Facility type and surgical specialty are associated with suboptimal surgical antimicrobial prophylaxis practice patterns: a multi-center, retrospective cohort study

Auto-Substitutions to Optimize Perioperative Antimicrobial Prophylaxis: Pre-Post Intervention Study

BACKGROUND

Appropriate administration of perioperative antibiotics can prevent antimicrobial resistance, adverse drug events, surgical site infections, and increased costs to the health care system for many surgeries in Otolaryngology-Head and Neck Surgery (OHNS).

OBJECTIVE

The objective of the study is to achieve 90% compliance with evidence-based perioperative antibiotic prophylaxis guidelines among elective surgical procedures in OHNS.

METHODS

The pre-intervention group consisted of patients undergoing elective surgical procedures in the 13 months prior to the interventions (September 2019-2020) whereas the post-intervention group comprised patients undergoing elective procedures during the 8 months following the implementation (October 2020-May 2021). The 4 Es of knowledge translation and the Donabedian framework were used to frame the study. Components of the intervention included educational grand rounds and automatic substitutions in electronic health records. In June 2021, a survey of staff and residents assessed the self-reported perception of following evidence-based guidelines.

RESULTS

Compliance with antimicrobial prophylaxis guidelines were evaluated based on agent and dose. The overall compliance improved from 38.8% pre-intervention to 59.0% post-intervention (p < 0.001). Agent compliance did not improve from pre- to post-intervention, that is, 60.7% to 62.8%, respectively, (p = 0.68), whereas dose compliance improved from 39.6% to 89.2% (p < 0.001). Approximately 78.5% of survey respondents felt that they strongly agreed or agreed with always following evidence-based antimicrobial prophylaxis guidelines.

CONCLUSION

Compliance with antimicrobial prophylaxis guidelines improved, primarily due to increased dosing compliance. Future interventions will target agent compliance and selected procedures with lower compliance rates.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3403-3408, 2023.

Engaging patients in antimicrobial stewardship: co-designed educational tool to improve periprocedural care through de-implementation of guideline-discordant antimicrobial use

Effective de-implementation models often include replacement of an ineffective practice with an alternative. We co-developed patient education materials as a replacement strategy for inappropriate post-procedural antibiotics in cardiac device procedures. Lessons learned and developed materials may be used to promote infection prevention in other periprocedural settings.

Impact of antimicrobial stewardship intervention in clean and clean‐contaminated surgical procedures at a Vietnamese national hospital

Objectives

We investigated the characteristics of prophylactic antimicrobial use in clean and clean‐contaminated surgical procedures and assessed the efficacy of a prophylactic antimicrobial stewardship intervention at Thong Nhat Hospital, Ho Chi Minh City, Vietnam.

Methods

A cross‐sectional study was conducted on 354 patients who underwent either clean or clean‐contaminated surgical procedures at Thong Nhat Hospital. Eligible patients were classified with respect to three periods of intervention from 2017 to 2020. Data collection included surgical procedures, patient characteristics, and prophylactic antimicrobial usage. We determined the efficacy of antimicrobial stewardship intervention based on comparisons among the primary outcome (the appropriateness of prophylactic antimicrobials) and secondary outcomes (postoperative antimicrobial prophylaxis (AP) prolongation, length of postoperative hospital stay, and cost of antimicrobials).

Results

The mean age of patients in periods 1, 2, and 3 was 54.5 ± 16.6, 50.2 ± 16.5, and 52.8 ± 17.3 years, respectively, with an overall male/female ratio of 1.1/1. No significant differences were detected in basic patient characteristics during the three periods. Majority of the surgical procedures were clean (56%–59%) and scheduled (85%–86%). Prophylactic antimicrobial stewardship intervention enhanced AP appropriateness (by 12.7%, 12.7%, and 39.0% in periods 1, 2, and 3, respectively, p < 0.001), decreased postoperative prophylactic antimicrobial duration [3.0 (0–6), 1.5 (0–5), and 0.0 (0–1) days, respectively, p < 0.001], and reduced average antimicrobial expenses (p < 0.001).

Conclusions

The prophylactic antimicrobial stewardship interventions introduced at Thong Nhat Hospital had several positive impacts on the appropriateness of prophylactic antimicrobial use and treatment costs.

