Antimicrobial Stewardship in Surgery: Challenges and Opportunities

Antibiotics for UTI Prevention After Intradetrusor OnabotulinumtoxinA Injections

IMPORTANCE

Urinary tract infections (UTIs) occur in 8.6% to 48.1% of patients after intradetrusor onabotulinumtoxinA injections.

OBJECTIVE

The objective of this study was to evaluate both choice and duration of antibiotic prophylaxis on the incidence of UTI within 30 days after in-office onabotulinumtoxinA injections.

STUDY DESIGN

We included a single-site, retrospective cohort of 305 patients with overactive bladder or bladder pain syndrome receiving postprocedure prophylactic antibiotics for in-office, 100-unit intradetrusor onabotulinumtoxinA injections from 2019 to 2023. Categories of antibiotic prophylaxis compared included (1) nitrofurantoin 100 mg twice daily for 3 days, (2) nitrofurantoin 100 mg twice daily for 5 days, (3) trimethoprim-sulfamethoxazole 160 mg/800 mg twice daily for 3 days, and (4) "other regimens." Primary outcome was incidence of UTI within 30 days. Variables were compared via χ2 test. Crude/adjusted odds were estimated using binary logistic regression.

RESULTS

Incidence of UTI was 10.4% for 3-day nitrofurantoin, 20.5% for 5-day nitrofurantoin, 7.4% for 3-day trimethoprim-sulfamethoxazole, and 25.7% among "other regimens" (P = 0.023). Differences among primary regimens were substantial but not statistically significant: 3-day trimethoprim-sulfamethoxazole had 31% lower odds of UTI versus 3-day nitrofurantoin (odds ratio [OR], 0.689; P = 0.518). Compared with 3-day nitrofurantoin regimen, the 5-day nitrofurantoin regimen had twice the odds of UTI (OR, 2.22; P = 0.088). Those receiving "other regimens" had nearly 3 times the odds of UTI (OR, 2.98; P = 0.018). Results were similar adjusting for age and race. Overall urinary retention rate was 1.97%.

CONCLUSIONS

Prophylactic antibiotic choice and duration of treatment potentially affect UTI incidence after in-office, intradetrusor onabotulinumtoxinA injections. Nitrofurantoin and trimethoprim-sulfamethoxazole for 3 days have the lowest UTI incidence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Significance and current approaches to vascular graft infection

Vascular graft/endograft infection (VGEI) is a constant in cardiovascular surgery with published rates between 1 and 5%. Every graft type and anatomical location is a potential target for infectious complications. These patients are sick patients with high frailty burden. Management of VGEI entails a multidisciplinary and multimodality approach. Here we review some aspects of the problem of VGEI including prevention, diagnosis, and surgical therapy with focus on recent developments in the field.

Intra-operative drug level monitoring of pre-operative antibiotic for surgical prophylaxis in the patients of elective spinal surgery

OBJECTIVES

Single dose prophylaxis is good enough for general surgery with low risk patients. However, the evidence for the effectiveness of single dose anti-microbial prophylaxis (AMP) is not conclusive in high risk patients and spinal surgeries requiring instrumentation or the use of implants in particular. No studies have explored the various concentration of ceftriaxone in plasma and tissue as well during an ongoing spinal surgery. Therefore, the objective of study was to correlate the serum and tissue concentrations of ceftriaxone with the SSI and identify patients with increased risk of SSI.

METHODS

It was an open label prospective study in 50 consecutive patients who underwent elective spine surgery under prophylactic cover of ceftriaxone. Serum and tissue concentration were estimated by high pressure liquid chromatography during the ongoing surgery.

RESULTS

Subjects were observed for any post-operative complications including SSI. Serum (p=0.002) and tissue (p=0.012) concentrations of ceftriaxone at the closure of spinal surgery were associated with SSI. Duration of the surgery (p=0.04) and use of implants (p=0.02) were also important surgery related risk factors.

CONCLUSIONS

Serum and tissue concentrations of ceftriaxone at the closure and duration of surgery and instrumentation or use of implants in the spinal surgery are good predictors of SSI.

Reducing the duration of antibiotic therapy in surgical patients through a specific nationwide antimicrobial stewardship program. A prospective, interventional cohort study

BACKGROUND

Guidelines recommend 5-7 days of antibiotic treatment in patients with surgical infection and adequate source control. This nationwide stewardship intervention aimed to reduce the duration of treatments in surgical patients to <7 days.

