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Erekson E, Whitcomb EL, Kamdar N, Swift S, Cundiff GW, Yaklic J, Strohbehn K, Adam R, Danford J, Willis-Gray MG, Maxwell R, Edenfield A, Pulliam S, Gong M, Malek M, Hanissian P, Towers G, Guaderrama NM, Slocum P, Morgan D. Performance of Perioperative Tasks for Women Undergoing Anti-incontinence Surgery: Developed by the AUGS Quality Improvement and Outcomes Research Network. UROGYNECOLOGY (PHILADELPHIA, PA.) 2023; 29:660-669. [PMID: 37490706 DOI: 10.1097/spv.0000000000001392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
OBJECTIVES Surgery for the correction of stress urinary incontinence is an elective procedure that can have a dramatic and positive impact on quality of life. Anti-incontinence procedures, like inguinal hernia repairs or cholecystectomies, can be classified as high-volume/low-morbidity procedures. The performance of a standard set of perioperative tasks has been suggested as one way to optimize quality of care in elective high-volume/low-morbidity procedures. Our primary objective was to evaluate the performance of 5 perioperative tasks-(1) offering nonsurgical treatment, (2) performance of a standard preoperative prolapse examination, (3) cough stress test, (4) postvoid residual test, and (5) intraoperative cystoscopy for women undergoing surgery for stress urinary incontinence-compared among surgeons with and without board certification in female pelvic medicine and reconstructive surgery (FPMRS). STUDY DESIGN This study was a retrospective chart review of anti-incontinence surgical procedures performed between 2011 and 2013 at 9 health systems. Cases were reviewed for surgical volume, adverse outcomes, and the performance of 5 perioperative tasks and compared between surgeons with and without FPMRS certification. RESULTS Non-FPMRS surgeons performed fewer anti-incontinence procedures than FPMRS-certified surgeons. Female pelvic medicine and reconstructive surgery surgeons were more likely to perform all 5 perioperative tasks compared with non-FPMRS surgeons. After propensity matching, FPMRS surgeons had fewer patients readmitted within 30 days of surgery compared with non-FPMRS surgeons. CONCLUSIONS Female pelvic medicine and reconstructive surgery surgeons performed higher volumes of anti-incontinence procedures, were more likely to document the performance of the 5 perioperative tasks, and were less likely to have their patients readmitted within 30 days.
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Affiliation(s)
| | | | | | - Steve Swift
- Medical University of South Carolina, Charleston, SC
| | | | - Jerome Yaklic
- University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Rony Adam
- Vanderbilt University Medical Center
| | | | | | | | | | | | - Merry Gong
- Surrey Memorial Hospital, University of British Columbia, Surrey, British Columbia, Canada
| | | | | | | | | | - Paul Slocum
- Premier Urogynecology of North Texas, Dallas, TX
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McKay KM, Burchette R, Shi JM, Henry SL, Harness NG. Evidence-Based Antibiotic Prophylaxis in Clean Hand Surgeries: An Educational Intervention to Decrease Use. J Hand Surg Am 2023:S0363-5023(23)00208-3. [PMID: 37318406 DOI: 10.1016/j.jhsa.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 04/11/2023] [Accepted: 04/21/2023] [Indexed: 06/16/2023]
Abstract
PURPOSE Evidence for the use of prophylactic antibiotics in clean hand surgery is limited, yet surgeons continue to administer antibiotics to prevent postoperative infections. We sought to assess the effect of a program directed at reducing the use of antibiotic prophylaxis in carpal tunnel release surgery and elicit reasons for continued use. METHODS A surgeon leader implemented a program between September 1, 2018 and September 30, 2019 to reduce antibiotic prophylaxis in clean hand surgeries in a hospital system of 10 medical centers. It consisted of (1) an evidence-based educational session for all participating orthopedic and hand surgeons during which the elimination of the use of antibiotics in clean hand surgeries was requested and (2) a year-long, monthly antibiotic use audit and feedback cycle using carpal tunnel release (CTR) as a proxy for clean hand surgery. The rate of antibiotic use in the year of the intervention was compared to the rate prior to the intervention. Multivariable regression was used to determine patient-related risk factors for receiving antibiotics. Participating surgeons completed a survey to elucidate factors that contributed to continued use. RESULTS Antibiotic prophylaxis decreased from 1223/2379 (51%) in 2017-2018 to 531/2550 (21%) in 2018-2019. During the last month of evaluation, the rate decreased to 28/208 (14%). Logistic regression revealed a higher rate of antibiotic use during the period after the intervention among patients who had diabetes mellitus or who were operated upon by an older surgeon. The follow-up surgeon survey revealed a strong positive correlation between surgeon willingness to administer antibiotics and patient hemoglobin A1c and body mass index. CONCLUSIONS The rate of antibiotic use in carpal tunnel release decreased from 51% the year prior to 14% the final month of implementing a surgeon-led program to reduce antibiotic prophylaxis. Multiple barriers to the implementation of evidence-based practice were identified. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Kevin M McKay
- Department of Orthopedic Surgery, Loma Linda University Health, Loma Linda, CA.
