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Fiallo P, Williams T, Bush LM. When Antimicrobial Treatment and Surgical Prophylaxis Collide: A Stewardship Opportunity. Hosp Pharm 2024; 59:460-464. [PMID: 38919764 PMCID: PMC11195835 DOI: 10.1177/00185787241230079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Background: In 2002, the Centers for Medicare and Medicaid Services (CMS) in collaboration with the Centers for Disease Control and Prevention (CDC) established the Surgical Infection Prevention (SIP) project for the purposes of developing and standardizing quality improvement measures known to reduce the rates of post-operative surgical site infections (SSIs). Four years later the Surgical Care Improvement Project (SCIP), an expansion of SIP, was published in governmental Specifications Manual for National Inpatient Quality Measures and provided several additional initiatives applicable to the perioperative period. Central to both projects are the assurance of the timeliness, selection, and duration of peri-operative surgical prophylactic antibiotics. In support of this objective, various medical associations, such as the American Society of Health-System Pharmacists (ASHP) and the Infectious Diseases Society of America (IDSA), have developed the Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. To ensure compliance with quality measures, hospitals are required to report data to the Physicians Quality Reporting System, which is then reviewed by CMS for reimbursement purposes and to measure hospital performance. To maintain optimal standards of care and satisfy all core measures, it is expected that patients undergoing most categories of surgical procedures receive prophylactic antibiotics. We recognized that patients already being administered antimicrobial therapy as treatment for the condition requiring the surgery not uncommonly also were prescribed unwarranted and redundant pre-operative antibiotics. Our study was meant to quantify such antibiotic redundancy, which only risks the development of antimicrobial resistance and adverse events, to bolster our and other hospitals antimicrobial stewardship programs. Methods: A retrospective analysis of computerized hospital records over a one-month period of time (November 2022) was conducted focusing on hospital admissions that involved surgical operative procedures. Only those patients who had received a pre-operative surgical prophylactic antibiotic were included in the analysis. Results: Of the 92 surgeries that fulfilled the inclusion criteria, 38 (41.3%) were performed on patients who were already receiving therapeutic antibiotics for more than 24 hours targeted to treat the infection for which they were undergoing surgery. These included laparoscopic cholecystectomy (24), appendectomy (12), wound debridement (12), and soft tissue incision and drainage procedures (9), comprising nearly 50% of each type of these operations performed during the study time period. Conclusion: These findings demonstrate a clear opportunity to strengthen both our, and presumably other, hospitals antimicrobial stewardship programs. Together with physician education, granting the pharmacy the ability to cancel unnecessary and redundant surgical prophylactic antibiotics would conceivably be of great benefit.
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Affiliation(s)
- Priscila Fiallo
- Department of Medicine, Wellington Regional Medical Center, Wellington, FL, USA
| | - Timothy Williams
- Department of Medicine, Wellington Regional Medical Center, Wellington, FL, USA
| | - Larry M. Bush
- Department of Medicine, Wellington Regional Medical Center, Wellington, FL, USA
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
- University of Miami-Miller School of Medicine, Palm Beach County, FL, USA
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Dhole S, Mahakalkar C, Kshirsagar S, Bhargava A. Antibiotic Prophylaxis in Surgery: Current Insights and Future Directions for Surgical Site Infection Prevention. Cureus 2023; 15:e47858. [PMID: 38021553 PMCID: PMC10680052 DOI: 10.7759/cureus.47858] [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: 09/05/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023] Open
Abstract
Surgical site infections (SSIs) remain a significant concern in the field of surgery, contributing to patient morbidity, prolonged hospital stays, and increased healthcare costs. Antibiotic prophylaxis, the administration of antibiotics before surgery, has been a cornerstone in preventing SSIs for decades. This review explores the current state of antibiotic prophylaxis in surgery, offering insights into its effectiveness, challenges, and emerging trends. In this comprehensive analysis, we delve into the historical development of antibiotic prophylaxis, examining its evolution from early practices to modern guidelines. We explore the various classes of antibiotics commonly used, their dosing regimens, and the importance of timing in optimizing prophylactic interventions. Additionally, we investigate the role of patient-specific factors, such as comorbidities and allergies, in tailoring antibiotic prophylaxis to individual needs. While antibiotic prophylaxis has undeniably reduced the incidence of SSIs, concerns about antimicrobial resistance and adverse effects necessitate a reevaluation of current practices. This review presents a critical assessment of the challenges posed by the overuse and misuse of antibiotics in surgery and highlights the urgent need for judicious antibiotic stewardship. Moreover, the future of antibiotic prophylaxis holds promise with the emergence of innovative strategies such as antimicrobial coatings, probiotics, and immunomodulatory agents. We discuss these novel approaches and their potential to enhance SSI prevention while minimizing antibiotic-related risks. In conclusion, antibiotic prophylaxis in surgery has been instrumental in reducing SSIs, but its continued effectiveness requires a multifaceted approach. By addressing current challenges, promoting antibiotic stewardship, and embracing innovative strategies, we can advance the field of SSI prevention and improve patient outcomes in the years to come. This review provides valuable insights and direction for clinicians, researchers, and policymakers as they navigate the evolving landscape of surgical prophylaxis.
