Surgical antimicrobial prophylaxis

Antimicrobial prescribing in referral hospitals in Timor-Leste: results of the first two national point prevalence surveys, 2020-21

Objectives

To describe antimicrobial use (AMU) in patients admitted to hospitals in Timor-Leste.

Methods

In 2020 and 2021, we undertook antimicrobial prescribing point prevalence surveys across all six hospitals in Timor-Leste (one national and five municipal) to describe AMU and appropriateness in admitted patients.

Results

In 2020, 291/394 (73.9%) surveyed patients had been prescribed antimicrobials, compared with 260/403 (64.5%) in 2021 (P = 0.004). Most (309/551; 56.1%) were prescribed one antimicrobial, and 179/551 (32.5%) were prescribed two. The most commonly prescribed antibiotics were ceftriaxone (38.5% in 2020, 41.5% in 2021) and ampicillin (35.7% in 2020, 32.3% in 2021), followed by gentamicin, metronidazole and cloxacillin. Reserve antibiotics like meropenem and vancomycin were minimally used. Of all antimicrobial prescriptions, 70.8% were deemed appropriate in 2020 and 69.1% in 2021. Antimicrobial prescriptions for surgical and post-partum prophylaxis were frequently deemed inappropriate [37/50 (74.0%) and 39/44 (88.6%) prescriptions, respectively].

Conclusions

Most patients admitted to hospital in Timor-Leste are prescribed antimicrobials, and approximately one-third of these prescriptions are inappropriate. However, this was in the context of limited local guideline availability at the time of surveys and limited microbiological culture capacity outside of the capital, Dili. Improved microbiological guidance, iterative guideline revisions based on local antimicrobial resistance (AMR) surveillance data, and enhanced stewardship activities including further point prevalence studies, could improve antimicrobial use, optimize patient outcomes and reduce AMR in Timor-Leste.

Study of the Practice of Surgical Antibiotic Prophylaxis Use for Elective Neurosurgical Cases in a Tertiary Hospital and Understanding the Rationale

BACKGROUND

This study aims to evaluate the adherence to surgical antibiotic prophylaxis (SAP) guidelines in elective neurosurgery and assess the impact on surgical site infection (SSI) rates in a tertiary teaching hospital in Malaysia.

METHOD

A retrospective review was conducted on patients who underwent elective neurosurgical procedures from January 1, 2021, to December 31, 2021, in a 1600-bed tertiary teaching hospital. The study assessed adherence to national and hospital SAP guidelines, focusing on the choice of antibiotic, dosage, timing, and duration. Additionally, a survey was conducted among neurosurgeons to evaluate their knowledge, attitudes, and practices regarding SAP.

RESULT

Out of 202 patients included, there was a 99% compliance rate with antibiotic choice and 69.8% with the antibiotic duration. The SSI rate was identified at 6.4%. The knowledge, attitudes, and practices survey highlighted a strong awareness of SAP guidelines among surgeons, albeit with variations in practice, particularly in antibiotic duration and choice of antibiotics.

CONCLUSIONS

While there is high adherence to the correct choice of antibiotic for SAP in elective neurosurgery, there are gaps in compliance with the recommended duration of antibiotic use. The study highlights the need for targeted interventions to improve adherence to SAP guidelines, which could potentially reduce the incidence of SSI in neurosurgery. Ongoing education and auditing are essential to optimize SAP practices and enhance patient outcomes in neurosurgery.

Ten-year trends of antibiotic prescribing in surgery departments of two private sector hospitals in Central India: a prospective observational study

BACKGROUND

Inappropriate antibiotic use contributes to the global rise of antibiotic resistance, prominently in low- and middle-income countries, including India. Despite the considerable risk of surgical site infections, there is a lack of antibiotic prescribing guidelines and long-term studies about antibiotic prescribing in surgery departments in India. Therefore, this study aimed to analyse 10 years' antibiotic prescribing trends at surgery departments in two tertiary-care hospitals in Central India.

METHODS

Data was prospectively collected from 2008 to 2017 for surgery inpatients in the teaching (TH-15,016) and the non-teaching hospital (NTH-14,499). Antibiotics were classified based on the World Health Organization (WHO) Access Watch Reserve system and analysed against the diagnoses and adherence to the National List of Essential Medicines India (NLEMI) and the WHO Model List of Essential Medicines (WHOMLEM). Total antibiotic use was calculated by DDD/1000 patient days. Time trends of antibiotic prescribing were analysed by polynomial and linear regressions.