| | - Raoul Burchette
- Kaiser Permanente Orange County - Anaheim Medical Center, Anaheim, CA
| | - Jiaxiao M Shi
- Kaiser Permanente Orange County - Anaheim Medical Center, Anaheim, CA
| | - Shayna L Henry
- Kaiser Permanente Orange County - Anaheim Medical Center, Anaheim, CA
| | - Neil G Harness
- Kaiser Permanente Orange County - Anaheim Medical Center, Anaheim, CA
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Lim CY, Alonso A, Koh YY, Roydhouse S, McCormack L, Deans R, Nesbitt-Hawes E, Rao A, Causer L, Abbott JA. A Double-Blinded, Randomised, Placebo-Controlled Trial of Antibiotic Prophylaxis in Elective Non-Hysterectomy Laparoscopic Surgery for Benign Gynaecological Conditions: A Pilot Study. J Minim Invasive Gynecol 2022; 29:992-997. [PMID: 35513301 DOI: 10.1016/j.jmig.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE To determine the feasibility of a double-blinded randomised, placebo-controlled study in determining the efficacy of antibiotic prophylaxis in preventing postoperative infections (POI) in elective non-hysterectomy laparoscopic procedures for benign gynaecological conditions. DESIGN Double-blinded, randomised, placebo-controlled trial. SETTING University-affiliated tertiary referral hospital in Sydney, Australia. PATIENTS Women over the age of 18 undergoing elective non-hysterectomy laparoscopic procedures for benign gynaecological conditions were eligible for the study and approached. INTERVENTIONS Prior to surgery, participants were randomised to receive either 2g cephazolin or placebo (10ml normal saline) administered by the anaesthetist. Participants and other research staff were blinded to group allocation. MEASUREMENTS AND MAIN RESULTS The primary outcome was study feasibility measured by recruitment rates, compliance rates of drug administration, compliance rates of delivery, maintenance of double blinding and follow-up rates. Secondary outcomes included rate of postoperative infections, length of hospitalisation, re-admission to hospital, unscheduled presentations to healthcare facilities and antibiotic-related reactions. Between February 2019 and March 2021, 170 patients were approached with 117 (68.8%) participants recruited and randomised. The study had a high compliance rate of trial drug delivery (95.7%) and a high follow-up rate (99.1%). CONCLUSION This pilot study has demonstrated feasibility of a large-scale study with a recruitment rate of 68% of patients approached and excellent trial drug delivery and follow-up rates. As anticipated, it is underpowered for identifying clinically significant findings for postoperative infection rates. A large-scale study is appropriate and essential to determine the health-related risks of antibiotic prophylaxis with an emphasis on antimicrobial stewardship. The sample size for a large-scale study is 1678 participants based on infection rates in this pilot study.
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Affiliation(s)
- Claire Yinn Lim
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Anaïs Alonso
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Yi Ying Koh
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Stephanie Roydhouse
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Lalla McCormack
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Rebecca Deans
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Erin Nesbitt-Hawes
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Archana Rao
- Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Louise Causer
- Kirby Institute, UNSW Sydney, New South Wales, Australia
| | - Jason A Abbott
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia.
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Menz BD, Charani E, Gordon DL, Leather AJM, Moonesinghe SR, Phillips CJ. Surgical Antibiotic Prophylaxis in an Era of Antibiotic Resistance: Common Resistant Bacteria and Wider Considerations for Practice. Infect Drug Resist 2021; 14:5235-5252. [PMID: 34908856 PMCID: PMC8665887 DOI: 10.2147/idr.s319780] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/19/2021] [Indexed: 01/19/2023] Open
Abstract
The increasing incidence of antimicrobial resistance (AMR) presents a global crisis to healthcare, with longstanding antimicrobial agents becoming less effective at treating and preventing infection. In the surgical setting, antibiotic prophylaxis has long been established as routine standard of care to prevent surgical site infection (SSI), which remains one of the most common hospital-acquired infections. The growing incidence of AMR increases the risk of SSI complicated with resistant bacteria, resulting in poorer surgical outcomes (prolonged hospitalisation, extended durations of antibiotic therapy, higher rates of surgical revision and mortality). Despite these increasing challenges, more data are required on approaches at the institutional and patient level to optimise surgical antibiotic prophylaxis in the era of antibiotic resistance (AR). This review provides an overview of the common resistant bacteria encountered in the surgical setting and covers wider considerations for practice to optimise surgical antibiotic prophylaxis in the perioperative setting.
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Affiliation(s)
- Bradley D Menz
- SA Pharmacy, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Esmita Charani
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK
| | - David L Gordon
- Flinders Health & Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Division of Medicine, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Andrew J M Leather
- Centre for Global Health and Health Partnerships, School of Population Health and Environmental Science, Kings College London, London, UK
| | - S Ramani Moonesinghe
- Centre for Perioperative Medicine, UCL Division of Surgery and Interventional Science, London, UK.,UCL Hospitals NIHR Biomedical Research Centre, London, UK
| | - Cameron J Phillips
- SA Pharmacy, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia.,Flinders Health & Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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5
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M. Magdy A, A. Seksaka M, F. Balata G. Antibiotic overuse in obstetric and gynecologic procedures at Zagazig university hospitals: A prospective observational study. PHARMACIA 2021. [DOI: 10.3897/pharmacia.68.e71923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Surgical site infection (SSI) constitutes a major problem in healthcare in terms of healthcare cost, morbidity and mortality. Surgical antibiotic prophylaxis (SAP) is one of the effective strategies for SSI prevention. Poor adherence to SAP guidelines across different countries has been observed. Misuse of prophylactic antibiotics threatens patient safety and leads to an increase in the acquisition of antibiotic resistance. The aim of this study was to assess the utilization of SAP in obstetric and gynecologic procedures in terms of indication for prophylaxis, antibiotic selection, timing of administration and prophylaxis duration. A prospective observational study was conducted at the obstetrics and gynecology department of Zagazig University Hospital during the period from January 2020 to June 2020. Medical records of 264 women were recorded and evaluated. The American Society of Health-System Pharmacists (ASHP) therapeutic guidelines, World Health Organization (WHO) recommendations and The American College of Obstetricians and Gynecologists (ACOG) practice bulletin were used for data evaluation and hence women were stratified into two groups. For women who underwent procedures in which guidelines recommended the use of SAP (200 patients; 75.75%), 198 women (99%) received preoperative prophylaxis. None of women (0%) received the recommended first line antibiotic by guidelines while the most commonly used prophylactic antibiotics were Cefotaxime (86 patients; 43.43%) and Ampicillin-sulbactam (62 patients; 31.31%). Preoperative antibiotic prophylaxis timing was 0-60 minutes before skin incision. All women received postoperative prophylaxis that extended to an average of 7 days. Regarding the other group who underwent procedures in which prophylactic antibiotics weren’t recommended by guidelines (64 patients; 24.24%), 37 women (57.81%) followed the guidelines and didn’t receive SAP while 27 women (42.18%) received SAP. Poor adherence to guidelines recommendations regarding prophylactic antibiotic selection and prophylaxis duration was observed. High utilization rate of prophylactic antibiotics in procedures that didn’t require their use was reported..