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Affiliation(s)
- Simran Dhole
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Chandrashekhar Mahakalkar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shivani Kshirsagar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Abhilasha Bhargava
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Shrestha I, Shrestha S, Vijayageetha M, Koju P, Shrestha S, Zachariah R, Khogali MA. Surgical Antibiotic Prophylaxis Administration Improved after introducing Dedicated Guidelines: A Before-and-After Study from Dhulikhel Hospital in Nepal (2019-2023). Trop Med Infect Dis 2023; 8:420. [PMID: 37624358 PMCID: PMC10615196 DOI: 10.3390/tropicalmed8080420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023] Open
Abstract
(1) Background: Surgical antibiotic prophylaxis (SAP) is important for reducing surgical site infections. The development of a dedicated hospital SAP guideline in the Dhulikhel Hospital was a recommendation from a baseline study on SAP compliance. Compliance with this new guideline was enhanced through the establishment of a hospital committee, the establishment of an antibiotic stewardship program and the funding and training of healthcare professionals. Using the baseline and a follow-up study after introducing dedicated hospital SAP guidelines, we compared: (a) overall compliance with the SAP guidelines and (b) the proportion of eligible and non-eligible patients who received initial and redosing of SAP; (2) Methods: A before-and-after cohort study was conducted to compare SAP compliance between a baseline study (July 2019-December 2019) and a follow-up study (January 2023-April 2023); (3) Results: A total of 874 patients were in the baseline study and 751 in the follow-up study. Overall SAP compliance increased from 75% (baseline) to 85% in the follow-up study (p < 0.001). Over 90% of those eligible for the initial dose of SAP received it in both studies. Inappropriate use for those not eligible for an initial dose was reduced from 50% to 38% (p = 0.04). For those eligible for redosing, this increased from 14% to 22% but was not statistically significant (p = 0.272); (4) Conclusions: Although there is room for improvement, introduction of dedicated SAP guidelines was associated with improved overall SAP compliance. This study highlights the role of operational research in triggering favorable interventions in hospital clinical care.
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Affiliation(s)
- Indira Shrestha
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel 45200, Nepal; (S.S.); (P.K.)
- Kathmandu University School of Medical Sciences, Dhulikhel 45200, Nepal
| | - Sulekha Shrestha
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel 45200, Nepal; (S.S.); (P.K.)
- Kathmandu University School of Medical Sciences, Dhulikhel 45200, Nepal
| | | | - Pramesh Koju
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel 45200, Nepal; (S.S.); (P.K.)
- Kathmandu University School of Medical Sciences, Dhulikhel 45200, Nepal
| | - Saugat Shrestha
- World Health Emergencies Programme, WHO Country Office, Kathmandu 44600, Nepal;
| | - Rony Zachariah
- UNICEF, UNDP, World Bank, WHO Special Programme for Research and Training in Tropical Diseases (TDR), CH-1211 Geneva, Switzerland;
| | - Mohammed Ahmed Khogali
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain P.O. Box 17666, United Arab Emirates;
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Carshon-Marsh R, Squire JS, Kamara KN, Sargsyan A, Delamou A, Camara BS, Manzi M, Guth JA, Khogali MA, Reid A, Kenneh S. Incidence of Surgical Site Infection and Use of Antibiotics among Patients Who Underwent Caesarean Section and Herniorrhaphy at a Regional Referral Hospital, Sierra Leone. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074048. [PMID: 35409731 PMCID: PMC8998544 DOI: 10.3390/ijerph19074048] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/21/2022] [Accepted: 03/25/2022] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Ronald Carshon-Marsh
- District Health Management Team, Ministry of Health and Sanitation (MOHS), Bo District, Bo City 00232, Sierra Leone
- Correspondence: ; Tel.: +232-79884881
| | - James Sylvester Squire
- National Disease Surveillance Programme, Directorate of Health Security and Emergencies, MOHS, Cockerill, Wilkinson Road, Freetown 00232, Sierra Leone; (J.S.S.); (K.N.K.)
| | - Kadijatu Nabbie Kamara
- National Disease Surveillance Programme, Directorate of Health Security and Emergencies, MOHS, Cockerill, Wilkinson Road, Freetown 00232, Sierra Leone; (J.S.S.); (K.N.K.)
| | | | - Alexandre Delamou
- Department of Public Health, Gamal University of Conakry, Conakry BP 1147, Guinea;
| | - Bienvenu Salim Camara
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Maferinyah National Center for Training and Research in Rural Health, Forécariah BP 2649, Guinea;
| | | | - Jamie Ann Guth
- Global Health Connections, Center Barnstead, Barnstead, NH 03225, USA;
| | - Mohamed Ahmed Khogali
- Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organisation, Avenue Appia 20, 1211 Geneva, Switzerland;
| | - Anthony Reid
- Operational Research Unit Luxembourg, Medecins Sans Frontieres/Doctors without Borders, 68 Rue Gasperich, L-1617 Luxembourg, Luxembourg;
| | - Sartie Kenneh
- Office of the Chief Medical Officer, Ministry of Health and Sanitation, 4th Floor, Youyi Building, Brookfields, Freetown 00232, Sierra Leone;
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