METHODS

Prospective cohort study evaluating surgical patients receiving antibiotics ≥7 days in 32 hospitals. Indication for treatment, quality of source control, type of recommendations issued, and adherence to the recommendations were analysed. Temporal trends in the percentages of patients with treatment >7 days were evaluated using a linear regression model and Pearson's correlation coefficients.

RESULTS

A total of 32 499 patients were included. Of these, 13.7% had treatments ≥7 days. In all, 3912 stewardship interventions were performed, primarily in general surgery (90.7%) and urology (8.1%). The main types of infection were intra-abdominal (73.4%), skin/soft tissues (9.8%) and urinary (9.2%). The septic focus was considered controlled in 59.9% of cases. Out of 5458 antibiotic prescriptions, the most frequently analysed drugs were piperacillin/tazobactam (21.7%), metronidazole (11.2%), amoxicillin/clavulanate (10.3%), meropenem (10.7%), ceftriaxone (9.3%) and ciprofloxacin (6.7%). The main recommendations issued were: treatment discontinuation (35.0%), maintenance (40.0%) or de-escalation (15.5%), and the overall adherence rate was 91.5%. With adequate source control, the most frequent recommendation was to terminate treatment (51.2%). Throughout the study period, a significant decrease in the percentage of prolonged treatments was observed (Pc=-0.69;P < 0.001).

CONCLUSIONS

This stewardship programme reduced the duration of treatments in surgical departments. Preference was given to general surgery services, intra-abdominal infection, and beta-lactam antibiotics, including carbapenems. Adherence to the issued recommendations was high.

Surgical Antibiotic Prophylaxis Administration Improved after introducing Dedicated Guidelines: A Before-and-After Study from Dhulikhel Hospital in Nepal (2019-2023)

(1) Background: Surgical antibiotic prophylaxis (SAP) is important for reducing surgical site infections. The development of a dedicated hospital SAP guideline in the Dhulikhel Hospital was a recommendation from a baseline study on SAP compliance. Compliance with this new guideline was enhanced through the establishment of a hospital committee, the establishment of an antibiotic stewardship program and the funding and training of healthcare professionals. Using the baseline and a follow-up study after introducing dedicated hospital SAP guidelines, we compared: (a) overall compliance with the SAP guidelines and (b) the proportion of eligible and non-eligible patients who received initial and redosing of SAP; (2) Methods: A before-and-after cohort study was conducted to compare SAP compliance between a baseline study (July 2019-December 2019) and a follow-up study (January 2023-April 2023); (3) Results: A total of 874 patients were in the baseline study and 751 in the follow-up study. Overall SAP compliance increased from 75% (baseline) to 85% in the follow-up study (p < 0.001). Over 90% of those eligible for the initial dose of SAP received it in both studies. Inappropriate use for those not eligible for an initial dose was reduced from 50% to 38% (p = 0.04). For those eligible for redosing, this increased from 14% to 22% but was not statistically significant (p = 0.272); (4) Conclusions: Although there is room for improvement, introduction of dedicated SAP guidelines was associated with improved overall SAP compliance. This study highlights the role of operational research in triggering favorable interventions in hospital clinical care.

Considerations for an ideal post-surgical wound dressing aligned with antimicrobial stewardship objectives: a scoping review

OBJECTIVE

Most surgical wounds heal by primary or secondary intention. Surgical wounds can present specific and unique challenges including wound dehiscence and surgical site infection (SSI), either of which can increase risk of morbidity and mortality. The use of antimicrobials to treat infection in these wounds is prevalent, but there is now an imperative to align treatment with reducing antimicrobial resistance and antimicrobial stewardship (AMS). The aim of this review was to explore the published evidence identifying general considerations/criteria for an ideal post-surgical wound dressing in terms of overcoming potential wound healing challenges (including infection) while supporting AMS objectives.

METHOD

A scoping review examining evidence published from 1954-2021, conducted by two authors acting independently. Results were synthesised narratively and have been reported in line with PRISMA Extension for Scoping Reviews.

RESULTS

A total of 819 articles were initially identified and subsequently filtered to 178 for inclusion in the assessment. The search highlighted six key outcomes of interest associated with post-surgical wound dressings: wound infection; wound healing; physical attributes related to comfort, conformability and flexibility; fluid handling (e.g., blood and exudate); pain; and skin damage.

CONCLUSION

There are several challenges that can be overcome when treating a post-surgical wound with a dressing, not least the prevention and treatment of SSIs. However, it is imperative that the use of antimicrobial wound dressings is aligned with AMS programmes and alternatives to active antimicrobials investigated.

