Document Type : Original Article
Authors
1 Department of Clinical Pharmacy, Pharmaceutical Sciences Research Center, Mazandaran University of Medical Sciences, Sari, Iran
2 Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
Abstract
Objective: Surgical site infections are the second most common type of adverse events
occurring in hospitalized patients, whereas an estimated 40-60% of these infections are thought
to be preventable. Choice of regimen, administration timing or duration of antibiotic prophylaxis
is reported to be inappropriate in approximately 25-50% of cases. We tried to evaluate an
antibiotic administration pattern for surgical antibiotic prophylaxis in a teaching hospital.
Methods: This study was conducted at the general surgery and orthopedic wards
of a teaching hospital affiliated with Mazandaran University of Medical Sciences. The
medical records of admitted patients who underwent different surgical procedures were
reviewed. Compliance was assessed with the recommendations of the American Society
of Health‑System Pharmacists’ guidelines for every aspect of antibiotic prophylaxis. All data
were coded and analyzed by SPSS16 software using Student’s t‑test and Chi‑square test.
Findings: During 1 year, 759 patients who underwent different surgeries were included in
the study. Mean age of patients was 32.02 ± 18.79 years. Hand and foot fractures repair were
the most frequent surgery types. About 56.4% of administered prophylactic antibiotics were
in accordance with the American Society of Health System Pharmacists (ASHP) guidelines
regarding prophylaxis indication. The most commonly antibiotic used was cefazolin and
antibiotic choices were appropriate in 104 of 168 surgical procedures (62%). Gentamicin,
metronidazole and ceftriaxone were the most frequently antibiotics that used inappropriately.
Only in 100 of 168 procedures, duration was concordant with the ASHP guideline, whereas
in 68 procedures, duration was longer than recommended time. In 98 procedures, the dose
was lower and in one procedure, it was higher than recommended doses.
Conclusion: Although such guidelines have been in place for many years, studies showed
that much inappropriate antibiotic use as prophylaxis and poor adherence to guidelines
are still major issues. It is essential for surgeons to be aware to consider the best antibiotic
choices, dose and duration based on reliable guidelines for antibiotic prophylaxis.
Keywords
- Dellinger EP. Surgical infections and choice of antibiotics.
Sabiston Textbook of Surgery. 16th ed. Philadelphia,
Pennsylvania: Saunders; 2002.171‑2.
2. Griffin FA. Best‑practice protocols: Preventing surgical site
infection. Nurs Manage 2005;36:20, 22‑6.
3. Delgado‑Rodríguez M, Sillero‑Arenas M, Medina‑Cuadros M,
Martínez‑Gallego G. Nosocomial infections in surgical
patients: Comparison of two measures of intrinsic patient
risk. Infect Control Hosp Epidemiol 1997;18:19‑23.
4. Horan TC, Culver DH, Gaynes RP, Jarvis WR, Edwards JR,
Reid CR. Nosocomial infections in surgical patients in the
United States, January 1986‑June 1992. National Nosocomial
Infections Surveillance (NNIS) System. Infect Control Hosp
Epidemiol 1993;14:73‑80.
5. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG.
CDC definitions of nosocomial surgical site infections, 1992: A
modification of CDC definitions of surgical wound infections.
Infect Control Hosp Epidemiol 1992;13:606‑8.
6. Horan TC, Emori TG. Definitions of key terms used in the
NNIS System. Am J Infect Control 1997;25:112‑6.
7. Wallace WC, Cinat M, Gornick WB, Lekawa ME, Wilson SE.
Nosocomial infections in the surgical intensive care unit: A
difference between trauma and surgical patients. Am Surg
1999;65:987‑90.
8. Scheel O, Stormark M. National prevalence survey on hospital
infections in Norway. J Hosp Infect 1999;41:331‑5.
9. SCIP Target Areas. Available from: http://www.medqic.org/
scip. [Last cited on 2006 Feb 13].
10. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ.
The impact of surgical‑site infections in the 1990s: Attributable
mortality, excess length of hospitalization, and extra costs.
Infect Control Hosp Epidemiol 1999;20:725‑30. - 11. Dimick JB, Weeks WB, Karia RJ, Das S, Campbell DA Jr. Who
pays for poor surgical quality? Building a business case for
quality improvement. J Am Coll Surg 2006;202:933‑7.
12. Burke JP. Infection control‑A problem for patient safety. N Engl
J Med 2003;348:651‑6.
13. Centers for Medicare and Medicaid Services. QualityNet.
Available from: http://www.qualitynet.org. [Last accessed on
2009 Jun 03].
14. Bratzler DW, Houck PM, Richards C, Steele L, Dellinger EP,
Fry DE, et al. Use of antimicrobial prophylaxis for major
surgery: Baseline results from the National Surgical Infection
Prevention Project. Arch Surg 2005;140:174‑82.