Lack of association of post-discharge prophylactic antibiotics with decreased risk of surgical site infection following spinal fusion

OBJECTIVES

To determine the prevalence and factors associated with post-discharge prophylactic antibiotic use after spinal fusion and whether use was associated with decreased risk of surgical site infection (SSI).

METHODS

Persons aged 10-64 years undergoing spinal fusion between 1 January 2010 and 30 June 2015 were identified in the MarketScan Commercial Database. Complicated patients and those coded for infection from 30 days before to 2 days after the surgical admission were excluded. Outpatient oral antibiotics were identified within 2 days of surgical discharge. SSI was defined using ICD-9-CM diagnosis codes within 90 days of surgery. Generalized linear models were used to determine factors associated with post-discharge prophylactic antibiotic use and with SSI.

RESULTS

The cohort included 156 446 fusion procedures, with post-discharge prophylactic antibiotics used in 9223 (5.9%) surgeries. SSIs occurred after 2557 (1.6%) procedures. Factors significantly associated with post-discharge prophylactic antibiotics included history of lymphoma, diabetes, 3-7 versus 1-2 vertebral levels fused, and non-infectious postoperative complications. In multivariable analysis, post-discharge prophylactic antibiotic use was not associated with SSI risk after spinal fusion (relative risk 0.98; 95% CI 0.84-1.14).

CONCLUSIONS

Post-discharge prophylactic oral antibiotics after spinal fusion were used more commonly in patients with major medical comorbidities, more complex surgeries and those with postoperative complications during the surgical admission. After adjusting for surgical complexity and infection risk factors, post-discharge prophylactic antibiotic use was not associated with decreased SSI risk. These results suggest that prolonged prophylactic antibiotic use should be avoided after spine surgery, given the lack of benefit and potential for harm.

Compliance with antibiotic prophylaxis guidelines in caesarean delivery: a retrospective, drug utilization study (indication-prescription type) at an Ecuadorian hospital

BACKGROUND

Preoperative antibiotic prophylaxis is essential for preventing surgical site infection (SSI). The aim of this study was to evaluate compliance with international and local recommendations in caesarean deliveries carried out at the Obstetrics and Gynaecology Service of the Ambato General Hospital, as well as any related health and economic consequences.

METHODS

A retrospective indication-prescription drug utilization study was conducted using data from caesarean deliveries occurred in 2018. A clinical pharmacist assessed guidelines compliance based on the following criteria: administration of antibiotic prophylaxis, antibiotic selection, dose, time of administration and duration. The relationship between the frequency of SSI and other variables, including guideline compliance, was analysed. The cost associated with the antibiotic used was compared with the theoretical cost considering total compliance with recommendations. Descriptive statistics, Odds Ratio and Pearson Chi Square were used for data analysis by IBM SPSS Statistics version 25.

RESULTS

The study included 814 patients with an average age of 30.87 ± 5.50 years old. Among the caesarean sections, 68.67% were emergency interventions; 3.44% lasted longer than four hours and in 0.25% of the deliveries blood loss was greater than 1.5 L. Only 69.90% of patients received preoperative antibiotic prophylaxis; however, 100% received postoperative antibiotic treatment despite disagreement with guideline recommendations (duration: 6.75 ± 1.39 days). The use of antibiotic prophylaxis was more frequent in scheduled than in emergency caesarean sections (OR = 2.79, P = 0.000). Nevertheless, the timing of administration, antibiotic selection and dose were more closely adhered to guideline recommendations. The incidence of surgical site infection was 1.35%, but tended to increase in patients who had not received preoperative antibiotic prophylaxis (OR = 1.33, P = 0.649). Also, a significant relationship was found between SSI and patient age (χ2 = 8.08, P = 0.036). The mean expenditure on antibiotics per patient was 5.7 times greater than that the cost derived from compliance with international recommendations.

CONCLUSIONS

Surgical antibiotic prophylaxis compliance was far below guideline recommendations, especially with respect to implementation and duration. This not only poses a risk to patients but leads to unnecessary expenditure on medicines. Therefore, this justifies the need for educational interventions and the implementation of institutional protocols involving pharmacists.

