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

Abstract 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.

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

Systematic Reviews ◽

10.1186/s13643-021-01577-w ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Sarah Hassan ◽

Vincent Chan ◽

Julie Stevens ◽

Ieva Stupans

Keyword(s):

Systematic Review ◽

Guideline Adherence ◽

Treatment Guidelines ◽

Antimicrobial Prophylaxis ◽

Local Level ◽

Theoretical Domains Framework ◽

Control Measures ◽

Eligibility Criteria ◽

Barriers And Enablers ◽

Surgical Antimicrobial Prophylaxis

Abstract 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.

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Appropriateness and pharmacoeconomics of surgical antimicrobial prophylaxis in open reduction internal fixation surgery practiced in a tertiary hospital compared to recommendations in the national center for disease control guidelines

Perspectives in Clinical Research ◽

10.4103/picr.picr_53_18 ◽

2019 ◽

Vol 10 (4) ◽

pp. 172 ◽

Cited By ~ 1

Author(s):

Vasundara Krishnaiah ◽

Priyanka Kumari ◽

JayaramB Siddegowda

Keyword(s):

Internal Fixation ◽

Disease Control ◽

Open Reduction ◽

Antimicrobial Prophylaxis ◽

Tertiary Hospital ◽

Open Reduction Internal Fixation ◽

Surgical Antimicrobial Prophylaxis

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An interdisciplinary approach to improve surgical antimicrobial prophylaxis

International Journal of Health Care Quality Assurance ◽

10.1108/ijhcqa-05-2017-0078 ◽

2018 ◽

Vol 31 (2) ◽

pp. 162-172 ◽

Cited By ~ 1

Author(s):

Oisín Conaty ◽

Leah Gaughan ◽

Colum Downey ◽

Noreen Carolan ◽

Megan Joanne Brophy ◽

...

Keyword(s):

Data Collection ◽

Antimicrobial Prophylaxis ◽

Interdisciplinary Approach ◽

Open Reduction Internal Fixation ◽

Unintended Consequences ◽

Content Type ◽

Dose Time ◽

Orthopaedic Patients ◽

Surgical Antimicrobial Prophylaxis ◽

Additional Education

Purpose The purpose of this paper is to improve surgical antimicrobial prophylaxis (SAP) prescribing in orthopaedic surgery using the model for improvement framework. Design/methodology/approach Orthopaedic patients receiving joint replacements, hip fracture repairs or open-reduction internal-fixation procedures were included. Antimicrobial(s); dose, time of administration and duration of SAP were evaluated for appropriateness based on the local SAP guidelines. After baseline data collection, a driver diagram was constructed with interventions devised for plan-do-study-act cycles. Data were fed back weekly using a point prevalence design (PPD). Interventions included SAP guideline changes, reminders and tools to support key messages. Findings SAP in 168 orthopaedic surgeries from 15 June 2016 to 31 January 2017 was studied. Prescribing appropriateness improved from 20 to 78 per cent. Junior doctor changeover necessitated additional education and reminders. Practical implications Due to constant staff changeover; continuous data collection, communication, education and reminders are essential to ensure continuous compliance with clinical guidance. Patients with hip fractures are difficult to weigh, requiring weight estimation for weight-based antimicrobial dosing. Unintended consequences of interventions included the necessity to change pre-operative workflow to accommodate reconstitution time of additional antimicrobials and inadvertent continuation of new antimicrobials post-operatively. Originality/value Rather than perform the traditional retrospective focused audit, we established a prospective, continuous, interventional quality improvement (QI) project focusing on internal processes within the control of the project team with rapid cyclical changes and interventions. The weekly PPD was pragmatic and enabled the QI project to be sustained with no additional resources.

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Faculty Opinions recommendation of The effectiveness of single-dose fosfomycin as antimicrobial prophylaxis for patients undergoing transrectal ultrasound-guided biopsy of the prostate.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.717967486.793467146 ◽

2012 ◽

Author(s):

John Smith

Keyword(s):

Single Dose ◽

Antimicrobial Prophylaxis ◽

Transrectal Ultrasound ◽

Ultrasound Guided ◽

Guided Biopsy ◽

Ultrasound Guided Biopsy

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Intraoperative Bacterial Contamination and Activity of Different Antimicrobial Prophylaxis Regimens in Primary Knee and Hip Replacement

Antibiotics ◽

10.3390/antibiotics10010018 ◽

2020 ◽

Vol 10 (1) ◽

pp. 18

Author(s):

Alba Rivera ◽

Alba Sánchez ◽

Sonia Luque ◽

Isabel Mur ◽

Lluís Puig ◽

...

Keyword(s):

Hip Replacement ◽

Bacterial Contamination ◽

Antimicrobial Prophylaxis ◽

Coagulase Negative Staphylococci ◽

Joint Infections ◽

Prosthetic Joint ◽

Prosthetic Joint Infections ◽

Total Knee ◽

Surgical Antimicrobial Prophylaxis ◽

Almost All

Surgical antimicrobial prophylaxis (SAP) is important for the prevention of prosthetic joint infections (PJIs) and must be effective against the microorganisms most likely to contaminate the surgical site. Our aim was to compare different SAP regimens (cefazolin, cefuroxime, or vancomycin, alone or combined with gentamicin) in patients undergoing total knee (TKA) and hip (THA) arthroplasty. In this preclinical exploratory analysis, we analyzed the results of intraoperative sample cultures, the ratio of plasma antibiotic levels to the minimum inhibitory concentrations (MICs) for bacteria isolated at the surgical wound and ATCC strains, and serum bactericidal titers (SBT) against the same microorganisms. A total of 132 surgical procedures (68 TKA, 64 THA) in 128 patients were included. Cultures were positive in 57 (43.2%) procedures (mostly for coagulase-negative staphylococci and Cutibacterium spp.); the rate was lower in the group of patients receiving combination SAP (adjusted OR 0.475, CI95% 0.229–0.987). The SAP regimens evaluated achieved plasma levels above the MICs in almost all of intraoperative isolates (93/94, 98.9%) and showed bactericidal activity against all of them (SBT range 1:8–1:1024), although SBTs were higher in patients receiving cefazolin and gentamicin-containing regimens. The potential clinical relevance of these findings in the prevention of PJIs remains to be determined.

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