RESULTS

The most common indications for surgery were inguinal hernia (TH-12%) and calculus of the kidney and ureter (NTH-13%). The most prescribed antibiotics were fluoroquinolones (TH-20%) and 3rd generation cephalosporins (NTH-41%), and as antibiotic prophylaxis, norfloxacin (TH-19%) and ceftriaxone (NTH-24%). Access antibiotics were mostly prescribed (57%) in the TH and Watch antibiotics (66%) in the NTH. Culture and susceptibility tests were seldom done (TH-2%; NTH-1%). Adherence to the NLEMI (TH-80%; NTH-69%) was higher than adherence to the WHOMLEM (TH-77%; NTH-66%). Mean DDD/1000 patient days was two times higher in the NTH than in the TH (185 vs 90). Overall antibiotic prescribing significantly increased in the TH (β1 =13.7) until 2012, and in the NTH (β2 =0.96) until 2014, and after that decreased (TH, β2= -0.01; NTH, β3= -0.0005). The proportion of Watch antibiotic use significantly increased in both hospitals (TH, β=0.16; NTH, β=0.96).

CONCLUSION

Total antibiotic use decreased in the last three (NTH) and five years (TH), whereas consumption of Watch antibiotics increased over 10 years in both hospitals. The choice of perioperative antibiotic prophylaxis was often inappropriate and antibiotic prescribing was mostly empirical. The results of this study confirmed the need for antibiotic prescribing guidelines and implementation of antimicrobial stewardship programs.

Efficiency of octenidine dihydrochloride alcohol combination compared to ethanol based skin antiseptics for preoperative skin preparation in dogs

OBJECTIVE

To quantify the bacterial burden after skin disinfection using an alcohol octenidine dihydrochloride combination (Octenisept®) compared to an 74.1% ethanol 10% 2-propanol combination (Softasept N®).

STUDY DESIGN

Prospective randomized clinical trial.

MATERIAL & METHODS

61 dogs undergoing clean or clean-contaminated surgeries (excluding surgeries on the gastrointestinal tract) were randomly assigned to group O (skin disinfection with alcohol and octenidine dihydrochloride after washing with octenidine containing soap) or to control group C (skin disinfection using the ethanol-2-propanol combination after washing with a neutral soap without antiseptic ingredients). Samples were then taken from 8 different locations within the surgical field at four different stages: after clipping, after washing, after disinfection and one hour later. At each stage, two different sampling techniques (wet-dry swab technique (WDS) and contact plates (CP)) were used for quantitative analysis of bacterial counts.

RESULTS

WDS detected about 100-fold more bacteria compared to CP sampling in cases with high bacterial burden, but was not accurate enough to detect small numbers. CP sampling was therefore used for comparison of treatment protocols. 30 dogs were assigned to group O and 31 to group C. A relative reduction of 69% in group O and 77 percent in group C was observed after the soap wash. No significant differences were detected between both groups. Washing and disinfection resulted in a reduction of bacterial counts of 99.99% in group O versus 99.7% in group C (p = 0.018). Bacterial reduction one hour after washing and disinfection was significantly higher in group O (99.9%) than in group C (98.5%, p = 0.001).

CONCLUSION

Additional octenidine dihydrochloride provided a slightly better decontamination effect after disinfection, particularly one hour after, which means it may only be indicated in longer surgeries. WDS is more sensitive but less specific to detect bacteria on the skin than the CP sampling.

Surgical site infection and antimicrobial prophylaxis prescribing profile, and its determinants among hospitalized patients in Northeast Ethiopia: a hospital based cross-sectional study

The inappropriate use of surgical antimicrobial prophylaxis is a common cause for increased risk of morbidity and mortality from surgical site infection in patients who underwent surgical procedures. The study aimed to evaluate surgical antimicrobial prophylaxis prescribing patterns, Surgical Site Infection (SSI), and its determinants in the surgical ward of Debre Berhan Comprehensive Specialized Hospital, northeast Ethiopia. A prospective cross-sectional study was conducted from October 1st 2022 to January 31st, 2023. Data collected from patient medical record cards and patient interviews were entered and analyzed using SPSS V26.0. The determinants of surgical site infection were determined from the multivariable logistic regression. P-value ≤ 0.05 was considered statistically significant. Ceftriaxone (70.5%) followed by a combination of ceftriaxone with metronidazole (21.90%) was the most frequently used prophylactic antibiotic. One hundred fifty-nine (78%) of patients were exposed to inappropriately used prophylactic antimicrobials and 62.2% of these were exposed to inappropriately selected antibiotics. One hundred twenty-six (61.9%) patients developed Surgical Site Infection (SSI). Duration of procedure longer than an hour and inappropriate use of antimicrobial prophylaxiswere the independent predictors for the occurrence of surgical site infections. Patients whose operation was lasted in longer than an hour were 3.39 times more likely to develop SSI compared to those whose operation was completed in less than an hour, AOR = 3.39 (95% CI: 1.24-9.30). Similarly, controlling the effect of other covariate variables, individuals who were given inappropriate antimicrobial prophylaxis were 6.67 times more likely to develop SSI compared to those given appropriate prophylaxis, AOR = 6.67 (95% CI: 1.05-42.49). The high rate of SSI requires due attention from clinicians as well as health policymakers. Duration of surgical procedure greater than an hour and inappropriate antimicrobial prophylaxis use was the independent predictor of surgical site infections.