Compliance of antibiotics used for surgical site infection prophylaxis among patients undergoing surgery in a Congolese teaching hospital

BACKGROUND

Surgical antibiotic prophylaxis (SAP) is one of the measures used for preventing surgical site infections. SAP has high impact but there is low compliance with antimicrobial guidelines in many developing countries like the Democratic Republic of the Congo. This study aimed to assess the compliance of antibiotics used for surgical site infection prophylaxis with international guidelines among patients undergoing surgery at the "Cliniques Universitaires du Graben" (CUG).

METHODS

This was a retrospective study including all patients who underwent surgery and received SAP between January 2017 and December 2018 at CUG. Surgical and Gynaecology-Obstetric patients were included. A total of 265 patients were included in the analysis. A standardized questionnaire was used for collecting pre-, per-, and post-operative data. The compliance of SAP was assessed for all patients. Data were analysed using SPSS version 22.

RESULTS

The compliance rate ofSAP among patients undergoing surgery at CUG was 18.1%. Emergency surgery increased the risk of SAP non-compliance by three fold (OR=3.5, 95% CI: 1.0-11.8, p = 0.033). The most frequent antibiotics used in SAP were ampicillin, cloxacillin, gentamicin and ceftriaxone, alone or in combination. Categories of non-compliance included; inappropriate initial dose of antibiotic (compliance rate of 23.8%) and incorrect duration of antibiotic use (compliance rate of 30.9%). Among the included patients, 22 (8.3%) presented with a surgical site infection, of those 20 (90.9%) had received non-compliant SAP.

CONCLUSION

The correct use of SAP among patients undergoing surgery at CUG is low. Implementing measures to optimize adherence to SAP guidelines should be encouraged. A high rate of surgical site infections is observed in cases where the SAP is prescribed or administered in a non-compliant manner.

Supporting global antimicrobial stewardship: antibiotic prophylaxis for the prevention of surgical site infection in low- and middle-income countries (LMICs): a scoping review and meta-analysis

BACKGROUND

The Scottish Antimicrobial Prescribing Group is supporting two hospitals in Ghana to develop antimicrobial stewardship. Early intelligence gathering suggested that surgical prophylaxis was suboptimal. We reviewed the evidence for use of surgical prophylaxis to prevent surgical site infections (SSIs) in low- and middle-income countries (LMICs) to inform this work.

METHODS

MEDLINE, Embase, Cochrane, CINAHL and Google Scholar were searched from inception to 17 February 2020 for trials, audits, guidelines and systematic reviews in English. Grey literature, websites and reference lists of included studies were searched. Randomized clinical trials reporting incidence of SSI following Caesarean section were included in two meta-analyses. Narrative analysis of studies that explored behaviours and attitudes was conducted.

RESULTS

This review included 51 studies related to SSI and timing of antibiotic prophylaxis in LMICs. Incidence of SSI is higher in LMICs, infection surveillance data are poor and there is a lack of local guidelines for antibiotic prophylaxis. Education to improve appropriate antibiotic prophylaxis is associated with reduction of SSI in LMICs. The random-effects pooled mean risk ratio of SSI in Caesarean section was 0.77 (95% CI: 0.51-1.17) for pre-incision versus post-incision prophylaxis and 0.89 (95% CI: 0.55-1.14) for short versus long duration. Reduction in cost and nurse time was reported in shorter-duration surgical antibiotic prophylaxis.

CONCLUSIONS

There is scope for improvement, but interventions must include local context and address strongly held beliefs. Establishment of local multidisciplinary teams will promote ownership and sustainability of change.

Identifying targets for improvement using a nationally standardized survey: Surgical antimicrobial prophylaxis in orthopedic surgery

BACKGROUND

Surgical antimicrobial prophylaxis (SAP) is commonly administered in orthopedic procedures. Research regarding SAP appropriateness for specific orthopedic procedures is limited and is required to facilitate targeted orthopedic prescriber behavior change.

OBJECTIVES

To describe SAP prescribing and appropriateness for orthopedic procedures in Australian hospitals.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, national, quality improvement study with retrospective analysis of data collected from Australian hospitals via Surgical National Antimicrobial Prescribing Survey (Surgical NAPS) audits from January 1, 2016, to April 15, 2019, were analyzed.