The Use of Antibiotics for the Prevention of Surgical Site Infections in Two Government Hospitals in Taif, Saudi Arabia: A Retrospective Study

Background

Surgical site infections (SSIs) are among the most common postoperative complications. To reduce the occurrence of surgical wound infections, suitable antimicrobials should be administered.

Aim of the work

This study investigated the prophylactic use of antibiotics to prevent SSIs, in terms of agents and/or combination preferences, and the adherence of surgeons to both national and international guidelines of surgical antibiotic prophylaxis in Taif city government hospitals.

Methods

This is a retrospective study using a chart review of patients' medical records in two government hospitals in Taif city, Saudi Arabia, from July 2016 to July 2018. While maintaining the confidentiality of the patient’s data, it was collected and analyzed using the chi-squared and Fisher’s exact tests, and the difference between means was tested using the student’s t-test.

Results

Prophylactic antibiotics were used in 157 patients who had surgery (Group 1) while 52 patients did not receive preoperative antibiotics (Group 2). The most commonly used prophylactic antibiotics were metronidazole, cefuroxime, cefazolin, and ceftriaxone. Other antimicrobials used included cefotaxime, amoxicillin/clavulanic acid, cephalexin, and amoxicillin. Surgical site infections developed in one patient of those who received antibiotics preoperatively and in three Group 2 patients. The mean hospital length of stay in Group 1 was 38.5±9.2 hours, and 57.3±12.1 hours in Group 2 patients. The types of antibiotics used were generally within the scope of national and international recommended guidelines.

Conclusion

The use of preoperative prophylactic antibiotics significantly reduces the development of surgical site infections and the mean length of hospital stay. Various antimicrobial drugs that were used prophylactically in surgical practice are within the recommendations of both national and international guidelines.

Antimicrobial Stewardship in Surgery: A Literature Bibliometric Analysis

Background

Antimicrobial resistance and the dwindling antibiotic development pipeline have resulted in a looming post-antibiotic era. Research related to antimicrobial stewardship (AMS) has grown rapidly in the past decade, especially in the field of surgery. We conducted a bibliometric analysis of these publications. In addition, we aimed to identify research hotspots and infer future research trends.

Methods

We screened global publications on AMS in the surgical field over ten years (between 2011 and 2020) from the Web of Science core collection database. The keywords “antimicrobial or antibiotic”, “stewardship”, “management”, “management strategies”, “programme”, “surgery” and “surgical” were used to search for related papers. VOS viewer, R software, and other machine learning and visualization tools were used to conduct the bibliometric analysis of the publications.

Results

We identified 674 publications on AMS in surgical fields; “antimicrobial stewardship” (with total link strength of 1,096) was the most frequent keyword, and had strong links to “antimicrobial resistance” and “guidelines”. The top 100 most cited papers had a mean citation count of 47.21 (range: 17–1155) citations, which were cited by survey research studies, clinical trials, and observational studies. The highest-ranking and most cited journal was Clinical Infectious Diseases with eight publications. Jason G. Newland from Washington University wrote seven papers and was cited 1,282 times. The University of Washington published 17 papers and was cited 1,258 times, with the largest number of publications by author and organization. The USA published 198 papers and cooperated with 21 countries, mainly partnering with Italy, the UK, and Canada. Published articles mainly focused on the current clinical situation regarding surgical AMS management, antibiotic prescription, and antibiotic resistance.

Conclusions

Publications on surgical AMS management have increased in recent decades, with the USA being the most prolific. Epidemiological investigations of surgical-related infections, antibiotic prescriptions, and antibiotic resistance are fast-developing research trends. However, further improvements are still needed according to the recommendations gained from the bibliometric analysis.

Does the Duration of Perioperative Antibiotic Prophylaxis Influence the Incidence of Postoperative Surgical-Site Infections in Implant-Based Breast Reconstruction in Women with Breast Cancer? A Retrospective Study

BACKGROUND

Perioperative antibiotic prophylaxis is an established concept to reduce the risk of surgical-site infections; however, the optimal treatment duration in prosthetic breast reconstruction is still controversial. This study evaluated a potential association between the perioperative antibiotic prophylaxis duration (≤24 hours versus >24 hours) and incidence of postoperative surgical-site infections in immediate implant-based breast reconstruction in breast cancer patients.

METHODS

A descriptive, retrospective analysis of surgical-site infections after immediate implant-based breast reconstruction in breast cancer patients between January of 2011 and December of 2018 was performed. The incidence of postoperative surgical-site infections in patients with more than 24 hours of perioperative antibiotic prophylaxis was compared to patients treated for 24 hours or less.

