxis. Compared with patients with an American Society of Anesthesiologists (ASA) score ≥4, those with a score of 2 were correlated with a 64% reduction in the odds of having an appropriate prophylaxis. The appropriateness of the timing of prophylactic antibiotic administration was observed in 53.4% of the procedures. Multivariate logistic regression model showed that such appropriateness was more frequent in older patients, in those admitted in general surgery wards, in those not having been underwent an endoscopic surgery, in those with a higher length of surgery, and in patients with ASA score 1 when a score ≥4 was chosen as the reference category. The most common antibiotics used inappropriately were ceftazidime, sultamicillin, levofloxacin, and teicoplanin.

CONCLUSIONS

Educational interventions are needed to improve perioperative appropriate antibiotic prophylaxis.

Cross-sectional study on surveillance of surgical site infections after vascular surgery

Aims: To determine the incidence and risk factors for surgical site infections (SSI) after vascular surgery, to evaluate the Dutch safety bundle to reduce adverse complications and to analyze causative microorganisms of SSIs. Materials & methods: The 3.5-year study was divided into two periods: the control period (before bundle implementation) and intervention period (after implementation). Postdischarge surveillance was performed until 30 days after surgery. Causative microorganisms from in-hospital wound swabs were determined. SSI rates between both periods were compared and a risk analysis was carried out by performing a logistic regression. Results: The study included 1719 operations. The in-hospital SSI rate increased significantly over time. Out of 140 SSIs, 39% were diagnosed postdischarge. Risk factors were diabetes, age >60 years and operations classified as contaminated or dirty. Pseudomonas aeruginosa susceptibility was the highest for gentamicin (97%). All Staphylococcus aureus were methicillin susceptible. Conclusion: As patient demographics are important to determine the effectiveness of infection preventive measures, (postdischarge) surveillance is important for developing SSI interventions.

Incidence and risk factors of surgical site infection in general surgery in a developing country

PURPOSE

To investigate the incidence of surgical site infections (SSIs) according to risk factors, etiological agents, antimicrobial resistance rates of pathogens, and antimicrobial prophylaxis (AMP) in a developing country.

METHODS

Prospective surveillance of SSIs was carried out in general surgery (GS) units between May 2005 and April 2009.

RESULTS

SSI was diagnosed in 415 (10.8%) patients. Cefazolin was used as AMP in 780 (49%) operations, whereas broad-spectrum antibiotics were used in the remaining operations. AMP was administered for >24 h in 69 and 64% of the GS patients. The most significant risk factors for SSI after GS were total parenteral nutrition, transfusion, and a drainage catheter. The most common pathogen was Escherichia coli, but all the isolated pathogens were multiresistant.

CONCLUSION

AMP is effective for reducing the risk of SSI; however, the prolonged use of AMP and broad-spectrum antibiotics may be associated with the emergence of resistant bacterial strains.

Determining the elements of procedural quality

Object

The definition and determination of quality health care is an important topic. The purpose of this study was to develop a longitudinal method to define a quality procedure by creating a formal approach to pre- and postoperative outcomes documentation. The authors worked to define quality outcomes by first documenting the patient's condition. Goals were determined together by the surgeon and the patient and then were evaluated to see if those goals were met.

Methods

The population consisted of cancer patients with newly diagnosed metastatic brain disease who were scheduled to undergo stereotactic radiosurgery. Surgeons recorded perioperatively objective information related to preoperative goals, clinical findings, surgical performance and/or error, and whether goals were met. In addition, patients completed pre- and postprocedure questionnaires (Rand 36-Item Short-Form Health Survey 1.0 [SF-36]).

Results

Procedural goals, defined as completing radiosurgery without error or complication and same-day discharge, were met in all patients. The clinically predetermined goal of tumor palliation was met in all but 1 patient at follow-up. The SF-36 scores remained stable except for the general health domain, which was lower (p = 0.006).

Conclusions

Procedural goals can be defined and objectively measured serially. The authors think that quality care can be defined as a process that achieves predefined goals without significant error and maintains or improves health.