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Seaman SJ, Han E, Arora C, Kim JH. Surgical site infections in gynecology: the latest evidence for prevention and management. Curr Opin Obstet Gynecol 2021; 33:296-304. [PMID: 34148977 DOI: 10.1097/gco.0000000000000717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Surgical site infection (SSI) remains one of the most common postoperative surgical complications. Prevention and appropriate treatment remain paramount. RECENT FINDINGS Evidence-based recommendations include recognition and reduction of preoperative risks including hyperglycemia and smoking, treatment of preexisting infections, skin preparation with chlorhexidine gluconate, proper use of preoperative antibiotics, and implementation of prevention bundles. Consideration should be given to the use of dual antibiotic preoperative treatment with cephazolin and metronidazole for all hysterectomies. SUMMARY Despite advancements, SSI in gynecologic surgery remains a major cause of perioperative morbidity and healthcare cost. Modifiable risk factors should be evaluated and patients optimized to the best extent possible prior to surgery. Preoperative risks include obesity, hyperglycemia, smoking, and untreated preexisting infections. Intraoperative risk-reducing strategies include appropriate perioperative antibiotics, correct topical preparation, maintaining normothermia, and minimizing blood loss. Additionally, early recognition and prompt treatment of SSI remain crucial.
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Affiliation(s)
- Sierra J Seaman
- Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, USA
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7
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Miao D, Fader AN. Surgical Clinical Trials in Gynecology: Rare, Challenging but Desperately Needed. J Minim Invasive Gynecol 2020; 28:379-383. [PMID: 33253959 DOI: 10.1016/j.jmig.2020.11.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/22/2020] [Accepted: 11/24/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Diana Miao
- Department of Gynecology and Obstetrics, Kelly Gynecologic Oncology Service, Johns Hopkins School of Medicine, Baltimore, Maryland (all authors)
| | - Amanda N Fader
- Department of Gynecology and Obstetrics, Kelly Gynecologic Oncology Service, Johns Hopkins School of Medicine, Baltimore, Maryland (all authors)..
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8
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Antibiotic Prophylaxis in Pelvic Floor Surgery. CURRENT BLADDER DYSFUNCTION REPORTS 2020. [DOI: 10.1007/s11884-020-00601-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lian T, Dybvik E, Gjertsen JE, Dale H, Westberg M, Nordsletten L, Figved W. Compliance with national guidelines for antibiotic prophylaxis in hip fracture patients: a quality assessment study of 13 329 patients in the Norwegian Hip Fracture Register. BMJ Open 2020; 10:e035598. [PMID: 32439694 PMCID: PMC7247399 DOI: 10.1136/bmjopen-2019-035598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE We assessed compliance with new guidelines for prophylactic antibiotics in hip fracture surgery in Norway introduced in 2013. DESIGN The data from the Norwegian Hip Fracture Register was used to assess the proportion of antibiotics given according to the national guidelines. SETTING All hospitals in Norway performing hip fracture surgery in the period from 2011 to 2016. PARTICIPANTS We studied 13 329 hemiarthroplasties (HAs) for acute hip fracture. MAIN OUTCOME MEASURE Type and timing between first and last dose of prophylactic antibiotics compared with the national guidelines. RESULTS Before the guidelines were introduced, the recommended drugs cephalotin or clindamycin was used in only 86.2% of all HAs. In 2016, one of the two recommended drugs was administered in 99.2% of HAs. However, hospitals' adaption of the recommended administration of the two drugs improved slowly, and by the end of the study period, only three out of five HAs were performed with the correct drug administered in the correct manner. We found major differences in compliance between hospitals. CONCLUSIONS The change towards correct administration of antibiotic prophylaxis was varied both when investigating university and non-university hospitals. We suggest that both hospital leaders and the national Directorate of Health need to investigate routines for better dissemination of information and education to involved parties. Strong leadership concerning evidence-based guidelines on antibiotic prophylaxis in surgery may take away some autonomy from executing healthcare professionals, but will result in better patient care and antibiotic stewardship.
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Affiliation(s)
- Tom Lian
- Orthopaedic Department, Baerum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
| | - Eva Dybvik
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Jan-Erik Gjertsen
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Håvard Dale
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Marianne Westberg
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Lars Nordsletten
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Wender Figved
- Orthopaedic Department, Baerum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
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Howard T, Tita A, Dimperio L, Harper L. Adherence to Guideline-Based Antibiotic Prophylaxis in Gynecology among Alabama Providers. South Med J 2020; 113:164-167. [PMID: 32239228 DOI: 10.14423/smj.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Surgical site infection (SSI) is a preventable cause of postoperative morbidity. The appropriate use of perioperative antibiotics for prevention of SSIs is a well-established quality metric. Little is known about the adherence to guidelines-based antibiotic prophylaxis among Alabama obstetricians and gynecologists. Our aims were to determine their adherence to guidelines-based antibiotic prophylaxis and identify the factors that are predictive of nonadherence. METHODS Online, self-administered survey of Alabama obstetricians and gynecologists. RESULTS Providers reported not providing the indicated antibiotics and/or giving nonindicated antibiotics in almost all surgical scenarios. The exceptions included hysterectomies, in which almost all (96%) providers routinely gave indicated antibiotics. No providers reported giving antibiotics during intrauterine device placement or endometrial biopsies, which is appropriate. The only factor predictive of inappropriate antibiotic use was the absence of a standing antibiotic protocol. CONCLUSIONS Alabama gynecologic surgeons can and should improve their compliance with guidelines-based antibiotic prophylaxis. More research is needed to determine which interventions would improve adherence in this provider population; our study suggests that the implementation of a standing antibiotic protocol may be a reasonable first step.