RESULTS

A total of 240 patients who met criteria were included. There were no relevant epidemiologic, clinical, or histopathologic differences between groups. Surgical-site infections as defined by the Centers for Disease Control and Prevention criteria occurred in 25.8 percent. A risk factor-adjusted analysis by a prespecified multiple logistic regression model showed that 24 hours or less of perioperative antibiotic prophylaxis was not inferior to treatment for more than 24 hours. The upper limit of the one-sided 95 percent confidence interval of the risk difference was 9.4 percent (below the prespecified noninferiority margin of 10 percent leading to statistical significance). Risk factors for a surgical-site infection included obesity and postoperative wound complications.

CONCLUSIONS

The study found no association between short-course perioperative antibiotic prophylaxis (≤24 hours) and an increased rate of postoperative surgical-site infection. This is of high clinical relevance because short-course treatment can help reduce side effects and the emergence of antimicrobial resistance and prevent surgical-site infections as effectively as a prolonged perioperative antibiotic prophylaxis course.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Retrospective Cohort Analysis of the Effect of Antimicrobial Stewardship on Postoperative Antibiotic Therapy in Complicated Intra-Abdominal Infections: Short-Course Therapy Does Not Compromise Patients’ Safety

Background: Recent evidence suggests that short-course postoperative antibiotic therapy (PAT) of intra-abdominal infections is non-inferior considering clinical outcomes. The aim of this study was to compare the outcome of short vs. long PAT in complicated intra-abdominal infections (cIAIs) without sepsis. Methods: We performed a single center-quality improvement study at a 1500 bed sized university hospital in Bavaria, Germany, with evaluation of the length of antibiotic therapy after emergency surgery on cIAIs with adequate source control during 2016 to 2018. We reviewed a total of 260 cases (160 short duration vs. 100 long duration). The antibiotic prescribing quality was assessed by our in-house antimicrobial stewardship team (AMS). Results: No significant differences of patient characteristics were observed between short and long PAT. The frequency of long PAT declined during the observation period from 48.1% to 26.3%. Prolongation of PAT was not linked with any clinical benefits, on the contrary clinical outcome of patients receiving longer regimes were associated with higher postoperative morbidity. AMS identified additional educational targets to improve antibiotic prescribing quality on general wards like unnecessary postoperative switches of antibiotic regimes, e.g., unrequired switches to oral antibiotics as well as prolongation of PAT due to elevated CRP. Conclusion: Short-course antibiotic therapy after successful surgical source control in cIAIs is safe, and long-duration PAT has no beneficial effects.

Variability in the serum and tissue concentrations of pre-incisional ceftriaxone for surgery in paediatric population and outcome of surgical-site infections; An open labelled, prospective, non-randomized, analytical study

Studies have determined the serum concentration of ceftriaxone in the adult population, but there are only a few studies that measured the tissue concentrations. However, no studies have concurrently evaluated the serum and tissue concentrations of ceftrixaone in elective pediatric surgery patients. Therefore, our study was planned to evaluate the serum and tissue concentrations of single dose intravenous prophylactic ceftriaxone intra-operatively during an ongoing pediatric surgery and the outcome of surgical-site infections (SSIs). We did a correlation analysis to determine the relationship of various concentrations and surgery related risk factors with the outcome of SSIs. It was an open label prospective study in 50 patients who underwent elective pediatric surgery under prophylactic cover of ceftriaxone. Serum and tissue concentration were estimated by High Pressure Liquid Chromatography (HPLC). Subjects were observed for post operative complications including SSI. Serum and tissue concentrations of ceftriaxone were significant at test value of 4 ​mg/L. Tissue concentrations of ceftriaxone at incision (p ​= ​0.02) and closure (p ​= ​0.04) were significantly correlated with SSI but there was no significant association. The measured serum ceftriaxone concentrations were more than 20 times the susceptible minimum inhibitory concentration (MIC) at any given point of the surgery. On the other hand, this target level was achieved at the tissue levels in the majority of the patient. The factors associated with SSI were duration of surgery, wound category of contaminated clean type, the use of urinary catheter and implants in the surgery. An intra-operative re-dose, extension of dose or addition of another antibiotic may be considered for such patients.

•

Currently, no standard guidelines are available for the pre-operative prophylactic antibiotic use in pediatric surgery.

•

This study addresses the issue about antibiotic dose and frequency in context of elective pediatric surgery patients.

•

The tissue concentration of ceftriaxone at incision and at closure of surgery are important predictors for SSI.

•

For optimizing the antibiotic use and re-dosing in SSI prophylaxis, tissue concentration of the antibiotic should be preferred over the plasma concentrations.

Surgical antibiotic prophylaxis administration practices

SETTING

A referral hospital in Kavre, Nepal.

