Current Antimicrobial Use in Horses Undergoing Exploratory Celiotomy: A Survey of Board-Certified Equine Specialists

In the past decade, there has been a considerable increase in the recognition of antimicrobial resistance in equine practice. The objective of this study was to survey the current clinical use of antimicrobials for a commonly performed surgical procedure (exploratory celiotomy) with the goal of understanding how recent literature and changes in microbial resistance patterns may have impacted antimicrobial selection practices. An electronic survey was distributed to veterinary professionals within the American College of Veterinary Internal Medicine (ACVIM) and the American College of Veterinary Surgery (ACVS). A total of 113 completed surveys were returned. Practitioners reported antimicrobials were most frequently given 30-60 min preoperatively (63.1%). Two antimicrobial classes were typically administered (95.5%), with gentamicin (98.2%) and potassium penicillin (74.3%) being the most common. Antimicrobials were typically not re-dosed intraoperatively (78.6%). Factors that affected overall treatment length postoperatively included resection (81.4%), bloodwork (75.2%), enterotomy (74.3%), fever (85.0%), incisional complications (76.1%), and thrombophlebitis (67.3%). The most common duration of antimicrobial use was 1-3 d for non-strangulating lesions (54.4% of cases) and inflammatory conditions such as enteritis or peritonitis (50.4%), and 3-5 d for strangulating lesions (63.7%). Peri-incisional and intra-abdominal antimicrobials were used by 24.8% and 11.5% of respondents, respectively. In summary, antimicrobial usage patterns were highly variable among practitioners and, at times, not concordant with current literature.

Evidence-based guideline for the prevention and management of perioperative infection

BACKGROUND

We have updated the guideline for preventing and managing perioperative infection in China, given the global issues with antimicrobial resistance and the need to optimize antimicrobial usage and improve hospital infection control levels.

METHODS

We conducted a comprehensive evaluation of the evidence for prevention and management of perioperative infection, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Revisions were made to the guidelines in response to feedback from the experts.

RESULTS

There were 17 questions prepared, for which 37 recommendations were made. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the meta-analysis results, recommendations were graded using the Delphi method to generate useful information.

CONCLUSIONS

This guideline provides evidence to perioperative antimicrobial prophylaxis that increased the rational use of prophylactic antimicrobial use, with substantial improvement in the risk-benefit trade-off.

Adherence to Guidelines for the Administration of Intraoperative Antibiotics in a Nationwide US Sample

IMPORTANCE

Despite widespread adherence to Surgical Care Improvement Project antibiotic measures, prevention of surgical site infections (SSIs) remains a clinical challenge. Several components of perioperative antibiotic prophylaxis guidelines are incompletely monitored and reported within the Surgical Care Improvement Project program.

OBJECTIVES

To describe adherence to each component of perioperative antibiotic prophylaxis guidelines in regard to procedure-specific antibiotic choice, weight-adjusted dosing, and timing of first and subsequent administrations in a nationwide, multicenter cohort of patients undergoing noncardiac surgery.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included adult patients undergoing general, urological, orthopedic, and gynecological surgical procedures involving skin incision between January 1, 2014, and December 31, 2018, across 31 academic and community hospitals identified within the Multicenter Perioperative Outcomes Group registry. Data were analyzed between April 2 and April 21, 2021.

MAIN OUTCOMES AND MEASURES

The primary end point was overall adherence to Infectious Diseases Society of America guidelines, including (1) appropriateness of antibiotic choice, (2) weight-based dose adjustment, (3) timing of administration with respect to surgical incision, and (4) timing of redosing when indicated. Data were analyzed using mixed-effects regression to investigate patient, clinician, and institutional factors associated with guideline adherence.