15. Silver A, Eichorn A, Kral J, Pickett G, Barie P, Pryor V, et al.
Timeliness and use of antibiotic prophylaxis in selected
inpatient surgical procedures. The Antibiotic Prophylaxis
Study Group. Am J Surg 1996;171:548‑52.
16. Larsen RA, Evans RS, Burke JP, Pestotnik SL, Gardner RM,
ClassenDC. Improved perioperative antibiotic use and reduced
surgical wound infections through use of computer decision
analysis. Infect Control Hosp Epidemiol 1989;10:316‑20.
17. Finkelstein R, Reinhertz G, Embom A. Surveillance of
the use of antibiotic prophylaxis in surgery. Isr J Med Sci
1996;32:1093‑7.
18. Matuschka PR, Cheadle WG, Burke JD, Garrison RN. A new
standard of care: Administration of preoperative antibiotics
in the operating room. Am Surg 1997;63:500‑3.
19. Gorecki P, Schein M, Rucinski JC, Wise L. Antibiotic
administration in patients undergoing common surgical
procedures in a community teaching hospital: The chaos
continues. World J Surg 1999;23:429‑32.
20. Zoutman D, Chau L, Watterson J, Mackenzie T, Djurfeldt M.
A Canadian survey of prophylactic antibiotic use among
hip‑fracture patients. Infect Control Hosp Epidemiol
1999;20:752‑5.
21. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG,
Bolon MK, et al. Clinical practice guidelines for antimicrobial
prophylaxis in surgery. Am J Health Syst Pharm 2013;70:195‑283.
22. Askarian M, Moravveji AR, Mirkhani H, Namazi S, Weed H.
Adherence to American Society of Health‑System Pharmacists
surgical antibiotic prophylaxis guidelines in Iran. Infect
Control Hosp Epidemiol 2006;27:876‑8.
23. Talon D, Mourey F, Touratier S, Marie O, Arlet G, Decazes JM,
et al. Evaluation of current practices in surgical antimicrobial
prophylaxis before and after implementation of local
guidelines. J Hosp Infect 2001;49:193‑8.
24. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR.
Guideline for prevention of surgical site infection, 1999.
Hospital Infection Control Practices Advisory Committee.
Infect Control Hosp Epidemiol 1999;20:250‑78.
25. Abdel‑AzizA, El‑MenyarA, Al‑Thani H, ZarourA, ParchaniA,
Asim M, et al. Adherence of surgeons to antimicrobial
prophylaxis guidelines in a tertiary general hospital in a rapidly
developing country. Adv Pharmacol Sci 2013;2013:842593.
26. Hammad MA, AL‑Akhali KM, Mohammed AT. Evaluation
of surgical antibiotic prophylaxis in aseer area hospitals in
kingdom of Saudi Arabia. J Phys Clin Sci 2013;6:1‑7.
27. Pons‑Busom M, Aguas‑Compaired M, Delás J,
Eguileor‑Partearroyo B. Compliance with local guidelines
for antibiotic prophylaxis in surgery. Infect Control Hosp
Epidemiol 2004;25:308‑12.
28. Zhang Y, Harvey K. Rational antibiotic use in China: Lessons
learnt through introducing surgeons to Australian guidelines.
Aust New Zealand Health Policy 2006;3:5.
29. Hosoglu S, Sunbul M, Erol S, Altindis M, Caylan R,
Demirdag K, et al. A national survey of surgical antibiotic
prophylaxis in Turkey. Infect Control Hosp Epidemiol
2003;24:758‑61.
30. Hosoglu S, Aslan S, Akalin S, Bosnak V. Audit of quality of
perioperative antimicrobial prophylaxis. Pharm World Sci
2009;31:14‑7.
31. Takahashi Y, Takesue Y, Nakajima K, Ichiki K, Wada Y,
Tsuchida T, et al. Implementation of a hospital‑wide project
for appropriate antimicrobial prophylaxis. J Infect Chemother
2010;16:418‑23.
32. Gomez MI, Acosta‑Gnass SI, Mosqueda‑Barboza L,
Basualdo JA. Reduction in surgical antibiotic prophylaxis
expenditure and the rate of surgical site infection by means of
a protocol that controls the use of prophylaxis. Infect Control
Hosp Epidemiol 2006;27:1358‑65.
33. Andrajati R, Vlcek J, Kolar M, Pípalová R. Survey of surgical
antimicrobial prophylaxis in Czech republic. Pharm World
Sci 2005;27:436‑41.
34. BaillyP, LallemandS, ThouverezM, TalonD. Multicentre study
on the appropriateness of surgical antibiotic prophylaxis.
J Hosp Infect 2001;49:135‑8.
35. Imai‑Kamata S, Fushimi K. Factors associated with adherence
to prophylactic antibiotic therapy for elective general surgeries
in Japan. Int J Qual Health Care 2011;23:167‑72
)