No more tears from surgical site infections in interventional pain management

As the field of interventional pain management (IPM) grows, the risk of surgical site infections (SSIs) is increasing. SSI is defined as an infection of the incision or organ/space that occurs within one month after operation or three months after implantation. It is also common to find patients with suspected infection in an outpatient clinic. The most frequent IPM procedures are performed in the spine. Even though primary pyogenic spondylodiscitis via hematogenous spread is the most common type among spinal infections, secondary spinal infections from direct inoculation should be monitored after IPM procedures. Various preventive guidelines for SSI have been published. Cefazolin, followed by vancomycin, is the most commonly used surgical antibiotic prophylaxis in IPM. Diagnosis of SSI is confirmed by purulent discharge, isolation of causative organisms, pain/tenderness, swelling, redness, or heat, or diagnosis by a surgeon or attending physician. Inflammatory markers include traditional (C-reactive protein, erythrocyte sedimentation rate, and white blood cell count) and novel (procalcitonin, serum amyloid A, and presepsin) markers. Empirical antibiotic therapy is defined as the initial administration of antibiotics within at least 24 hours prior to the results of blood culture and antibiotic susceptibility testing. Definitive antibiotic therapy is initiated based on the above culture and testing. Combination antibiotic therapy for multidrug-resistant Gram-negative bacteria infections appears to be superior to monotherapy in mortality with the risk of increasing antibiotic resistance rates. The never-ending war between bacterial resistance and new antibiotics is continuing. This article reviews prevention, diagnosis, and treatment of infection in pain medicine.

Appropriateness of surgical antimicrobial prophylaxis in a teaching hospital in Ghana: findings and implications

Background

Surgical site infections (SSIs) are among the most common infections seen in hospitalized patients in low- and middle-income countries (LMICs), accounting for up to 60% of hospital-acquired infections. Surgical antimicrobial prophylaxis (SAP) has shown to be an effective intervention for reducing SSIs and their impact. There are concerns of inappropriate use of SAP in Ghana and therefore our audit in this teaching hospital.

Methods

A retrospective cross sectional clinical audit of medical records of patients undergoing surgery over a 5 month duration from January to May 2021 in Ho Teaching Hospital. A data collection form was designed to collect key information including the age and gender of patients, type and duration of surgery, choice and duration of SAP. The collected data was assessed for the proportion of SAP compliance with Ghana Standard Treatment Guidelines (STGs) and any association with various patient, surgical wound and drug characteristics.

Results

Of the 597 medical records assessed, the mean age of patients was 35.6 ± 12.2 years with 86.8% (n = 518) female. Overall SAP compliance with the STG was 2.5% (n = 15). SAP compliance due to appropriate choice of antimicrobials was 67.0% (n = 400) and duration at 8.7% (n = 52). SAP compliance was predicted by duration of SAP (P < 0.000) and postoperative hospitalization duration (P = 0.005).

Conclusions

SAP compliance rate was suboptimal, principally due to a longer duration of prescription. Quality improvement measures such as education of front-line staff on guideline compliance, coupled with clinical audit and regular updates, are urgently needed to combat inappropriate prescribing and rising resistance rates.

Pattern of Antibiotic Use among Hospitalized Patients according to WHO Access, Watch, Reserve (AWaRe) Classification: Findings from a Point Prevalence Survey in Bangladesh

For supporting antibiotic stewardship interventions, the World Health Organization (WHO) classified antibiotics through the AWaRe (Access, Watch, and Reserve) classification. Inappropriate use of antimicrobials among hospital-admitted patients exposes them to the vulnerability of developing resistant organisms which are difficult to treat. We aimed to describe the proportion of antibiotic use based on the WHO AWaRe classification in tertiary and secondary level hospitals in Bangladesh. A point prevalence survey (PPS) was conducted adapting the WHO PPS design in inpatients departments in 2021. Among the 1417 enrolled patients, 52% were female and 63% were from the 15–64 years age group. Nearly 78% of patients received at least one antibiotic during the survey period. Third-generation cephalosporins (44.6%), penicillins (12.3%), imidazoles (11.8%), aminoglycosides (7.2%), and macrolides (5.8%) were documented as highly used antibiotics. Overall, 64.0% of Watch, 35.6% of Access, and 0.1% of Reserve group antibiotics were used for treatment. The use of Watch group antibiotics was high in medicine wards (78.7%) and overall high use of Watch antibiotics was observed at secondary hospitals (71.5%) compared to tertiary hospitals (60.2%) (p-value of 0.000). Our PPS findings underscore the need for an urgent nationwide antibiotic stewardship program for physicians including the development and implementation of local guidelines and in-service training on antibiotic use.