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Affiliation(s)
- Tera Howard
- From the Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham
| | - Alan Tita
- From the Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham
| | - Lisa Dimperio
- From the Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham
| | - Lorie Harper
- From the Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham
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11
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Carrubba AR, Whitmore GT, Radhakrishnan SJ, Sheeder J, Muffly TM. Postoperative infections in women undergoing hysterectomy for benign indications: a cohort study. ACTA ACUST UNITED AC 2019; 71:263-271. [PMID: 31146518 DOI: 10.23736/s0026-4784.19.04365-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND There is limited data on the incidence of postoperative infections following hysterectomy by route of surgery. We hypothesize that vaginal hysterectomy has lower rates of postoperative infection than laparoscopic and abdominal hysterectomies. METHODS A retrospective cohort study and independent hand review of charts of participants undergoing hysterectomy at five hospitals from September 2011 through May 2015 was performed. Cases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes and were reviewed by the investigators. The primary outcome was the development of Clostridium difficile infection, urinary tract infection, surgical site infection, or yeast vaginitis within 60 days following surgery. RESULTS In total, 2742 women underwent hysterectomy: abdominal 17.5% (AH), laparoscopic 65.8% (LH), and vaginal 16.7% (VH). The composite postoperative infection rate for the four specified variables was 8.5% (232). In comparing surgical route, AH was most commonly associated with CDI (0.6%, p <0.001), SSI (6.0%, P=0.001), and yeast vaginitis (1.9%, p <0.001), while VH was most commonly associated with UTI (8.1%, P=0.002). After controlling for demographic and operative factors, multivariable analysis showed that hysterectomy route was not associated with infection. Independent predictors for postoperative infection were increasing age, American Society of Anesthesiologists physical status classification, operative time, and hospital type. CONCLUSIONS Infectious complications after hysterectomy are uncommon, accounting for 8.5% of cases. Multivariable analysis showed that demographic and operative variables were more likely to serve as independent predictors of development of infection than hysterectomy route.
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Affiliation(s)
- Aakriti R Carrubba
- Department of Obstetrics and Gynecology, Denver Hospital, Denver, CO, USA -
| | | | | | - Jeanelle Sheeder
- Department of Obstetrics and Gynecology, Denver Hospital, Denver, CO, USA
| | - Tyler M Muffly
- Department of Obstetrics and Gynecology, Denver Hospital, Denver, CO, USA
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12
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Perioperative Antibiotic Use and Associated Infectious Outcomes at the Time of Myomectomy. Obstet Gynecol 2019; 133:626-635. [DOI: 10.1097/aog.0000000000003160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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13
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Preventing Surgical Site Infection: Approaching Zero Tolerance. Obstet Gynecol 2019; 133:624-625. [PMID: 30870292 DOI: 10.1097/aog.0000000000003194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shapiro R, Laignel R, Kowcheck C, White V, Hashmi M. Modifying pre-operative antibiotic overuse in gynecologic surgery. Int J Health Care Qual Assur 2018; 31:400-405. [PMID: 29865962 DOI: 10.1108/ijhcqa-04-2017-0066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose Previous studies indicate adherence to pre-operative antibiotic prophylaxis guidelines has been inadequate. The purpose of this paper is to determine adherence rates to current perioperative antibiotic prophylaxis guidelines in gynecologic surgery at a tertiary care, academic institution. As a secondary outcome, improving guidelines after physician re-education were analyzed. Design/methodology/approach A retrospective chart review (2,463 patients) was completed. The authors determined if patients received perioperative antibiotic prophylaxis in accordance with current guidelines from the America College of Obstetricians and Gynecologists. Data were obtained before and after physician tutorials. Quality control was implemented by making guideline failures transparent. Statistical analysis used Fisher's exact and agreement tests. Findings In total, 23 percent of patients received antibiotics not indicated across all procedures. This decreased to 9 percent after physician re-education and outcome transparency ( p<0.0001). Laparoscopy was the procedure with the lowest guideline compliance prior to education. The compliance improved from 52 to 92 percent ( p<0.0001) after re-education. Practical implications Gynecologic surgeons overuse antibiotics for surgical prophylaxis. Physician re-education and transparency were shown to enhance compliance. Originality/value Educational tutorials are an effective strategy for encouraging physicians to improve outcomes, which, in turn, allows the healthcare system a non-punitive way to monitor quality and mitigate cost.
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Affiliation(s)
- Robert Shapiro
- Department of Obstetrics/Gynecology, West Virginia University , Morgantown, West Virginia, USA
| | - Rose Laignel
- Department of Obstetrics/Gynecology, Alaska Native Medical Center, Anchorage, Alaska, USA
| | - Caitlin Kowcheck
- Department of Obstetrics/Gynecology West Virginia University , Morgantown, West Virginia, USA
| | - Valerie White
- West Virginia University , Morgantown, West Virginia, USA
| | - Mahreen Hashmi
- Department of Obstetrics/Gynecology, West Virginia University , Morgantown, West Virginia, USA
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Uppendahl L, Chiles C, Shields S, Dong F, Kraft E, Duong J, Delmore J. Appropriate Use of Prophylactic Antibiotic Agents in Gynecologic Surgeries at a Midwestern Teaching Hospital. Surg Infect (Larchmt) 2018; 19:397-402. [DOI: 10.1089/sur.2017.247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Locke Uppendahl
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, Minnesota
