An audit of perioperative antibiotic prescriptions in patients undergoing clean surgeries and compliance with antibiotic policy in a tertiary hospital

Sharmili Sinha; Sandeep Biswal

doi:10.4103/jpsic.jpsic_33_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 10 | Issue : 2 | Page : 38-42

An audit of perioperative antibiotic prescriptions in patients undergoing clean surgeries and compliance with antibiotic policy in a tertiary hospital

Sharmili Sinha¹, Sandeep Biswal²
¹ Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar, India
² Department of Orthopedics, Apollo Hospitals, Bhubaneswar, India

Date of Submission	28-Sep-2022
Date of Acceptance	16-Jan-2023
Date of Web Publication	01-Mar-2023

Correspondence Address:
Dr. Sharmili Sinha
Apollo Hospitals, Bhubaneswar, Odisha
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jpsic.jpsic_33_22

Abstract

Introduction: There has been a rise in the use of broad spectrum antibiotics in patients undergoing surgeries in perioperative period including clean surgeries. The use of such antimicrobials is also found to be longer than recommended and is responsible for emregence of multi drug resistant infections. These add to antibiotic related complications and cost as well.
Aim: To study the type of antibiotic prescription in patients undergoing clean surgeries and assess compliance with antibiotic policy and frame recommendations for improvements if any.
Method: Fifty five patients were prospectively evaluated for perioperative antibiotics prescriptions and followed up till discharge/1 month for any nosocomial infections or other complications. The kind and duration of antibiotics were noted and assessed for extent of compliance to antibiotic policy.
Results and Discussions: Compliance to perioperative surgical prophylaxis in time was good (91%) as per the protocol and all patients received prophylaxis. Broad spectrum antibiotics were used in almost 50% cases and duration was prolonged compared to the prescribed protocol. Prescription of oral antibiotics was continued in 72.7% % cases( 40/55 ). There was no increased incidence of health care associated infections(HAI) in these patients.
Conclusion: Compliance to Surgical antibiotic prophylaxis practices in clean surgeries is good in the hospital Broad spectrum antibiotics were in use in more than half cases and oral antibiotics were prescribed at discharge in most patients which is not in accordance with the protocol. The incidences of HAIs in these cases were not increased. Regular audit and continued training of all stake holders is necessary to raise awareness and improve practices for antimicrobial stewardship.

Keywords: Antibiotic policy, antibiotic prescription, clean surgeries, compliance, perioperative antibiotics

How to cite this article:
Sinha S, Biswal S. An audit of perioperative antibiotic prescriptions in patients undergoing clean surgeries and compliance with antibiotic policy in a tertiary hospital. J Patient Saf Infect Control 2022;10:38-42

How to cite this URL:
Sinha S, Biswal S. An audit of perioperative antibiotic prescriptions in patients undergoing clean surgeries and compliance with antibiotic policy in a tertiary hospital. J Patient Saf Infect Control [serial online] 2022 [cited 2023 Mar 30];10:38-42. Available from: https://www.jpsiconline.com/text.asp?2022/10/2/38/370886

Introduction

Increased usage of antibiotics and the emergence of resistant infections have become a global concern. Furthermore, broad-spectrum antibiotics are more often being prescribed for clean surgeries and for a prolonged period as opposed to the proposed guidelines for such cases. Nosocomial infections are often associated with multidrug resistance and add to the cost.

According to the Clinical and Laboratory Standards Institute (CLSI) recommendations, for clean surgeries, antibiotics are to be given 2 h before surgery and maximum 48 h post-operatively. There is a hospital Infection Control Manual in our institution which has a protocol for the administration of prophylactic antibiotic in surgical cases. In practice, wide variation is seen often.

In the National Health Service (UK), health care associated infections (HAIs) are one of the major concerns affecting one in ten patients admitted to the hospital.^[1] Surgical antibacterial prophylaxis (SAP) refers to the administration of a pre-operative (occasionally intra-operative) to reduce the risk of developing an surgical site infection (SSI) by inhibiting the growth of contaminating bacteria.^[2],[3],[4]

SSI is defined as an infection that occurs at or near a surgical incision within 30 days of the procedure or within 1 year if an implant is left in place.

The risk factors include the number and virulence of contaminating microorganisms, operative and environmental factors, kind of surgery, patient factors, comorbidities and local factors. In general, clean procedures do not require SAP unless a prosthetic implant is involved. However, the evidence of post-operative infections from other clean procedures is under-reported, and antibacterial prophylaxis is advisable for some procedures. SAP is required for the most clean contaminated procedures. In our hospital, which is a tertiary care multi-speciality hospital with around 300 beds, around 1800-2000 surgeries are performed per year. We intended to study the perioperative antibiotic practices in clean surgeries in our hospital.