Antimicrobial stewardship capacity and infection prevention and control assessment of three health facilities in the Ashanti Region of Ghana

Background

Addressing antimicrobial resistance (AMR) requires the rational use and optimization of available resources for prevention and management of infections. Structures in health facilities to support optimal antimicrobial therapy and AMR containment therefore need assessment and strengthening.

Objectives

To assess antimicrobial stewardship (AMS) capacity and conformance to National and WHO Infection Prevention and Control (IPC) guidelines in three hospitals in Ashanti region of Ghana.

Methods

A cross-sectional study using WHO's hospital questionnaire for AMS capacity assessment, and Infection Prevention and Control Framework (IPCAF) to assess IPC practices in the three hospitals.

Results

All the facilities had Drug and Therapeutics and IPC Committees with microbiology laboratory services. H3 and H1 did not have a formal AMS programme or an organizational structure for AMS. However, both institutions had a formal procedure to review antibiotics on prescriptions for quality assessment and relevance. H2 and H1 did not participate in any surveillance of antibiotic resistance patterns or consumption. H1 had basic, while H2 and H3 had intermediate-level IPC systems scoring 385, 487.5 and 435.8 out of 800 respectively.

Conclusions

All the facilities assessed had AMS capacity and IPC conformity gaps that require strengthening to optimize antimicrobial use (AMU) and successful implementation of IPC protocols. Regular surveillance of antimicrobial consumption and microbial resistance patterns should be an integral part of activities in health institutions to generate evidence for impactful actions to contain AMR and improve AMU.

Incidence of Surgical Site Infection and Use of Antibiotics among Patients Who Underwent Caesarean Section and Herniorrhaphy at a Regional Referral Hospital, Sierra Leone

Surgical site infections (SSIs) are common postoperative complications. Surgical antibiotic prophylaxis (SAP) can prevent the occurrence of SSIs if administered appropriately. We carried out a retrospective cohort study to determine the incidence of SSIs and assess whether SAP were administered according to WHO guidelines for Caesarean section (CS) and herniorrhaphy patients in Bo regional government hospital from November 2019 to October 2020. The analysis included 681 patients (599 CSs and 82 herniorrhaphies). Overall, the SSI rate was 6.7% among all patients, and 7.5% and 1.2% among CS patients and herniorrhaphy patients, respectively. SAP was administered preoperatively in 85% of CS and 70% of herniorrhaphy patients. Postoperative antibiotics were prescribed to 85% of CS and 100% of herniorrhaphy patients. Ampicillin, metronidazole, and amoxicillin were the most commonly used antibiotics. The relatively low rate of SSIs observed in this study is probably due to improved infection prevention and control (IPC) measures following the Ebola outbreak and the current COVID-19 pandemic. A good compliance rate with WHO guidelines for preoperative SAP was observed. However, there was a high use of postoperative antibiotics, which is not in line with WHO guidelines. Recommendations were made to ensure the appropriate administration of SAP and reduce unnecessary use of antibiotics.

Multicentre point-prevalence survey of antibiotic use and healthcare-associated infections in Ethiopian hospitals

OBJECTIVE

Effective antimicrobial containment strategies such as Antimicrobial Stewardship Programs (ASPs) require comprehensive data on antibiotics use which are scarce in Ethiopia. This study sought to assess antibiotics use and healthcare-associated infections (HCAIs) in Ethiopian public hospitals.

DESIGN

We conducted a cross-sectional study using the WHO point-prevalence survey protocol for systemic antibiotics use and HCAIs for low/middle-income countries.

SETTING

The study was conducted among 10 public hospitals in 2021.

PARTICIPANTS

All patients admitted to adult and paediatric inpatient and emergency wards before or at 08:00 on the survey date were enrolled.

OUTCOME MEASURE

The primary outcome measures were the prevalence of antibiotic use, HCAIs and the hospitals' readiness to implement ASP.