RESULTS

In the final cohort of 414 851 encounters across 31 institutions, 51.8% of patients were women, the mean (SD) age was 57.5 (15.7) years, 1.2% of patients were of Hispanic ethnicity, and 10.2% were Black. In this cohort, 148 804 encounters (35.9%) did not adhere to guidelines: 19.7% for antibiotic choice, 17.1% for weight-adjusted dosing, 0.6% for timing of first dose, and 26.8% for redosing. In adjusted analyses, overall nonadherence was associated with emergency surgery (odds ratio [OR], 1.35; 95% CI, 1.29-1.41; P < .001), surgery requiring blood transfusions (OR, 1.30; 95% CI, 1.25-1.36; P < .001), off-hours procedures (OR, 1.08; 95% CI, 1.04-1.13; P < .001), and procedures staffed by a certified registered nurse anesthetist (OR, 1.14; 95% CI, 1.11-1.17; P < .001). Overall adherence to guidelines for antibiotic administration improved over the study period from 53.1% (95% CI, 52.7%-53.5%) in 2014 to 70.2% (95% CI, 69.8%-70.6%) in 2018 (P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, although adherence to perioperative antibiotic administration guidelines improved over the study period, more than one-third of surgical encounters remained discordant with Infectious Diseases Society of America recommendations. Future quality improvement efforts targeting gaps in practice in relation to guidelines may lead to improved adherence and possibly decreased SSIs.

Barriers-enablers-ownership approach: a mixed methods analysis of a social intervention to improve surgical antibiotic prescribing in hospitals

OBJECTIVES

To assess an intervention for surgical antibiotic prophylaxis (SAP) improvement within surgical teams focused on addressing barriers and fostering enablers and ownership of guideline compliance.

DESIGN

The Queensland Surgical Antibiotic Prophylaxis (QSAP) study was a multicentre, mixed methods study designed to address barriers and enablers to SAP compliance and facilitate engagement in self-directed audit/feedback and assess the efficacy of the intervention in improving compliance with SAP guidelines. The implementation was assessed using a 24-month interrupted time series design coupled with a qualitative evaluation.

SETTING

The study was undertaken at three hospitals (one regional, two metropolitan) in Australia.

PARTICIPANTS

SAP-prescribing decisions for 1757 patients undergoing general surgical procedures from three health services were included. Six bimonthly time points, pre-implementation and post implementation of the intervention, were measured. Qualitative interviews were performed with 29 clinical team members. SAP improvements varied across site and time periods.

INTERVENTION

QSAP embedded ownership of quality improvement in SAP within surgical teams and used known social influences to address barriers to and enablers of optimal SAP prescribing.

RESULTS

The site that reported senior surgeon engagement showed steady and consistent improvement in prescribing over 24 months (prestudy and poststudy). Multiple factors, including resource issues, influenced engagement and sites/time points where these were present had no improvement in guideline compliance.

CONCLUSIONS

The barriers-enablers-ownership model shows promise in its ability to facilitate prescribing improvements and could be expanded into other areas of antimicrobial stewardship. Senior ownership was a predictor of success (or failure) of the intervention across sites and time periods. The key role of senior leaders in change leadership indicates the critical need to engage other specialties in the stewardship agenda. The influence of contextual factors in limiting engagement clearly identifies issues of resource distributions/inequalities within health systems as limiting antimicrobial optimisation potential.

Utilization of neurosurgical perioperative antimicrobial prophylaxis in a Chinese teaching hospital

Background Audits of antimicrobial prophylaxis is an essential strategy to identify practice gaps in antimicrobial prescribing in healthcare facilities. There is a lack of studies on the costs, quality, and antimicrobial use density of neurosurgical perioperative antimicrobial prophylaxis in China. Objectives Evaluate the appropriateness of perioperative antimicrobial prophylaxis in neurosurgeries and analyze the costs, quality, and antimicrobial use density of neurosurgical perioperative antimicrobial prophylaxis. Setting Beijing Tsinghua Changgung Hospital, a teaching hospital in Beijing. Methods This retrospective study was conducted among 262 neurosurgical patients without infections during 2017. The appropriateness of perioperative antimicrobial prophylaxis was determined based on relevant international and Chinese perioperative antimicrobial prophylaxis guidelines. Main outcome measures Discrepancy rates in perioperative antimicrobial prophylaxis, including indication, choice of antimicrobials, dose, route of administration, time of administration of the first dose, re-dosing, and duration, were analyzed. Results Discrepancies were observed between current practice and relevant guidelines. A total of 51 (32.1%) procedures failed to administer intraoperative re-dosing as needed, and the perioperative antimicrobial prophylaxis duration of 217 (82.8%) procedures was inappropriately prolonged. The choice of antimicrobial agents was optimal in 249 (95%) procedures, and the timing of perioperative antimicrobial prophylaxis was appropriate in all procedures. If perioperative antimicrobial prophylaxis was implemented according to guidelines, the defined daily dose per 100 procedures would decrease from 31.97 to 16.99, and the total cost would reduce from $2000 to $490. Conclusions Effective antimicrobial stewardship is urgently needed to promote the appropriateness of neurosurgical perioperative antimicrobial prophylaxis in China.