Aim

To study the type and duration of antibiotics in clean surgery cases
To analyse the antibiotic prescription practices in cases of clean surgeries in our hospital and extent of compliance with the hospital antibiotic protocol
To suggest managerial action for better compliance as per the CLSI recommendation.

Methods

The study was conducted in a tertiary hospital and included patients who are to undergo clean surgeries. The study design was an evaluative prospective study. It involved the analysis of records and was observational only.

A "clean case" is defined as an uninfected operative wound in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary and genitourinary tracts are not entered.

Data collection tools

Case records and the data collection sheet were filled, and case records were followed till discharge and up to 1 month for such cases. For orthopaedic cases involving implants, cases were followed up to 1-year period.

The study period

Fifty-five cases were included in the study for analysis between 1^st January 2020 and 28^th February 2020. The antibiotic prescription was as per the instruction of the surgeon and later compared with the antibiotic protocol of the hospital.

Ethical committee waived consent as it is a routine practice in the hospital, and the study is observational only with no active intervention. Data collection sheet is attached below. The type of surgeries performed, and antibiotics used were recorded. The administration time of antibiotics, duration of surgeries and duration of post-operative antibiotic usage were monitored by a dedicated team of nurses and doctors. The cases were followed up till discharge and then for 1 month after discharge for any soft-tissue infections (SSIs). In orthopaedic cases with implants in place, follow-up was up to 1-year period.

Results

Fifty-five cases of clean and clean-contaminated cases were taken up. The kind of surgeries included laparoscopic cholecystectomy, craniotomy cranioplasty, orthopaedic surgeries-closed fractures and cardiothoracic surgeries (valve repair and valvuloplasty). There were 34 males and 21 females. Average age for males was 42.26 years and 38.33 years for females.

Antibiotic administration time was a minimum 5 min to a maximum of 2 h 10 min. In two cases only (3.63%), antibiotic administration was delayed beyond 1 h. The post-operative duration of antibiotics was 5 days to 10 days maximum. Average days of antibiotic administration were 6 days. Soft-tissue infection was found in 3 out of 55 (5.45%) cases.

Antibiotic prophylaxis was used in all 55 cases. In 91% of cases, antibiotics were administered within 1 h of the commencement of surgery before incision. This is in accordance with the hospital antibiotic protocol. [Table 1] and [Figure 1] depict the number and kind of surgeries. Amongst the case studies, the highest number belonged to orthopaedics (18), followed by cardiothoracic (15) and laparoscopy (10) cases. The rest were from other specialities such as obstetrics and gynaecology, neurosurgery and plastic surgery.

Figure 1: Types of surgery

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Table 1: Type of surgery

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[Table 2] and [Figure 2] describe the kind of antibiotics used. Ceftriaxone was the most common molecule used for SAP, followed by broad-spectrum antibiotics such as a combination of piperacillin plus tazobactam and cefoperazone plus sulbactam and cefoperazone plus tazobactam. Cefotaxim and Metronidazole were used only in one case each. Broad-spectrum antibiotics were used in 28 (51%) cases of clean cases. As per the hospital antibiotic protocol, second-generation or third-generation cephalosporins are recommended for pre-operative antibiotic prophylaxis. All cases were discharged successfully. Only three cases reported soft-tissue infection (5.45%). The SSI rate is less than the reported incidences of SSI elsewhere (9%–13%). There was no obvious case of antibiotic-induced diarrhoea or other nosocomial infection in these 55 cases of clean surgeries during the hospital stay.

Figure 2: Types of antibiotics used

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Table 2: Types of antibiotics used

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Discussion

The duration of intravenous (IV) antibiotics in the post-operative period was not in accordance with the recommendations. The post-operative antibiotic cover lasted for average 5 days, with a minimum of 3 days to a maximum of 10 days during the hospital stay. Oral antibiotics for 5–7 days were prescribed in 40 out of 55 patients who were discharged.

Cha et al.^[5] conducted a study in Korea where a total of 360 consecutive patients who underwent clean wound surgery under local anaesthesia in an outpatient clinic. In the study group, a single surgeon administered first-generation cephalosporins intravenously within 1 h of skin incision and did not prescribe additional antibiotics. In the control group, two other surgeons prescribed oral first-generation cephalosporins postoperatively for 2–3 days without pre-operative antibiotics. They found that IV injection of single-dose first-generation cephalosporins 1 h before surgery without post-operative antibiotics did not increase the incidence of SSIs compared with the usual practice of giving only post-operative antibiotics prescription for 2–3 days in cases of clean wound surgery performed under local anaesthesia. In our study, antibiotics were commenced in pre-operative period, and the duration of post-operative antibiotic cover was longer.