METHODS

Logistic regression identified hospital, patient and surgical factors associated with appropriateness. Adjusted appropriateness was calculated from the multivariable model. Additional subanalyses were conducted on smaller subsets to calculate the adjusted appropriateness for specific orthopedic procedures.

RESULTS

In total, 140 facilities contributed to orthopedic audits in the Surgical NAPS, including 4,032 orthopedic surgical episodes and 6,709 prescribed doses. Overall appropriateness was low, 58.0% (n = 3,894). This differed for prescribed procedural (n = 3,978, 64.7%) and postprocedural doses (n = 2,731, 48.3%). The most common reasons for inappropriateness, when prophylaxis was required, was timing for procedural doses (50.9%) and duration for postprocedural prescriptions (49.8%). The adjusted appropriateness of each orthopedic procedure group was low for procedural SAP (knee surgery, 54.1% to total knee joint replacement, 74.1%). The adjusted appropriateness for postprocedural prescription was also low (from hand surgery, 40.7%, to closed reduction fractures, 68.7%).

CONCLUSIONS

Orthopedic surgical specialties demonstrated differences across procedural and postprocedural appropriateness. The metric of appropriateness identifies targets for quality improvement and is meaningful for clinicians. Targeted quality improvement projects for orthopedic specialties need to be developed to support optimization of antimicrobial use.

Factors influencing uptake of evidence-based antimicrobial prophylaxis guidelines for electrophysiology procedures

BACKGROUND

Clinical guidelines support early discontinuation of antimicrobials after cardiac device procedures; however, prolonged courses of antimicrobials are common.

METHODS

We conducted semistructured interviews with 13 electrophysiologists representing diverse geographic and clinical settings of care to identify perceived barriers and facilitators to discontinuing postprocedure antimicrobial prophylaxis as part of a formative evaluation prior to implementing a program to improve uptake of guideline recommendations. A directed content analysis approach was used to map responses to the Implementation Outcomes Framework.

RESULTS

Data indicated that electrophysiologists were not willing to stop postprocedural antimicrobials, indicating a lack of acceptability of clinical guidelines. Feasibility, fidelity, cost, and appropriateness were also frequently cited. Factors associated with prolonged antimicrobial prescribing included beliefs about lack of harm and possible benefit. There was a strong "cultural inertia" to conform to institutional normative practices. Reasons for conforming ranged from streamlining processes for clinical staff and concerns about being perceived as an "outlier."

CONCLUSIONS

Institutional culture and beliefs about consequences of cardiac device infections versus antimicrobial use appeared to be major drivers of current practice. The desire to promote institutional standardization suggests that strategies to enhance implementation of prophylaxis guidelines must include facility-level changes, rather than interventions directed only at individual-providers.

A Blueprint for Success: Design and Implementation of an Ideal Bronchoscopy Suite

Bronchoscopy is essential to the practice of pulmonary medicine. It is an important diagnostic and therapeutic tool for many disease processes. Bronchoscopy can be performed in a variety of clinical settings, from the bedside to an operating room. Although bronchoscopy has been practiced for more than a century, consensus recommendations from stakeholders have yet to be developed for the planning, implementation, and construction of a bronchoscopy suite. A wide range of procedures can be performed via bronchoscopy; therefore, the required tools and the procedure area must be aligned with the needs of the facility. Designing a bronchoscopy suite is by no means a "one size fits all" process. We present an overview of critical features to be considered in the planning for an ideal bronchoscopy suite. We use the term "ideal" because it represents a subjective conception of what is perfect and does not convey a rigid, universal blueprint.

Prolonged postprocedural antimicrobial use: A survey of the Society for Healthcare Epidemiology of America Research Network

Continuing surgical antimicrobial prophylaxis after the incision is closed is not recommended in current guidelines. Our survey found that only 30.8% of hospitals had fully adopted these new recommendations. Feedback on prophylaxis duration was infrequently provided. Promoting guideline-concordant surgical antimicrobial prophylaxis discontinuation is an important target for future stewardship interventions.