| | - Caitlin Chiles
- Department of Family Medicine, University of Kansas School of Medicine–Wichita, Wichita, Kansas
| | - Stephanie Shields
- Department of Family Medicine, University of Kansas School of Medicine–Wichita, Wichita, Kansas
| | - Fanglong Dong
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, California
| | - Elizabeth Kraft
- General Surgery. New York Methodist Hospital, Brooklyn, New York
| | - Jennifer Duong
- Department of Obstetrics and Gynecology, University of Kansas School of Medicine–Wichita, Wichita, Kansas
| | - James Delmore
- Department of Obstetrics and Gynecology, University of Kansas School of Medicine–Wichita, Wichita, Kansas
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Perioperative Antibiotics for Clean Hand Surgery: A National Study. J Hand Surg Am 2018; 43:407-416.e1. [PMID: 29398330 DOI: 10.1016/j.jhsa.2017.11.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 10/25/2017] [Accepted: 11/28/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Given that surgical site infections remain a common performance metric in assessing the quality of health care, we hypothesized that prophylactic antibiotics are overutilized in soft tissue hand surgery when antimicrobials are not indicated. METHODS We studied insurance claims from the Truven MarketScan Databases to identify patients who underwent 1 of 5 outpatient hand surgery procedures: open or endoscopic carpal tunnel release, trigger finger release, de Quervain release, and wrist ganglion excision between 2009 and 2015 (n = 305,946). Hospital payment claims for preoperative intravenous antibiotics and prescriptions filled for postoperative oral antibiotics were analyzed. We examined the rate and temporal trend of prophylactic antibiotics use and identified risk factors using multivariable logistic regression. We also calculated health care expenditures related to prophylaxis. RESULTS Prior to surgery, 13.6% (2009-2015) of patients received prophylactic intravenous antibiotics and trend analysis showed a statistically significant increase from 2009 (10.6%) to 2015 (18.3%), an increase of 72.5%. Preoperative prophylaxis was used most often prior to trigger finger release (17.5%) and least often prior to endoscopic carpal tunnel release (11.2%). Younger age, male sex, lower income, and obese patients had higher odds of receiving antibiotics. The total charge of prophylactic antibiotics medication used in this study equaled $1.6 million. CONCLUSIONS In 2015, prophylactic intravenous antibiotics were administered to nearly 1 in 5 patients prior to clean soft tissue hand surgery. Although consensus guidelines indicate prophylaxis is not indicated, their use has increased steadily in the United States from 2009 to 2015. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Kremer KM, Foster RT, Drobnis EZ, Hyde KJ, Brennaman LM. Non-indicated use of prophylactic antibiotics in gynaecological surgery at an academic tertiary medical centre. J OBSTET GYNAECOL 2018; 38:543-547. [PMID: 29405078 DOI: 10.1080/01443615.2017.1371119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Surgical site infections (SSI) are the most common surgical complication. Perioperative antibiotics can reduce SSI when used properly. Despite guidelines from The American College of Obstetrics and Gynecology, non-indicated antibiotic use is widespread which exposes women to unnecessary risks. This study represents a quality improvement analysis assessing surgeon compliance with established guidelines regarding antibiotic use in gynaecological surgery. This is a single centre, retrospective study examining gynaecological procedures over two years. Cases were identified using Current Procedure Terminology codes. Perioperative antibiotics were used contrary to published guidelines in 199 of 1046 cases. Three variables were independently associated with inappropriate administration of perioperative antibiotics: entrance into abdominal cavity, higher EBL, and longer procedures. Impact statement Overuse of antibiotics has unintended consequences including allergic sequelae, extended length of hospital stay, increased healthcare costs, and the formation of antibiotic-resistant organisms. Antibiotic stewardship programmes have been shown to reduce the number of resistant pathogens, decrease incidence of Clostridium difficile colitis, and decrease length of hospital stay without increasing infection rates. Further outcomes-based research is needed regarding the use of antibiotic stewardship programmes in gynaecological surgery.
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Affiliation(s)
- Kevin M Kremer
- a Department of Obstetrics, Gynecology, and Women's Health , University of Missouri Health Care , Columbia , MO , USA
| | - Raymond T Foster
- a Department of Obstetrics, Gynecology, and Women's Health , University of Missouri Health Care , Columbia , MO , USA
| | - Erma Z Drobnis
- a Department of Obstetrics, Gynecology, and Women's Health , University of Missouri Health Care , Columbia , MO , USA
| | - Kassie J Hyde
- a Department of Obstetrics, Gynecology, and Women's Health , University of Missouri Health Care , Columbia , MO , USA
| | - Lisa M Brennaman
- a Department of Obstetrics, Gynecology, and Women's Health , University of Missouri Health Care , Columbia , MO , USA
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Joyce J, Langsjoen J, Sharadin C, Kuehl TJ, Larsen WI. Inappropriate use of antibiotics in patients undergoing gynecologic surgery. Proc (Bayl Univ Med Cent) 2017; 30:30-32. [PMID: 28127125 DOI: 10.1080/08998280.2017.11929518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
We retrospectively examined prophylactic antibiotic use and documentation of wound classification in patients having gynecologic surgery at a tertiary hospital. Of the 326 cases reviewed, 175 (54%) received prophylactic antibiotics when not indicated according to guidelines of the American College of Obstetricians and Gynecologists. Antibiotic administration varied significantly (P < 0.02) among the different types of surgery, being given in 82% of laparoscopic cases, 35% of nonobstetrical dilation and curettage and operative hysteroscopy procedures, and 51% of open abdominal procedures. There were no recorded episodes of anaphylaxis or pseudomembranous colitis. In conclusion, antibiotic use is high among gynecologic surgeons at a tertiary hospital, but this use was unnecessary.