Basant et al.^[6] carried out a prospective study over a period of 1 year involving 102 patients between the age group of 20–70 years. All patients in the study group were given single dose inj Cefotaxime 1gm ,30 min before skin incision. All the cases in the control group received injection of cefotaxime 1 g (150 mg/kg) IV BD for 5 days. It was concluded that single-dose antibiotic prophylaxis is sufficient for clean and clean-contaminated surgeries because there was no difference found in SSI either using single-dose pre-operative antibiotic prophylaxis or using 5-day conventional post-operative antibiotic therapy with the added advantage of a significant reduction in hospital stay and savings in resources. The incidence of SSI in our study was significantly less than reported otherwise.

Prophylactic antibiotics should be discontinued within 24 h of surgery completion (48 h for cardiothoracic surgery). Current guidelines recommend that prophylactic antibiotics end within 24 h of surgery completion. There is no documented benefit of antibiotics after wound closure in the reduction of SSIs. The society of Thoracic Surgeons recommend that antibiotic prophylaxis be continued for 48 h after the completion of cardiothoracic surgery due to the effects of cardiopulmonary bypass on immune function and antibiotic pharmacokinetics.^[7],[8],[9] There is no evidence to support using prophylactic antibiotics for longer than 48 h. Antibiotics given for the implantation of a pacemaker or defibrillator should be discontinued within 24 h of surgery.^[10] We had 15 patients who underwent cardiothoracic surgery and received antibiotics for more than 48 h after surgery.

Surveys of academic orthopaedic surgeons in the United States^[11] and cardiac surgeons in the United Kingdom^[12] show that 45% and 28%, respectively, continue antibiotics, while drainage tubes are in place. However, there is no evidence to support antibiotic administration until drains are removed.^[11] The practice is not recommended by the American Academy of Orthopaedic Surgeons,^[13] Society of Thoracic Surgeons.^[7] We had 18 patients who underwent orthopaedic surgery and received post-operative antibiotics beyond 48 h with oral antibiotics on discharge. No cases of organ transplantation surgery were included in this series.

Hence, there was 91% compliance with pre-operative antibiotic administration in clean surgeries. Higher antibiotics were used in 51% of cases compared to the hospital antibiotic protocol.

There was prolonged antibiotic usage in post-operative period. This is contrary to the recommended duration of 48 h. The incidence of SSI was 5.45% which is less than the reported incidence of SSI worldwide. Furthermore, it was observed that oral antibiotics prescription was followed for all post-operative cases of clean surgeries. There is a good evidence to suggest that antibiotics do not provide any advantage. We believe that proactive steps taken will help improve the practices. Currently, in our organisation, perioperative antibiotic protocol is in place and has been circulated to all clinical departments. However, antibiotics prescription is widely diverse and customised to the patient and as per the surgeon's choice. The Hospital Infection Control Committee (HICC) meeting is held every month regarding hospital-acquired infections (HAIs). We believe that feedback should be delivered to the surgical team regarding any deviation from prophylactic antibiotic practices and elicit discussion to understand the rationale for their individualised approach. Administrative involvement and strict implementation of antibiotic stewardship programme are required to streamline perioperative antibiotic usage. An integrated approach involving medical and managerial personnel is suggested as follows:

Review of the antibiotic protocol of the organisation by HICC team
Perioperative checklist – to be monitored by operation theatre nurse and infection control nurse
Antibiotic s given – to be audited by pharmacologist and pharmacy team
Periodic audit of clean and clean-contaminated surgeries by the hospital infection control team
Any antibiotic-related complications such as allergy and antibiotic-associated diarrhoea
HICC meetings – days of antibiotics, HAI, multidrug-resistant organisms
Appraisal of the surgeons on the protocols and outcomes
Feedback given to surgeon/primary care physician
Questionnaire-based survey involving surgeons and primary physicians on ideas of perioperative antibiotic cover
Continued Medical Education (CME )on perioperative antibiotic protocol
Audit on compliance and presentation in HICC
Analyse the cost difference due to the excess use of antibiotics.

Conclusion

The compliance with surgical antimicrobial prophylaxis is good in clean surgeries in the Institute. It was noted that broad-spectrum antibiotics were used in almost 50% of cases. The duration of post-operative usage of intravenous antibacterial agents was prolonged compared to the recommendations of the hospital antibiotic protocol. The incidence of SSIs was less than reported otherwise in the literature. There were no incidences of any other HAIs such as antibiotic-associated diarrhoea or nosocomial pneumonia related to antibiotic overuse till the period of discharge from the hospital in these cases. There was a continued prescription of oral antibiotics after discharge from the hospital for clean surgeries. Regular audit of pre-operative antibiotic prescription, administration and follow-up into post-surgical period is necessary to bridge the gap between hospital antibiotic protocol and practice in clean surgeries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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