RESULTS

Data were collected from 1820 patient records. None of the surveyed hospitals had functional ASP. The common indication for antibiotics was for HCAIs (40.3%). Pneumonia was the most common bacterial infection (28.6%) followed by clinical sepsis (17.8%). Most treatments were empiric (96.7%) and the overall prevalence of antibiotic use was 63.8% with antibiotics prescription per patient ratio of 1.77. Ceftriaxone was the most commonly prescribed antibiotic (30.4%) followed by metronidazole (15.4%). Age, having HIV infection, ward type, type of hospital, catheterisation and intubation history had significant association with antibiotic use. Patients who were treated in paediatric surgical wards were about four times more likely to be on antibiotics compared with patients treated at an adult emergency ward. Patients on urinary catheter (adjusted OR (AOR)=2.74, 95% CI: 2.04 to 3.68) and intubation device (AOR=2.62, 95% CI: 1.02 to 6.76) were more likely to be on antibiotics than their non-intubated/non-catheterised counterparts. Patients treated at secondary-level hospitals had 0.34 times lower odds of being on antibiotics compared with those in tertiary hospitals.

CONCLUSIONS

Antibiotic use across the surveyed hospitals was common and most were empiric which has both practical and policy implications for strengthening ASP and promoting rational antibiotics use.

Developing a theory-based behavior change intervention to improve the prescription of surgical prophylaxis

Background Antimicrobial resistance (AMR) is increasingly pervasive due to multiple, complex prescribing and consuming behaviours. Accordingly, behaviour change is an important component of response to AMR. Little is known about the best approaches to change antibiotic use practices and behaviours. Aim This project aims to develop a context-specific behaviour change strategy focusing on promoting appropriate prescription practices following the World Health Organization recommendations for surgical prophylaxis in an orthopaedic surgery unit in Egypt. Method The project included a formative qualitative research study with 31 in-depth interviews with orthopaedic surgeons that was based on the Theoretical Domains Framework (TDF) and an intervention that was developed to following the Behaviour Change Wheel (BCW) in a knowledge co-production workshop with ten public health experts that ensured that the theory based intervention was a culturally acceptable, practical and implementable intervention. Results The prescription of surgical prophylaxis was influenced by eight TDF domains from which workshop participants selected five to be included in the behaviour change intervention including, knowledge, belief in consequences (mistrust towards infection prevention and control measures), environmental factors (lack of prescription guidelines), professional role and reinforcement (a lack of appropriate follow up actions influenced prescription of surgical prophylaxis). The appropriate set of behaviour change functions of BCW and related activities to improve the current practices included education, enablement, persuasion, environmental restructuring and restriction. Conclusion The study showed that a theory based, and context specific intervention can be created by using the TDF and BCW together with knowledge-co creation to improve the prescription of surgical prophylaxis in and Egyptian orthopaedic unit. The intervention needs to piloted and scaled up.

Antibiotic Prophylaxis Prescribing Practice in Head and Neck Tumor Resection and Free Flap Reconstruction

Background

Adherence to guidelines for antibiotic prophylaxis is often poor and is an important target for antimicrobial stewardship programs. Prescribing audits that suggested poor adherence to guidelines in a plastic surgery department led to a targeted education program to bring antibiotic prescriptions in line with hospital guidelines. We reviewed whether this intervention was associated with changed perioperative prescribing and altered surgical outcomes, including the rate of surgical site infections, specifically looking at clean-contaminated head and neck tumor resections with free flap reconstruction.

Methods

A retrospective cohort study was performed on 325 patients who underwent clean-contaminated head and neck tumor resection and free flap reconstruction from January 1, 2013, to February 19, 2019. Patients were divided into 2 groups, those before (pre-intervention) and after (postintervention) the education campaign. We analyzed patient demographic and disease characteristics, intraoperative and postoperative factors, and surgical outcomes.

Results

Patients pre-intervention were prescribed longer courses of prophylactic antibiotics (median [interquartile range], 9 [8] vs 1 [1]; P < .001), more topical chloramphenicol ointment (21.82% vs 0%; P < .001), and more oral nystatin (36.9% vs 12.2%; P < .001). Patients postintervention had higher rates of recipient infections (36.11% vs 17.06%; P < .001) and donor site infections (6.94% vs 1.19%; P = .006).

Conclusions

Following the education campaign, patients were prescribed shorter courses of prophylactic antibiotics, more of the recommended cefazolin-metronidazole regimen, and fewer topical antibiotics. However, patients also had a higher rate of surgical site infections.

Surgical antimicrobial prophylaxis in open reduction internal fixation procedures at a metropolitan hospital in Australia: a retrospective audit

Background

Open reduction internal fixation (ORIF) of closed fractures is a required indication for surgical antimicrobial prophylaxis (SAP). Guidelines contain recommendations on how best to prescribe SAP, however, adherence to SAP guidelines remains suboptimal. The Australian Therapeutic Guidelines: Antibiotic v16 (updated April 2019) advocates for single dose prophylaxis for ORIF procedures. There is a paucity of information on how SAP is prescribed for ORIF of closed fractures in Australian hospitals. The aim of this study was to identify prescribing practice and to evaluate guideline adherence pre- and post-guideline update.