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Affiliation(s)
- John Joyce
- Department of Obstetrics and Gynecology, Scott & White Healthcare, and the Texas A&M School of Medicine and Health Sciences, Temple, Texas
| | - Jessica Langsjoen
- Department of Obstetrics and Gynecology, Scott & White Healthcare, and the Texas A&M School of Medicine and Health Sciences, Temple, Texas
| | - Cynthia Sharadin
- Department of Obstetrics and Gynecology, Scott & White Healthcare, and the Texas A&M School of Medicine and Health Sciences, Temple, Texas
| | - Thomas J Kuehl
- Department of Obstetrics and Gynecology, Scott & White Healthcare, and the Texas A&M School of Medicine and Health Sciences, Temple, Texas
| | - Wilma I Larsen
- Department of Obstetrics and Gynecology, Scott & White Healthcare, and the Texas A&M School of Medicine and Health Sciences, Temple, Texas
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Cohen ME, Salmasian H, Li J, Liu J, Zachariah P, Wright JD, Freedberg DE. Surgical Antibiotic Prophylaxis and Risk for Postoperative Antibiotic-Resistant Infections. J Am Coll Surg 2017; 225:631-638.e3. [PMID: 29030239 DOI: 10.1016/j.jamcollsurg.2017.08.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 08/10/2017] [Accepted: 08/10/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Antibiotic-resistant infections have high rates of morbidity and mortality, and exposure to antibiotics is the crucial risk factor for development of antibiotic resistance. If surgical antibiotic prophylaxis (SAP) increases risk for antibiotic-resistant infections, prophylaxis may cause net harm, even if it decreases overall infection rates. STUDY DESIGN This retrospective cohort study included adults who underwent elective surgical procedures and developed infections within 30 postoperative days. Procedures from multiple disciplines were included if SAP was considered discretionary by current guidelines. Postoperative antibiotic-resistant infections were defined as positive culture results from any site within 30 postoperative days, showing intermediate or nonsusceptibility across 1 or more antibiotic classes. Surgical antibiotic prophylaxis included use of antibiotics within any class and at any dose from 1 hour before first incision until the end of the operation. RESULTS Among 689 adults with postoperative infections, 338 (49%) had postoperative resistant infections. Use of SAP was not associated with postoperative antibiotic-resistant infections (odds ratio [OR] 0.99; 95% CI 0.67 to 1.46). This result remained robust when the SAP definition was extended to antibiotics given within 4 hours before first incision (OR 0.94; 95% CI 0.63 to 1.40) and when the follow-up window was narrowed to 14 days (OR 0.82; 95% CI 0.50 to 1.34). Previous antibiotic-resistant infections were associated with risk for postoperative antibiotic-resistant infections (OR 1.81; 95% CI 1.16 to 2.83). CONCLUSIONS Use of SAP was not associated with risk for postoperative antibiotic-resistant infections in a large cohort of patients with postoperative infections. This provides important reassurance regarding use of surgical antibiotic prophylaxis.
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Affiliation(s)
- Margot E Cohen
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Hojjat Salmasian
- Biomedical Informatics, New York-Presbyterian Hospital, New York, NY
| | - Jianhua Li
- Biomedical Informatics, New York-Presbyterian Hospital, New York, NY
| | - Jianfang Liu
- School of Nursing, Columbia University, New York, NY
| | - Philip Zachariah
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY.
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Patterns of Specialty-Based Referral and Perioperative Outcomes for Women With Endometrial Cancer Undergoing Hysterectomy. Obstet Gynecol 2017; 130:81-90. [PMID: 28594765 DOI: 10.1097/aog.0000000000002100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine patterns of referral to gynecologic oncologists and perioperative outcomes based on surgeon specialty for women with endometrial cancer and hyperplasia. METHODS The National Surgical Quality Improvement Program database was used to perform a retrospective cohort study of women with endometrial cancer and hyperplasia who underwent hysterectomy from 2014 to 2015. Patients were stratified based on treatment by a gynecologic oncologist or other health care provider. Patterns of referral to a gynecologic oncologist was the primary outcome, and mode of hysterectomy and complications were secondary outcomes. RESULTS A total of 6,510 women were identified. Gynecologic oncologists performed 90.9% (95% confidence interval [CI] 90.1-91.7) of the hysterectomies for endometrial cancer, 66.8% (95% CI 63.1-70.4) for complex atypical endometrial hyperplasia, and 49.3% (95% CI 44.7-53.8) for endometrial hyperplasia without atypia. Older women and those with a higher American Society of Anesthesiology score were more likely to be treated by an oncologist. Minimally invasive hysterectomy was performed in 73.6% (95% CI 72.1-75.1) of women with endometrial cancer operated on by gynecologic oncologists compared with 73.8% (95% CI 68.8-78.2) of those treated by other physicians (odds ratio [OR] 0.99, 95% CI 0.80-1.23); lymphadenectomy was performed in 56.3% of women treated by gynecologic oncologists compared with 34.8% of those treated by other specialists (OR 2.42, 95% CI 1.99-2.94). Severe complications were uncommon and there was no difference in complication rates based on specialty, 2.6% (95% CI 2.2-3.1) compared with 2.0% (95% CI 0.8-3.3). CONCLUSION Gynecologic oncologists provide care for the majority of women with endometrial cancer who undergo hysterectomy in the United States and are also involved in the care of a large percentage of women with endometrial hyperplasia.
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Gouvêa M, Novaes CDEO, Iglesias AC. Assessment of antibiotic prophylaxis in surgical patients at the Gaffrée e Guinle University Hospital. Rev Col Bras Cir 2016; 43:225-34. [PMID: 27679941 DOI: 10.1590/0100-69912016004001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 06/04/2016] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE : to evaluate the antibiotic prophylaxis in surgical patients at the Gaffrée e Guinle University Hospital - HUGG. METHODS : we conducted a rospective study of a cohort of 256 patients undergoing elective operations between January and September 2014. We collected data on demographics, use or not of prophylactic antibiotic and the antibiotic prophylaxis following characteristics: type of antibiotic used, moment of administration and duration of postoperative use. The analyzed outcomes were "justified use or non-use of antibiotic prophylaxis", "correct antibiotic choice," "administration of the antibiotic at the right time" and "discontinuation of the antibiotic at the right time." RESULTS : antibiotic prophylaxis was used in 91.8% of cases. The use or non-use of antibiotic prophylaxis was justified in 78.9% of patients, the choice of the administered antibiotic was considered correct in 97.9%, antibiotic administration was made at the right time in only 27.2% of patients and discontinuation of the antibiotic was performed at the correct time in 95.7% of cases. CONCLUSION : the surgical antibiotic prophylaxis was not fully adequately performed in the sample. OBJETIVO avaliar a antibioticoprofilaxia em pacientes cirúrgicos do Hospital Universitário Gaffrée e Guinle. MÉTODOS estudo prospectivo de uma coorte de 256 pacientes submetidos à operações eletivas, entre janeiro e setembro de 2014. Foram coletados dados demográficos dos pacientes, se ocorreu utilização ou não do antibiótico profilático e as seguintes características da antibioticoprofilaxia: tipo de antibiótico utilizado, momento da administração e tempo de duração do uso no pós-operatório. Os desfechos de interesse analisados foram "uso ou não uso justificado da antibioticoprofilaxia", "escolha correta do antibiótico", "administração do antibiótico no tempo correto" e "descontinuação do antibiótico no tempo correto". RESULTADOS a antibioticoprofilaxia foi utilizada em 91,8% dos casos. O uso ou não uso da antibioticoprofilaxia foi justificado em 78,9% dos pacientes, a escolha do antibiótico administrado foi considerada correta em 97,9%, a administração do antibiótico foi feita no momento correto em apenas 27,2% dos pacientes e a descontinuação do antibiótico foi realizada no tempo correto em 95,7% dos casos. CONCLUSÃO a antibioticoprofilaxia cirúrgica não foi realizada de forma plenamente adequada na amostra estudada.