Factors that influence adherence to surgical antimicrobial prophylaxis (SAP) guidelines: a systematic review

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.

Compliance with surgical prophylaxis guidelines in liver and kidney transplantations

Background Patients undergoing solid organ transplantations are at a high risk of surgical site infections. Complying with surgical prophylaxis guidelines minimize post-operative infection rate. Objectives The study aimed to evaluate the compliance with the American Society of Health-System Pharmacists surgical prophylaxis guidelines related to antibiotic selection, dosing, administration time, and duration of surgical prophylaxis in liver and kidney transplantations. However, the re-dosing time was only assessed for liver transplantation cases. Setting The study was conducted at the solid organ transplantation center at King Abdualziz Medical City, Riyadh, Saudi Arabia. Method A retrospective chart review including all patients who had a liver or kidney transplantation from January 2016 to December 2018. Main outcome measure The compliance rate with the surgical prophylaxis guideline related to selecting the recommended antibiotic, dosing, administration time, and antibiotic exposure duration. The re-dosing time was assessed in liver transplantations. Results The study included 54 liver recipients and 163 kidney recipients, with an average age of 56 and 43 years, respectively. The majority of the included patients (68% and 56%) were male in both groups. The compliance rates to the recommendations in liver and kidney operations were 82.6% and 77.09% in terms of the choice of antibiotic, 44.5% and 13.4% in terms of dosing, 31.5% and 43.5% in terms of timing, and 18.47% and 84.36% in terms of duration, respectively. None of liver recipients received a re-dosed antibiotic at the recommended time. Conclusion The study concluded that there was an optimal compliance rate to the choice of antibiotic recommendations in both liver and kidney transplantations. Similarly, a high compliance rate was observed for the duration of antibiotic exposure after kidney transplantations. However, the compliance rate in terms of dosing and administration time was low in both transplantations. Low compliance rates were also observed in the duration of antibiotic exposure and the re-dosing time recommendations in liver transplants.

Adherence to surgical antimicrobial prophylaxis: "checking-the-box" is not enough

PURPOSE

The purpose of this paper is to review surgical antimicrobial prophylaxis administration practices in a small cohort and assess compliance with national guidelines.

DESIGN/METHODOLOGY/APPROACH

Patients that developed surgical site infections (SSI) in a tertiary care academic medical center over a two-year period were identified. Their electronic medical records were reviewed for compliance with national guidelines with respect to surgical antibiotic prophylaxis.

FINDINGS

Over a two-year period, 283 SSI patients were identified. An appropriate antibiotic was chosen in 80 percent, an appropriate dose was administered in 45 percent and timing complied in 89 percent. The antibiotics were appropriately re-dosed in only 9.2 percent in whom the requirement was met. The prescribing guidelines were adhered to in entirety in only 54 patients (23.8 percent).

PRACTICAL IMPLICATIONS

Timely and appropriate antibiotic administration prior to surgery is essential to prevent SSI. Proper diligence is required to accomplish this task effectively.

ORIGINALITY/VALUE

Based on the findings, it appears that merely, "checking a box" for antibiotic administration during surgery is not enough, and a multidisciplinary approach should be followed to ensure "appropriate" antibiotic administration.

Physician Behavior Change: A Systematic Review

Evidence-based medicine (EBM) has been advocated as one of the central dogmas of health care since the late 20th century. EBM provides health care entities the prospect to revolutionize health care practices and improve the standard of health care for everyone. Therefore, the potential benefits for adopting EBM practices cannot be overlooked. However, physicians face an increasingly difficult challenge, both personal and professional, when adopting EBM practices. Therefore, knowledge of effective strategies for driving physician behavioral is necessary. To this effort, this systematic review is tasked to compile and analyze the literature focused on physician behavior change. After a review of 1970 studies, 29 different studies were meticulously evaluated by 2 separate reviewers. Studies were then categorized into 5 broad distinctions based on their assessed outcomes: (1) physician knowledge; (2) ordering of tests; (3) compliance with protocols; (4) prescription of medications; and (5) complication rates. The testing group was focused on osteoporosis screening, using educational interventions. Protocol compliance studies were heterogeneous, ranging from diagnosing supracondylar fractures in pediatric patients to antimicrobial administration. Prescription pattern studies were primarily focused around the management of osteoporosis. Multimodal interventions seemed to be more effective when producing change. However, due to the variability in intervention type and outcomes assessment, it is difficult to conclude the most effective intervention for driving physician behavioral change. Physician behavior and specifically surgeon behavior are disproportionately influenced by mentors, fellowship training, and memories of excellent or catastrophic outcomes much more so than literature and data. Adopting evidence-based practices (EBM) and value centric care may provide an opportunity for physicians to improve personal performance.

Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.

Improvisation versus guideline concordance in surgical antibiotic prophylaxis: a qualitative study

PURPOSE

Surgical antibiotic prophylaxis (SAP) is a common area of antimicrobial misuse. The aim of this study was to explore the social dynamics that influence the use of SAP.

METHODS

20 surgeons and anaesthetists from a tertiary referral hospital in Australia participated in semi-structured interviews focusing on experiences and perspectives on SAP prescribing. Interview data were analysed using the framework approach.

RESULTS

Systematic analysis of the participants' account of the social factors influencing SAP revealed four themes. First, antibiotic prophylaxis is treated as a low priority with the competing demands of the operating theatre environment. Second, whilst guidelines have increased in prominence in recent years, there exists a lack of confidence in their ability to protect the surgeon from responsibility for infectious complications (thus driving SAP over-prescribing). Third, non-concordance prolonged duration of SAP is perceived to be driven by benevolence for the individual patient. Finally, improvisation with novel SAP strategies is reported as ubiquitous, and acknowledged to confer a sense of reassurance to the surgeon despite potential non-concordance with guidelines or clinical efficacy.

CONCLUSIONS

Surgical-specific concerns have thus far not been meaningfully integrated into antimicrobial stewardship (AMS) programmes, including important dynamics of confidence, trust and mitigating fear of adverse infective events. Surgeons require specific forms of AMS support to enact optimisation, including support for strong collaborative ownership of the surgical risk of infection, and intra-specialty (within surgical specialties) and inter-specialty (between surgery, anaesthetics and infectious diseases) intervention strategies to establish endorsement of and address barriers to guideline implementation.

How do professional relationships influence surgical antibiotic prophylaxis decision making? A qualitative study

BACKGROUND

Surgical antibiotic prophylaxis (SAP) is a critical area to optimize to reduce the escalation of antimicrobial resistance. This article explores the ways by which interpersonal relationships influence SAP decision making.

METHODS

Twenty surgeons and anesthetists participated in in-depth semistructured interviews on SAP prescribing. Results were analyzed using the framework approach.

RESULTS

Analysis revealed 3 ways by which interpersonal relationships influence SAP: relationship dynamics between the surgeon and the anesthetist determine appropriateness of SAP, particularly operative risk ownership; perceived hierarchies within, and between, surgical and anesthetist specialties influence antibiotic prescribing decisions; and surgical distance from the antimicrobial stewardship team, which influences use of antimicrobial stewardship principles.

CONCLUSIONS

Interventions to optimize SAP are more likely to be effective in enacting sustained change if they consider the interpersonal and social contexts, including issues of familiarity and cohesiveness, hierarchical patterns, and sense of place within a team. Significant relational dynamics in SAP decision making are centered around risk; that is, personal/reputational risk to different professional groups and ownership of risk for individual patient outcomes. Risk must therefore be considered for sustainable SAP optimization interventions.

Incidence and risk factors for surgical site infection post-hysterectomy in a tertiary care center

BACKGROUND

Preoperative antibiotic prophylaxis and surgical technological advances have greatly reduced, but not totally eliminated surgical site infection (SSI) posthysterectomy. We aimed to identify risk factors for SSI posthysterectomy among women with a high prevalence of gynecologic malignancies, in a tertiary care setting where compliance with the Joint Commission's Surgical Care Improvement Project core measures is excellent.

METHODS

The study was a matched case-control, 2 controls per case, matched on date of surgery. Study time was January 2, 2012-December 31, 2015. Procedures included abdominal and vaginal hysterectomies (open, laparoscopic, and robotic). SSI (superficial incisional or deep/organ/space) was defined as within 30 days postoperatively, per Centers for Disease Control and Prevention criteria. Statistical analysis included bivariate analysis and conditional logistic regression controlling for demographic and clinical variables, both patient-related and surgery-related, including detailed prophylactic antibiotic exposure.