OBJECTIVES

To assess 1) compliance with National Antibiotic Treatment Guidelines (NATG), specifically, whether the administration of surgical antibiotic prophylaxis (SAP) (initial dosing and redosing) was in compliance with NATG for patients who were and were not eligible, and 2) development of surgical site infections (SSIs) among patients who underwent surgery in the Department of General Surgery (July-December 2019).

DESIGN

This was a retrospective cohort analysis.

RESULTS

The analysis included 846 patients, of which 717 (85%) patients were eligible for SAP and 129 (15%) were ineligible. Of those eligible, 708 (99%) received the initial dose; while 65 (50%) of the ineligible did not receive any dose. Of those who received the initial dose, 164 (23%) were eligible for redosing. Of these, only 23 (14%) received at least one redosing and 141 (86%) did not receive it. Overall compliance with NATG was achieved in 75% (632/846) of patients. SSIs occurred in 23 (3%) patients, 8 (35%) of whom did not have SAP administered according to NATG.

CONCLUSION

A relatively high overall compliance with NATG for SAP administration was reported. Recommendations were made to improve compliance among those who were ineligible for SAP and those who were eligible for redosing.

Antimicrobial stewardship measures in cardiac surgery and its impact on surgical site infections

Objective

The goal of this study was to monitor the compliance and impact on a protocol change of surgical antimicrobial prophylaxis in cardiac surgery favouring cefazolin instead cefuroxime, initiated by the hospital’s antimicrobial stewardship team.

Methods

This quality improvement study was performed in a tertiary care hospital in collaboration with the department of cardiothoracic surgery and the hospitals antimicrobial stewardship team following a revision of the standard for surgical antimicrobial prophylaxis including 1029 patients who underwent cardiac surgery. 582 patients receiving cefuroxime and 447 patients receiving cefazolin respectively were compared without altering any other preventative perioperative measures including its postoperative duration of less than 24 h. Adherence and surgical site infections were compiled and analysed.

Results

A complete adherence was achieved. Overall surgical site infections occurred in 37 (3.6%) of the cases, 20 (3.4%) in cefuroxime patients and 17 (3.8%) in cefazolin patients (p value = 0.754). No statistically significant differences could be found in any of the primary endpoints, but there was a trend towards less deep sternal wound infections in the cefazolin group.

Conclusions

The study supports the role of antimicrobial stewardship in cardiac surgery and mirrors the success of a multidisciplinary team aiming to minimize adverse events by optimizing antibiotic use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01693-7.

Antibiotic Stewardship Program Experience in a Training and Research Hospital

Objectives

Antibiotic Stewardship Programs (ASP) have been developed for the spread of rational antibiotic use. Our hospital is one of the first centers where ASP applications were launched in Turkey. In this study, we aimed to share our experience with ASP which has been applied in our hospital since 2013.

Methods

We adapted ASP to our hospital program from Centers for Disease Control and Prevention's ASP checklist. Revisions on surgical prophylaxis guidelines and practices were performed. Surgical prophylaxis was evaluated from hospital infection surveillance and antibiotic usage by point prevalence surveys. Antibiotic consumption indexes (ACI) were calculated from hospital pharmacy records. Rapid antigen detection test (RADT) for Group A beta-hemolytic streptococcus and influenza rapid antigen test were started to be used. Cumulative antibiotic susceptibility results were prepared annually.

Results

Surgical prophylaxis was started to be administered in the operating room within 60 min of incision. Third-generation cephalosporin usage for surgical prophylaxis could be restricted in all clinics but the duration could only be shortened in neurosurgery and general surgery. There was no statistically significant change in antibiotic usage rates and appropriateness between 2014 and 2018. ACI for the class J01 in adult wards was 80.5 daily defined doses (DDD) per 100 patient days in 2014 and reduced to 64.8 DDD per 100 patient days in 2018. 22.445 pediatric patients presenting with complaints of the upper respiratory tract were evaluated with RADT and 75.1% were treated without antibiotics.

Conclusion

In this global antimicrobial resistance era, all hospitals should have motivated antimicrobial stewardship teams. Each hospital should establish its own stewardship program and often revise it. Improvement in rational antibiotic use is hard to achieve without multidisciplinary involvement.