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Affiliation(s)
- Marise Gouvêa
- - Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro (UNIRIO)
| | | | - Antonio Carlos Iglesias
- - Department of General and Specialized Surgery, School of Medicine and Surgery, Federal University of the State of Rio de Janeiro (UNIRIO)
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Bakkum-Gamez JN, Dowdy SC. Improving Surgical Site Infection Rates Through Continuous Quality Improvement. Ann Surg Oncol 2016; 24:305-307. [PMID: 27586006 DOI: 10.1245/s10434-016-5524-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Jamie N Bakkum-Gamez
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Sean C Dowdy
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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Abstract
OBJECTIVE To evaluate associations between prophylactic preoperative antibiotic choice and surgical site infection rates after hysterectomy. METHODS A retrospective cohort study was performed of patients in the Michigan Surgical Quality Collaborative undergoing hysterectomy from July 2012 to February 2015. The primary outcome was a composite outcome of any surgical site infection (superficial surgical site infections or combined deep organ space surgical site infections). Preoperative antibiotics were categorized based on the recommendations set forth by the American College of Obstetricians and Gynecologists and the Surgical Care Improvement Project. Patients receiving a recommended antibiotic regimen were categorized into those receiving β-lactam antibiotics and those receiving alternatives to β-lactam antibiotics. Patients receiving nonrecommended antibiotics were categorized into those receiving overtreatment (excluded from further analysis) and those receiving nonstandard antibiotics. Multivariable logistic regression models were developed to estimate the independent effect of antibiotic choice. Propensity score matching analysis was performed to validate the results. RESULTS The study included 21,358 hysterectomies. The overall rate of any surgical site infection was 2.06% (n=441). Unadjusted rates of "any surgical site infection" were 1.8%, 3.1%, and 3.7% for β-lactam, β-lactam alternatives, and nonstandard groups, respectively. After adjusting for patient and operative factors within clusters of hospitals, compared with the β-lactam antibiotics (reference group), the risk of "any surgical site infection" was higher for the group receiving β-lactam alternatives (odds ratio [OR] 1.7, confidence interval [CI] 1.27-2.07) or the nonstandard antibiotics (OR 2.0, CI 1.31-3.1). CONCLUSION Compared with women receiving β-lactam antibiotic regimens, there is a higher risk of surgical site infection after hysterectomy among those receiving a recommended β-lactam alternative or nonstandard regimen.
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Antibiotic Prophylaxis for Gynecologic Procedures prior to and during the Utilization of Assisted Reproductive Technologies: A Systematic Review. J Pathog 2016; 2016:4698314. [PMID: 27047692 PMCID: PMC4800103 DOI: 10.1155/2016/4698314] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 02/16/2016] [Indexed: 02/05/2023] Open
Abstract
The use of assisted reproductive technologies (ART) has increased steadily. There has been a corresponding increase in the number of ART-related procedures such as hysterosalpingography (HSG), saline infusion sonography (SIS), hysteroscopy, laparoscopy, oocyte retrieval, and embryo transfer (ET). While performing these procedures, the abdomen, upper vagina, and endocervix are breached, leading to the possibility of seeding pelvic structures with microorganisms. Antibiotic prophylaxis is therefore important to prevent or treat any procedure-related infections. After careful review of the published literature, it is evident that routine antibiotic prophylaxis is generally not recommended for the majority of ART-related procedures. For transcervical procedures such as HSG, SIS, hysteroscopy, ET, and chromotubation, patients at risk for pelvic infections should be screened and treated prior to the procedure. Patients with a history of pelvic inflammatory disease (PID) or dilated fallopian tubes are at high risk for postprocedural infections and should be given antibiotic prophylaxis during procedures such as HSG, SIS, or chromotubation. Antibiotic prophylaxis is recommended prior to oocyte retrieval in patients with a history of endometriosis, PID, ruptured appendicitis, or multiple prior pelvic surgeries.
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Adherence to guidelines for surgical antibiotic prophylaxis: a review. Braz J Infect Dis 2015; 19:517-24. [PMID: 26254691 PMCID: PMC9427538 DOI: 10.1016/j.bjid.2015.06.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 06/20/2015] [Accepted: 06/22/2015] [Indexed: 11/28/2022] Open
Abstract
Context and objectives The appropriate use of antibiotic prophylaxis in the perioperative period may reduce the rate of infection in the surgical site. The purpose of this review was to evaluate adherence to guidelines for surgical antibiotic prophylaxis. Methods The present systematic review was performed according to the Cochrane Collaboration methodology. The databases selected for this review were: Medline (via PubMed), Scopus and Portal (BVS) with selection of articles published in the 2004–2014 period from the Lilacs and Cochrane databases. Results The search recovered 859 articles at the databases, with a total of 18 studies selected for synthesis. The outcomes of interest analyzed in the articles were as follows: appropriate indication of antibiotic prophylaxis (ranging from 70.3% to 95%), inappropriate indication (ranging from 2.3% to 100%), administration of antibiotic at the correct time (ranging from 12.73% to 100%), correct antibiotic choice (ranging from 22% to 95%), adequate discontinuation of antibiotic (ranging from 5.8% to 91.4%), and adequate antibiotic prophylaxis (ranging from 0.3% to 84.5%). Conclusions Significant variations were observed in all the outcomes assessed, and all the studies indicated a need for greater adherence to guidelines for surgical antibiotic prophylaxis.