Methods

A retrospective audit was conducted for patients undergoing an ORIF of closed fractures at a metropolitan teaching hospital in a 6-month period during 2018 (pre-guideline update) and 2019 (post-guideline update). Data were collected on prescribing practice (perioperative antibiotics prescribed, dose, time and route of administration and duration of prophylaxis) and compared to SAP recommendations in Therapeutic Guidelines: Antibiotic v15 (2018) and v16 (2019). Descriptive statistics and Chi square tests were used to report categorical variables. Binary logistic regression was used to identify factors associated with guideline adherence. A p-value < 0.05 was deemed statistically significant.

Results

Data were collected for a total of 390 patients (n = 185, 2018; n = 205, 2019). Cefazolin was the most commonly prescribed antibiotic as per guideline recommendations, with variable, yet appropriate doses observed across the two audit periods. While 78.3% of patients received SAP for the correct duration in 2018, only 20.4% of patients received single dose prophylaxis in 2019. Overall adherence to guidelines was 63.2% in the 2018, and 18.0% in the 2019 audit periods respectively. Patient age was significantly associated with an increase in overall guideline adherence, while lower limb fractures, an American Society of Anesthesiologists (ASA) score of 3 and emergency admissions were associated with decreased overall adherence to SAP guidelines.

Conclusion

Adherence to guidelines was greater with v15 (2018) compared with v16 (2019). Patient factors, including limb fracture site and ASA score, had little impact on guideline adherence. Further research is required to understand what influences guideline adherence in the orthopaedic setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01398-7.

Quantity and quality profiles of antibiotics pre, on, and post surgery in a hospital setting

Background Providing proper antibiotics is undoubtedly crucial to prevent infections during surgery. Objective This study set out to evaluate the medication administration in antibiotic prophylaxis using both quantitative and qualitative methods. Setting The study employed a retrospective design and observed patients who underwent surgical procedures during hospitalization at a private hospital in Indonesia within the period of January-June 2019. Methods The data obtained were evaluated quantitatively and qualitatively; and analyzed descriptively. The quantitative evaluation used the defined daily dose (DDD) per 100 bed-days. The qualitative evaluation was expressed as the percentage of antibiotic suitability based on antibiotic administration, i.e. (1) type; (2) timing; (3) dosage; (4) duration; and (5) route. Main outcome measure Suitability of antibiotic prophylaxis in a hospital setting. Results There were 164 prescriptions recorded from 20 types of surgical procedures, of which the most common was cholecystectomy (23 patients, 14%). Most antibiotics were administered 61-120 min before the incision time (55 patients, 37%), and had a duration of more than 24 h (119 patients, 80%). The total DDD per 100 bed-days for pre-, on-, and post-surgery antibiotic use were 44.2, 33.3, and 66.7 respectively. The suitability profiles of the antibiotics used according to the Antibiotic Use Guideline for Hospital (2018) were as follows: 26.3% right type, 52.9% right time, 24.8% right dosage, 19.1% right duration, 91.8% right route, while according to American Society of Health-System Pharmacists Therapeutic Guidelines (2014) there were 17.6% right type, 53.4% right time, 16.4% right dosage, 19.1% right duration, and 96.6% right route. Conclusion Ceftriaxone was the first-choice prophylactic antibiotic administered in this Indonesian hospital. The data indicate a considerable non-compliance with local and international guidelines.

WHAT'S NEW IN INFECTION ON SURGICAL SITE AND ANTIBIOTICOPROPHYLAXIS IN SURGERY?

INTRODUCTION

Infection of the surgical site is the common complication, with significant rates of morbidity and mortality, representing a considerable economic problem for the health system.

OBJECTIVE

To carry out a narrative review of the literature on surgical site infection and the principles of antibiotic prophylaxis to update the knowledge of its use in surgery.

METHOD

Medline, Ovid, Google Scholar, National Library of Medicine (PubMed), Cochrane and SciELO were used for the research. The keywords used were "anti-bacterial agents"; "antibioticoprophylaxis" AND "surgical wound infection". The inclusion criteria were articles of recent publication, with full texts available and performed in humans.

RESULT

A total of 29 articles were evaluated and selected according to the eligibility criteria.

CONCLUSION

Infection of the surgical site is the most common postoperative complication. The key point of its prevention is the combination of several interventions that aim to reduce risk factors, such as: compliance with the new guidelines of the Center for Disease Control and Prevention; the principles of the use of prophylactic antibiotics; factors and risk index of the surgical site; administration time; duration and dosage of antibiotics. These data are available in this article.