Impact of an Education-Based Antimicrobial Stewardship Program on the Appropriateness of Antibiotic Prescribing: Results of a Multicenter Observational Study

To evaluate the effect that an education-based Antimicrobial stewardship program (ASP) implemented in two hospitals in southern Italy had on the quality and appropriateness of antibiotic prescription. We conducted a multicenter observational study in two hospitals in the Campania region. Only some departments of both hospitals were already participating in the ASP. We collected data on all patients admitted on the day of evaluation in antibiotic therapy or prophylaxis through a case report form. The primary outcome was to investigate the difference in the appropriateness of the antibiotic prescriptive practice in the departments that had joined the ASP and in those that had not participated in the project (non-ASP). The total number of patients assessed was 486. Of these, 78 (16.05%) were in antibiotic prophylaxis and 130 (26.7%) in antibiotic therapy. The prescriptive appropriateness was better in the units that had joined ASP than in those that had not, with respectively 65.8% versus 22.7% (p < 0.01). Patients in the non-ASP units more frequently received unnecessary antibiotics (44.9% versus 0%, p = 0.03) and, as surgical prophylaxis, the use of antibiotics not recommended by the guidelines (44.2% versus 0%, p = 0.036). Multivariable analysis of the factors associated with prescriptive appropriateness identified ASP units (p = 0.02) and bloodstream or cardiovascular infections (p = 0.03) as independent predictors of better prescriptive appropriateness. The findings of the present study reinforce the importance of adopting an educational ASP to improve the quality of antimicrobial prescription in clinical practice.

Pharmacological evaluation of prophylactic anti-microbial use in laparoscopic cholecystectomy; an open labelled study evaluating the concentrations of single dose intravenous ceftriaxone at serum and tissue level

OBJECTIVE

The goal of administering preoperative systemic prophylactic antibiotics is to have the concentration in the tissues at its optimum level at the start and throughout the surgery. The rationale for the use of antibiotics is not well accepted; possible side effects and development of microbial resistance patterns are potential risks along with the financial burden. Therefore, the present study was conducted with the aim to clinically evaluate the serum and tissue concentration of single-dose prophylactic ceftriaxone during an ongoing laparoscopic cholecystectomy (LC) and to find out risk factors for post operative surgical site infections (SSI).

METHOD

It was an open labelled prospective study in 50 consecutive patients who underwent elective laparoscopic cholecystectomy under prophylactic cover of ceftriaxone. Serum and tissue concentration were estimated by High Performance Liquid Chromatography during the ongoing surgery. Subjects were observed for any post-operative complications including SSI.

RESULTS

Serum and tissue concentrations of ceftriaxone were significant at test value of 4 milligrams/Litre. Body mass index was significantly correlated with the tissue concentration of ceftriaxone at the time of incision. The rate of SSI was 2%. It significantly correlated with age more than 60 years, diabetes and infected bile.

CONCLUSION

A single prophylactic intra-venous dose of 1 g ceftriaxone immediately prior to skin incision in LC is good enough for prevention of SSI in Indian patients.

Surgeon-led 7-VINCut Antibiotic Stewardship Intervention Decreases Duration of Treatment and Carbapenem Use in a General Surgery Service

Antibiotic stewardship programs optimize the use of antimicrobials to prevent the development of resistance and improve patient outcomes. In this prospective interventional study, a multidisciplinary team led by surgeons implemented a program aimed at shortening the duration of antibiotic treatment <7 days. The impact of the intervention on antibiotic consumption adjusted to bed-days and discharges, and the isolation of multiresistant bacteria (MRB) was also studied. Furthermore, the surgeons were surveyed regarding their beliefs and feelings about the program. Out of 1409 patients, 40.7% received antibiotic therapy. Treatment continued for over 7 days in 21.5% of cases, and, as can be expected, source control was achieved in only 48.8% of these cases. The recommendations were followed in 90.2% of cases, the most frequent being to withdraw the treatment (55.6%). During the first 16 months of the intervention, a sharp decrease in the percentage of extended treatments, with R2 = 0.111 was observed. The program was very well accepted by surgeons, and achieved a decrease in both the consumption of carbapenems and in the number of MRB isolations. Multidisciplinary stewardship teams led by surgeons seem to be well received and able to better manage antibiotic prescription in surgery.

Preoperative antibiotic prophylaxis regimen in brain tumour surgery in Sweden: a quasi-experimental study

Background

There has been varied clinical practice concerning antibiotic prophylaxis in patients undergoing craniotomy. In Sweden, both Cloxacillin and Cefuroxime have frequently been used. We aimed to study the clinical effectiveness of these two regimens.

Methods

A quasi-experimental design was used. The sample consisted of 580 adult (> 18 years) patients operated 2012–2015, of which 375 received Cloxacillin (pre-intervention group) and 205 received Cefuroxime (intervention group). Primary endpoint was the incidence of surgical site infection (SSI) 12 months after surgery, while secondary endpoints were the need for reoperation due to SSI, the amount antibiotics used and the number of visits in the outpatient clinic related to SSI. A control group from another institution was reviewed to rule out clinical trial effects.