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Erekson EA, Iglesia CB. Improving Patient Outcomes in Gynecology: The Role of Large Data Registries and Big Data Analytics. J Minim Invasive Gynecol 2015; 22:1124-9. [PMID: 26188310 DOI: 10.1016/j.jmig.2015.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 06/28/2015] [Accepted: 07/03/2015] [Indexed: 11/19/2022]
Abstract
Value-based care is quality health care delivered effectively and efficiently. Data registries were created to collect accurate information on patients with enough clinical information to allow for adequate risk adjustment of postoperative outcomes. Because most gynecologic procedures are elective and preference-sensitive, offering nonsurgical alternatives is an important quality measure. The Center for Medicare and Medicaid Services (CMS), in conjunction with mandates from the Affordable Care Act, passed by Congress in 2010, has developed several initiatives centered on the concept of paying for quality care, and 1 of the first CMS initiatives began with instituting payment penalties for hospital-acquired conditions, such as catheter-associated urinary tract infections, central line-associated bloodstream infections, and surgical site infections. Registries specific to gynecology include the Society for Assisted Reproductive Technology registry established in 1996; the FIBROID registry established in 1999; the Pelvic Floor Disorders Registry established by the American Urogynecologic Society in conjunction with other societies (2014); and the Society of Gynecologic Oncologists Clinical Outcomes Registry. Data from these registries can be used to critically analyze practice patterns, find best practices, and enact meaningful changes in systems and workflow. The ultimate goal of data registries and clinical support tools derived from big data is to access accurate and meaningful data from electronic records without repetitive chart review or the need for direct data entry. The most efficient operating systems will include open-access computer codes that abstract data, in compliance with privacy regulations, in real-time to provide information about our patients, their outcomes, and the quality of care that we deliver.
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Affiliation(s)
- Elisabeth A Erekson
- Department of Obstetrics and Gynecology and the Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Cheryl B Iglesia
- Departments of Obstetrics/Gynecology and Urology, Georgetown University School of Medicine, and Section of Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center and the National Center for Advanced Pelvic Surgery at MedStar, Washington, DC.
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Abstract
OBJECTIVE To analyze factors associated with 30-day readmission among women who underwent hysterectomy for uterine cancer and benign indications. METHODS We used the National Surgical Quality Improvement Project database to perform a cohort study of women who underwent hysterectomy from 2011 to 2012. Patients were stratified by surgical indication (uterine cancer or benign indications). Multivariable logistic regression models were constructed to determine factors associated with 30-day readmission. Model fit statistics were used to evaluate the importance of demographic factors, preoperative comorbidities, and postoperative complications on readmission. RESULTS The rate of 30-day readmission was 6.1% among 4,725 women with uterine cancer and 3.4% after hysterectomy for benign gynecologic disease in 36,471 patients. In a series of multivariable models, postoperative complications including wound complications, infections, and pulmonary emboli and myocardial infarctions were the factors most strongly associated with readmission. Compared with women without a complication, complications increased the readmission rate from 2.5 to 20.3% for women with uterine cancer and from 1.5 to 15.1% for those without cancer. Among women with uterine cancer, postoperative complications explained 34.3% of the variance in readmission compared with 5.9% for demographic factors and 2.2% for preoperative comorbidities. For patients with benign diseases, complications accounted for 32.1%, preoperative conditions 1.2%, and demographic factors 2.5% of the variance in readmission. CONCLUSION Efforts to reduce readmission should be directed at initiatives to reduce complications and improve the care of women who experience a complication.
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Wright JD. Measuring what matters: quality in gynecologic surgery. Am J Obstet Gynecol 2015; 212:257-8. [PMID: 25725657 DOI: 10.1016/j.ajog.2014.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/10/2014] [Indexed: 11/27/2022]
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Engineered cationic antimicrobial peptides to overcome multidrug resistance by ESKAPE pathogens. Antimicrob Agents Chemother 2014; 59:1329-33. [PMID: 25421473 DOI: 10.1128/aac.03937-14] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Multidrug resistance constitutes a threat to the medical achievements of the last 50 years. In this study, we demonstrated the abilities of two de novo engineered cationic antibiotic peptides (eCAPs), WLBU2 and WR12, to overcome resistance from 142 clinical isolates representing the most common multidrug-resistant (MDR) pathogens and to display a lower propensity to select for resistant bacteria in vitro compared to that with colistin and LL37. The results warrant an exploration of eCAPs for use in clinical settings.
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Brubaker SG, Friedman AM, Cleary KL, Prendergast E, D'Alton ME, Ananth CV, Wright JD. Patterns of use and predictors of receipt of antibiotics in women undergoing cesarean delivery. Obstet Gynecol 2014; 124:338-344. [PMID: 25004352 DOI: 10.1097/aog.0000000000000392] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Perioperative antibiotics are recommended during cesarean delivery to reduce the risk of postoperative infections and resulting maternal morbidity. We examined the patterns of use and predictors of receipt of antibiotics in women undergoing cesarean delivery. METHODS We identified a national cohort of women who underwent a cesarean delivery between 2003 and 2010 using a commercial hospitalization database. Women who received antibiotics on the day of cesarean delivery were classified as having received perioperative antibiotics. Multivariable regression models were developed to account for patient, obstetric, physician, and hospital factors on receipt of antibiotics. Between-hospital variation was calculated using generalized linear mixed models. RESULTS Among 1,137,804 women who underwent cesarean delivery, 59.5% received perioperative antibiotics. The proportion of patients receiving antibiotics increased over time from 52.5% in 2003 to 63.1% in 2010 (P<.001) and varied significantly by geographic region. Women who did not labor were more likely to receive antibiotics than those who had a cesarean delivery after labor (66% compared with 44%, P<.001). Age, race, and insurance status were not major determinants of the use of perioperative antibiotics. CONCLUSION Among women undergoing cesarean delivery, compliance with the recommendation for universal perioperative antibiotic prophylaxis is poor. Coordinated efforts are needed to enhance use of guideline-based perioperative antibiotic prophylaxis for women undergoing cesarean delivery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sara G Brubaker
- Divisions of Maternal-Fetal Medicine and Gynecologic Oncology, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, and the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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