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

BACKGROUND

Despite the extensive research that has been conducted to date, practice often differs from established guidelines and will vary between individuals and organisations. It has been noted that the global uptake of local and international surgical antimicrobial prophylaxis (SAP) guidelines is poor with limited research investigating factors that affect guideline adherence. The purpose of this systematic review was to determine the reported barriers and enablers to the adherence of SAP guidelines.

METHODS

A search of the literature was performed using four electronic databases (CINAHL, EMBASE, PubMed and SCOPUS) for articles published in the English language from January 1998 to December 2018. Articles were included if they were solely related to SAP and discussed the barriers or enablers to SAP guideline adherence. Articles that assessed the adherence to a range of infection control measures or discussed adherence to antibiotic treatment guidelines rather than SAP guidelines were excluded from this review. Barriers and enablers were mapped to the Theoretical Domains Framework (TDF). The Mixed Methods Appraisal Tool was used to assess the quality of included studies.

RESULTS

A total of 1489 papers were originally retrieved, with 48 papers meeting the eligibility criteria. Barriers and enablers were mapped to 11 out of 14 TDF domains: knowledge, skills, social/professional role and identity, beliefs about capabilities, beliefs about consequences, reinforcement, memory, attention and decision processes, environmental context and resources, social influences, emotion and behavioural regulation. Barriers were further categorised into personal or organisational barriers, while enablers were arranged under commonly trialled interventions.

CONCLUSIONS

There are numerous factors that can determine the uptake of SAP guidelines. An identification and understanding of these factors at a local level is required to develop tailored interventions to enhance guideline adherence. Interventions, when used in combination, can be considered as a means of improving guideline use.

Discitis Following Radiofrequency Nucleoplasty: A Case Report

Introduction

Radiofrequency nucleoplasty is a minimally invasive procedure to treat chronic low back pain, especially mild degenerative disc diseases. Discitis after radiofrequency nucleoplasty is a rare case.

Case Presentation

A 62-year-old male patient with a chief complaint of 10 years low back pain, gradually worsening for the last two years, a history of hypertension, chronic kidney disease, and routine dialysis twice a week, referred to the center. He underwent a lumbar medial branch block using radiofrequency and radiofrequency nucleoplasty procedure of lumbar 4-5 (L4-L5). Three weeks after the intervention, he could not move his legs, associated with urinary and fecal incontinence. MRI (magnetic resonance imaging) of the lumbar spine was performed, and the results indicated hyperintensity in L4-L5, suspicious of discitis. Laminectomy at L4 and L5 was performed. Eight months after surgery, the patient could feel and lift legs, and urinary and fecal incontinence was also controlled.

Conclusions

Early diagnosis of discitis is critical and challenging. Delay in diagnosis may lead to treatment delay and the development of neurological deficits. Comprehensive treatment with bed rest, antimicrobial therapy, and sensible application of timely surgery are essentials to an optimal outcome.

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.

Adherence to the guidelines for surgical antimicrobial prophylaxis in a Saudi tertiary care hospital

Objective

The study evaluated the adherence to the guidelines for surgical antimicrobial prophylaxis in a Saudi tertiary care hospital.

Methods

The medical records of 707 patients from the surgical units over a selected 3-month period were selected. The data were reviewed and statistically analysed.

Results

Of the 707 respondents, 51.2% were women and most were older than 50 years. The most common surgical procedures involved orthopaedics (28.3%), followed by vascular surgery (15.1%). One hundred and thirty-eight (19.5%) patients received antibiotics according to the guidelines for surgical prophylaxis. More than half of the patients (399/56.4%) received antibiotics for more than 24 h and 129 (18.2%) received antibiotics for less than 24 h. Single dose antibiotic therapy was used in 179 (25.3%) patients. Two hundred and ninety-seven (42%) patients underwent clean surgery, 284 (40%) clean-contaminated and 128 (18%) contaminated surgery. A significant difference was evident between the antibiotics administered according to the recommended guidelines and the duration of antibiotic therapy (p = 0.001), duration (p = 0.001) and the type of surgical procedure (p = 0.00).

Conclusion

The findings of this study suggest that healthcare professionals do not strictly adhere to the guidelines for surgical antibiotic prophylaxis. Physicians are therefore encouraged to follow the recommendations appropriately and to regularly implement surgical antimicrobial prophylaxis for patient safety.

Surgical Antimicrobial Prophylaxis and Incidence of Surgical Site Infections at Ethiopian Tertiary-Care Teaching Hospital

BACKGROUND

Surgical site infections (SSIs) are infections that develop within 30 days after an operation or surveillance of surgical wound infection implementation within 90 days after surgery when an implant is placed. The objective of this study was to assess preoperative and postoperative antimicrobial use in St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia.