RESULTS

Of the total 1,531 hysterectomies performed, we identified 52 SSIs (3%), with 60% being deep incisional or organ/space infections. All case patients received appropriate preoperative antibiotics (timing, choice, and weight-based dosing). Bivariate analysis showed that higher median weight, higher median Charlson comorbidity index, immune suppressed state, American Society of Anesthesiologists score ≥ 3, prior surgery within 60 days, clindamycin/gentamicin prophylaxis, surgery involving the omentum or gastrointestinal tract, longer surgery duration, ≥4 surgeons present in the operating room, higher median blood loss, ≥7 catheters or invasive devices in the operating room, and higher median length of hospital stay increased SSI risk (P < .05 for all). Cefazolin preoperative prophylaxis, robot-assisted surgery, and laparoscopic surgery were protective (P < .05 for all). Duration of surgery was the only independent risk factor for SSI identified on multivariate analysis (odds ratio, 3.45; 95% confidence interval, 1.21-9.76; P = .02).

CONCLUSIONS

In our population of women with multimorbidity and hysterectomies largely due to underlying gynecologic malignancies, duration of surgery, presumed a marker of surgical complexity, is a significant SSI risk factor. The choice of preoperative antibiotic did not alter SSI risk in our study.

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

BACKGROUND

Surgical site infections (SSIs) complicate surgery, resulting in higher morbidity and mortality. Infection control bundles and antibiotic stewardship can be effective at reducing SSIs. The influence of long-term serial interventions is unclear.

OBJECTIVE

The goal of this retrospective quasiexperimental study was to assess the influence of a 5-year serial infection control and antibiotic stewardship intervention on SSIs.

METHODS

The multidisciplinary program actively implemented pre-, intra-, and postoperative strategies over a 5-year period from 2009-2014 for all patients undergoing coronary artery bypass graft (CABG), valve replacement, or both at a tertiary care public institution. Outcomes are compared with a 2-year preinterventions period (2007-2009) and 1-year postinterventions period (2014-2015).

RESULTS

A total of 6,518 procedures were included. After interventions, the overall combined infection rate for CABG, CABG and valve, and valve procedures decreased by 66.3%, from 11.9%-4.0% (odds ratio, 0.34; 95% confidence interval, 0.23-0.49; P < .001). A significant decrease of >50% (P < .001) relative rate was observed in overall, sternum, leg, CABG, and combined CABG and valve infection rates when comparing pre- and postinterventions groups. The antibiotic stewardship intervention increased overall conformity to the internal surgical prophylaxis protocol by 46.8%, from 39.8%-86.6% (95% confidence interval, 41.0-52.4; P < .001).

CONCLUSION

Long-term, serial comprehensive infection control and antibiotic stewardship interventions decrease overall SSIs in patients undergoing CABG and valve replacement procedures.

Mapping Antimicrobial Stewardship in Undergraduate Medical, Dental, Pharmacy, Nursing and Veterinary Education in the United Kingdom

Objectives

To investigate the teaching of antimicrobial stewardship (AS) in undergraduate healthcare educational degree programmes in the United Kingdom (UK).

Participants and Methods

Cross-sectional survey of undergraduate programmes in human and veterinary medicine, dentistry, pharmacy and nursing in the UK. The main outcome measures included prevalence of AS teaching; stewardship principles taught; estimated hours apportioned; mode of content delivery and teaching strategies; evaluation methodologies; and frequency of multidisciplinary learning.

Results

80% (112/140) of programmes responded adequately. The majority of programmes teach AS principles (88/109, 80.7%). ‘Adopting necessary infection prevention and control precautions’ was the most frequently taught principle (83/88, 94.3%), followed by 'timely collection of microbiological samples for microscopy, culture and sensitivity’ (73/88, 82.9%) and ‘minimisation of unnecessary antimicrobial prescribing’ (72/88, 81.8%). The ‘use of intravenous administration only to patients who are severely ill, or unable to tolerate oral treatment’ was reported in ~50% of courses. Only 32/88 (36.3%) programmes included all recommended principles.

Discussion

Antimicrobial stewardship principles are included in most undergraduate healthcare and veterinary degree programmes in the UK. However, future professionals responsible for using antimicrobials receive disparate education. Education may be boosted by standardisation and strengthening of less frequently discussed principles.