Results

When analysed by intention to treat, the pre-intervention group had a significant higher incidence of SSI, 13.3% (50/375) vs 5.4% (11/205) in the intervention group (p < 0.01). A treatment per protocol analysis confirmed the result. The number of reoperations due to SSI were significantly reduced in the intervention group, 3.4% (7/205) vs 8.3% (31/375) (p = 0.02), as was the total antibiotic use (p = 0.03) and the number of visits in the outpatient clinic (p < 0.01). In the control group, the reoperation rate as result of SSI was lower (p = 0.02) prior to the opposite change from Cefuroxime to Cloxacillin, 1.8% (27/1529) vs 3.1% (43/1378).

Conclusion

In Sweden, Cefuroxime as prophylaxis in brain tumour surgery by craniotomy seems to be superior to Cloxacillin.

Antibiotic prophylaxis and surgical site infections; a prospective open label study to clinically evaluate the serum and tissue concentration of single dose prophylactic ceftriaxone in laparoscopic cholecystectomy

OBJECTIVE

The goal of administering preoperative systemic prophylactic antibiotics is to have the concentration in the tissues at its optimum level at the start and throughout the surgery. The rationale for the use of antibiotics is not well accepted, possible side effects and development of microbial resistance patterns are potential risks along with the financial burden. Therefore, the present study was conducted with the aim to clinically evaluate the serum and tissue concentration of single dose prophylactic ceftriaxone during an ongoing laparoscopic cholecystectomy and to find out risk factors for postoperative surgical site infection.

METHOD

It was an open label prospective study in 50 consecutive patients who underwent elective laparoscopic cholecystectomy under prophylactic cover of ceftriaxone. Serum and tissue concentrations were estimated by HPLC during the ongoing surgery. Subjects were observed for any postoperative complications including SSI.

RESULTS

Serum and tissue concentrations of ceftriaxone were significant at test value of 4 mg/L. Body mass index was significantly correlated with the tissue concentration of ceftriaxone at the time of incision. The rate of SSI was 2%. It was significantly correlated with age more than 60 years, diabetes, and infected bile.

CONCLUSION

A single prophylactic iv dose of 1 g ceftriaxone immediately prior to skin incision in LC is good enough for prevention of SSI in Indian patients.

Controversies in Perioperative Antimicrobial Prophylaxis

Although clinical guidelines for antibiotic prophylaxis across a wide array of surgical procedures have been proposed by multidisciplinary groups of physicians and pharmacists, clinicians often deviate from recommendations. This is particularly true when recommendations are based on weak data or expert opinion. The goal of this review is to highlight certain common but controversial topics in perioperative prophylaxis and to focus on the data that does exist for the recommendations being made.

How Does Antimicrobial Stewardship Affect Inappropriate Antibiotic Therapy in Urological Patients?

Antimicrobial stewardship teams (ASTs) have been well-accepted in recent years; however, their clinical outcomes have not been fully investigated in urological patients. The purpose of this study was to evaluate the outcomes of intervention via a retrospective review of urological patients, as discussed in the AST meetings, who were treated with broad-spectrum antibiotics between 2014 and 2018 at the Department of Urology, Kobe University Hospital in Japan. Interventions were discussed in AST meetings for patients identified by pharmacists as having received inappropriate antibiotic therapy. The annual changes in numbers of inappropriate medications and culture submissions over five years at the urology department were statistically analyzed. Among 1,033 patients audited by pharmacists, inappropriate antibiotic therapy was found in 118 cases (11.4%). The numbers of inappropriate antibiotic use cases and of interventions for indefinite infections had significantly decreased during the study period (p = 0.012 and p = 0.033, respectively). However, the number of blood and drainage culture submissions had significantly increased (p = 0.009 and p = 0.035, respectively). Our findings suggest that urologists have probably become more familiar with infectious disease management through AST intervention, leading to a decrease in inappropriate antibiotic use and an increase in culture submissions.

Investigation of perioperative work processes in provision of antibiotic prophylaxis: a prospective descriptive qualitative study across surgical specialties in Norway

OBJECTIVE

Surgical site infections are known postoperative complications, yet the most preventable of healthcare-associated infections. Correct provision of surgical antibiotic prophylaxis (SAP) is crucial. Use of the WHO Safe Surgical Checklist (SSC) has been reported to improve provision of SAP, and reduce infections postoperatively. To understand possible mechanisms and interactions generating such effects, we explored the underlying work processes of SAP provision and SSC performance at the intersection of perioperative procedures and actual team working.