Appropriateness of surgical antimicrobial prophylaxis in the Latium region of Italy, 2008: a multicenter study

BACKGROUND

There is still wide variability in surgical antimicrobial prophylaxis (SAP) practice by different surgical teams and specialties, with potential impact on adverse events and the emergence of antibiotic resistance.

METHODS

We assessed SAP appropriateness in a regional prospective multicenter study on the basis of the agreement of the Surgical Care Improvement Project indicators (SCIP-Inf) with Italian guidelines (GL).

RESULTS

Prophylaxis was administered in 2,664 of 2,835 procedures (94%): In 2,346 of 2,468 (95%) as indicated and in 318 of 367 (86.6%) in which they were not indicated. The SCIP-Inf1 (timing), SCIP-Inf2 (antibiotic choice), and SCIP-Inf3 (duration) were in agreement with GL in 1,172 (50%), 1,983 (84.5%), and 1,121 (48%) of 2,346 procedures, respectively.

CONCLUSIONS

These results suggest the need for implementation of an antimicrobial stewardship program in this surgical setting.

Surgical site infections and their prevention

PURPOSE OF REVIEW

Recent studies have assessed interventions and bundles of interventions to prevent surgical site infections (SSIs). We reviewed numerous studies to identify those with the strongest evidence supporting interventions for preventing SSIs.

RECENT FINDINGS

Bundles that included more than one intervention to decrease the risk of Staphylococcus aureus wound contamination, such as chlorhexidine bathing and nasal application of mupirocin, had the strongest supporting evidence. However, bundles should be tested to ensure that their components are not antagonistic. Vancomycin prophylaxis and extended antimicrobial prophylaxis should not be used routinely, but should be reserved for high-risk populations such as patients who carry methicillin-resistant S. aureus (MRSA). Novel interventions to prevent SSIs (e.g., topical or oral antimicrobial agents, skin sealant, and antimicrobial sutures) need further evaluation before surgeons implement them routinely.

SUMMARY

There is some evidence that bundled interventions can reduce SSIs. However, more research should be done evaluating the effectiveness of these interventions. Future studies of bundles should use robust methodologies, such as randomized controlled trials, cluster randomized trials, or quasi-experimental studies analyzed by time series analysis.

Antimicrobial prescribing practices following publication of guidelines for the prevention of infections associated with combat-related injuries

BACKGROUND

Timely and limited antibiotic prophylaxis (postinjury antimicrobial therapy) targeting specific traumatic injuries is a well-recognized measure to lessen posttraumatic infection. Modern military combat injuries raise significant challenges because of complex multiple injuries and limited data derived directly from well-controlled trials to base recommendations. Expert consensus review of available evidence led to published guidance for selection and duration of antimicrobial therapy for combat-related trauma infection prevention. This analysis evaluates antibiotic-prescribing practices by military physicians in the operational theater relative to the published guidance.

METHODS

Trauma history and infectious disease-specific inpatient care information is captured through the Joint Theater Trauma Registry along with a supplemental infectious disease module. Injury patterns are classified based on documented International Classification of Diseases-9th Revision codes with a composite assessment of each patient's injury pattern. Antimicrobial use categorized as prophylaxis is prescribed within the first 48 hours postinjury. Adherence to published guidance is reported along with patient characteristics and injury severity to assess for potential explanations of nonadherence.

RESULTS

During June to November 2009, 75% of the 610 eligible trauma patients received antimicrobial prophylaxis. Adherence to the recommended antibiotic agent on the day of injury was in the range of 46% to 50% for the most common extremity injury patterns and <10% in penetrating abdominal injuries. Antibiotics were given in 39% of patients sustaining injuries that are recommendations to not receive antimicrobial prophylaxis.

CONCLUSIONS

This first evaluation of combat trauma-related antibiotic prophylaxis shows adherence levels comparable or superior to reported rates in civilian settings despite the austere, frequently mass casualty environment. Areas for interval surveillance and education-based strategies for improved adherence to practice guidance are identified.