METHODS

A hospital-based cross-sectional study was undertaken in surgery wards of SPHMMC for 4 months by reviewing 413 patients' charts. All patients 13 years and older who were admitted and underwent different types of surgical procedures were included in the study. Epi info 7 was used for data entry, and then data were exported to Statistical Package for Social Sciences (SPSS) version 20.0 software for analysis. Descriptive analyses were computed and rate of SSI was calculated in this study. Moreover, bivariate analysis was done to examine the relationship between the outcome variable and predictor variables with a value of P < .2 retained for subsequent multivariate analyses using multiple logistic regressions. P value of <.05 was considered as statistically significant.

RESULTS

Out of 413 patients, 152 (36.8%) were operated for general surgery, and the remaining were for other types of surgeries. Most of the patients, 196 (79.7%), were managed by a single surgical antibiotic agent, followed by 2 agents (20.3%) for surgical prophylaxis indication. Surgical site infections occurred in 46 (11.1%) patients before discharge from the hospital. In those patients who need treatment for SSIs, almost half of them (49.5%) received combination therapy of ceftriaxone and metronidazole. Emergency surgical cases were 2.647 times more likely to develop SSIs than the elective surgical cases (adjusted odds ratio [AOR] = 2.647; 95% confidence interval [CI] = 1.406-4.983; P = .003). Patients who did not receive antibiotic prophylaxis were 2.572 times more likely to develop SSIs compared to those who received antibiotic prophylaxis (AOR = 2.572; 95% CI = 1.02-6.485; P = .045). Clean-contaminated and contaminated types of wound were a protective factor against SSI in our study.

CONCLUSIONS

This study indicated that most of the patients (72.1%) received surgical antimicrobial prophylaxis. The overall incidence rate of SSIs was 11.1% in the studied hospital. Ceftriaxone was the most commonly used drug. Being not receiving prophylaxis, wound class, and surgery types were significantly associated with the development of SSI.

Infection Rates After Microlaryngeal and Open Phonosurgery: The Role of Postoperative Antibiotics

OBJECTIVE

Although it is known that the airway has bacterial contamination that seeds the surgical site during microlaryngeal surgery, literature on the use of postoperative antibiotics is lacking. We performed a retrospective analysis of open phonosurgical and phonomicrosurgical cases at a single institution to assess whether use of postoperative antibiotics impacts the incidence of surgical site infections (SSI).

METHODS

In this retrospective cohort study, we reviewed 228 phonomicrosurgery and 53 open phonosurgery cases performed for benign diseases. Surgeries were performed by two laryngologists between February 2016 and August 2018. The surgeons differ in their postoperative antibiotic regimens: no antibiotics versus a 5- to 7-day postoperative course. Data collected include demographics, medical comorbidities, type of benign laryngeal disease, and surgical procedure. The primary outcome measure was postoperative infection, defined as the patient requiring a new prescription for antibiotics, an extended course of antibiotics, or any mention of infection at follow-up/emergency visits within the first month postoperatively.

RESULTS

The overall rate of SSI was 3.1% and 0% for phonomicrosurgery and open phonosurgery cases, respectively. For phonomicrosurgery, there was no difference in the rate of SSI for patients who received or did not receive antibiotics perioperatively: 2.9% versus 3.2% (P = 0.99). Similarly, there was no difference in the infection rate for open phonosurgical cases.

CONCLUSION

Infection rates after endoscopic and open phonosurgery are low. In this study, we found no evidence to suggest a protective effect associated with postoperative use of antibiotics.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1128-1131, 2020.

Antibiotic utilization pattern for surgical site infection prophylaxis at Dil Chora Referral Hospital Surgical Ward, Dire Dawa, Eastern Ethiopia

Objective

The aim of this study was to assess utilization pattern of surgical antibiotic prophylaxis in surgical wards of Dil Chora Referral Hospital.

Results

Prophylactic antibiotics were given in all surgical procedures. More than half of the participants 206(53.6%) were given Ceftriaxone while combination of Ceftriaxone and Metronidazole were used for 159(41.4%) patients. The most common procedure (88.3%), appendectomy, was managed with combination of Ceftriaxone and Metronidazole while the remaining was on Ceftriaxone. Hernia repair, another common procedure seen in this ward, was majorly managed by combination of Ceftriaxone and Metronidazole (60.7%) while the rest were on ceftriaxone alone. In general, inconsistence in antibiotic selection for different types of surgical procedures was seen. The surgical prophylactic antibiotics should be prescribed according to the international guidelines.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3629-6) contains supplementary material, which is available to authorized users.