DESIGN

An ethnographic study including observations and in-depth interviews. A combination of deductive and inductive content analysis of the data was conducted.

SETTING

Operating theatres with different surgical specialities, in three Norwegian hospitals.

PARTICIPANTS

Observations of perioperative team working (40 hours) and in-depth interviews of 19 experienced perioperative team members were conducted. Interview participants followed a maximum variation purposive sampling strategy.

RESULTS

Analysis identified provision of SAP as a process of linked activities; sequenced, yet disconnected in time and space throughout the perioperative phase. Provision of SAP was handled in relation to several interactive factors: preparation and administration, prescription accuracy, diversity of prescription order systems, patient-specific conditions and changes in operating theatre schedules. However, prescription checks were performed either as formal SSC reviews of SAP items or as informal checks of relevant documents. In addition, use of cognitive reminders and clinical experiences were identified as mechanisms used to enable administration of SAP within the 60 min timeframe described in the SSC.

CONCLUSION

Provision of SAP was identified as a complex process. Yet, a key element in provision of SAP was the given 60 min. timeframe of administration before incision, provided in the SSC. Thus, the SSC seems beneficial in supporting timely SAP administration practice by either being a cognitive tool and/or as a cognitive intervention.

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.

Addressing social influences reduces antibiotic duration in complicated abdominal infection: a mixed methods study

BACKGROUND

Antimicrobial therapy for intra-abdominal infections is often inappropriately prolonged. An intervention addressing factors influencing the duration of intravenous antibiotic use was undertaken. This study reports the antibiotic prescribing patterns before and after the intervention and a qualitative analysis of the experience of the intervention.

METHODS

Quantitative: A retrospective audit of patients with complicated intra-abdominal infection before and after a multifaceted persuasive intervention was performed. Qualitative: Semi-structured interviews were performed to evaluate which elements of the intervention were perceived to be effective.

RESULTS

An intervention including collaborative inter-specialty and inter-professional educational meetings, and education of all professional streams was undertaken. Quantitative: Twenty-three patients before and 22 patients after the intervention were included. The total duration of antibiotics decreased significantly following the intervention (9.2 versus 6.6 days P = 0.02). The duration of intravenous antibiotics did not change significantly (5.4 versus 4.5 days, P = 0.06). Qualitative: Eighteen health-care professionals participated. Thematic analysis indicated that a collaborative approach between senior surgical and infectious disease specialists in the pre-intervention stage led to perceived ownership and leadership of the intervention by the surgical team, which was thought critical to the success of the intervention. Conversely, the ability of nurses and pharmacists to influence antibiotic practice was considered limited and a poster promoting the intervention was perceived as ineffective.

CONCLUSION

Consultant leadership and specialty ownership of the process were perceived to be critical in the success of the intervention. Antibiotic stewardship programs which address social factors may have greater efficacy to optimize antimicrobial prescribing.

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.

[Perception of surgeons on the use of antimicrobial stewardships programs]

INTRODUCTION

The misuse and overuse of antimicrobials can contribute to an increase in antimicrobial resistance, increasing the risk of infections caused by drug-resistant bacteria. Most common surgical pathologies are infectious (either primary or as a complication), often being over-treated. Exploring the perception of surgeons on the use of implementing Antimicrobial stewardship programs (ASPs) is relevant in order to adapt the program to local context.

OBJECTIVE

To determine the perception of surgeons on the management of infections and antibiotic (AB) prescription in a General Surgery Department (GSD).

METHODS

A cross-sectional and descriptive study was conducted using an anonymous questionnaire that was distributed to assess the aspects related to AB management.

RESULTS

A total of 42 questionnaires were completed, with a 65% response rate. The large majority (75%) considered that antimicrobial resistance was an important problem. The main situations considered with medium/high margin of improvement were: time from taking the specimen to receiving the results (70%), use of a wide spectrum AB, and excessive duration (88% and 89%), dose adjustment according to renal function (81%), unnecessary prolongation of intravenous AB treatment (87%) and excessive duration of it (89%), preference for intravenous AB administration until discharge of the patient (73%). There were also difficulties in ASP implementation, as well as established and solid AB patterns (84%) and the heterogeneity of the GSD (84%).

CONCLUSIONS

Organisational aspects of the GSD constitute one of the problems to implement the ASPs. A specific multidisciplinary team has been constituted to address different training aspects. This will also serve as a forum of discussion of certain complex patients with difficulties in antibiotic management.