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.

Antimicrobial stewardship measures in cardiac surgery and its impact on surgical site infections

Objective The goal of this study was to monitor the compliance and impact on a protocol change of surgical antimicrobial prophylaxis in cardiac surgery favouring cefazolin instead cefuroxime, initiated by the hospital’s antimicrobial stewardship team. Methods This quality improvement study was performed in a tertiary care hospital in collaboration with the department of cardiothoracic surgery and the hospitals antimicrobial stewardship team following a revision of the standard for surgical antimicrobial prophylaxis including 1029 patients who underwent cardiac surgery. 582 patients receiving cefuroxime and 447 patients receiving cefazolin respectively were compared without altering any other preventative perioperative measures including its postoperative duration of less than 24 h. Adherence and surgical site infections were compiled and analysed. Results A complete adherence was achieved. Overall surgical site infections occurred in 37 (3.6%) of the cases, 20 (3.4%) in cefuroxime patients and 17 (3.8%) in cefazolin patients (p value = 0.754). No statistically significant differences could be found in any of the primary endpoints, but there was a trend towards less deep sternal wound infections in the cefazolin group. Conclusions The study supports the role of antimicrobial stewardship in cardiac surgery and mirrors the success of a multidisciplinary team aiming to minimize adverse events by optimizing antibiotic use.

1080 An Audit on Compliance with Recommended Duration of Surgical Antimicrobial Prophylaxis in St. Vincent’s University Hospital, Dublin, Ireland

Aim Surgical site infection (SSI) is a common healthcare-associated infection, and a frequent cause of post-operative morbidity. SSI comprises any infection of the operative incision, cavity or involved organ, that occurs within the 30-day post-operative period. Antimicrobial prophylaxis is critical in reducing SSIs. Our aim was to assess adherence to the recommended surgical antimicrobial prophylaxis guidelines in St. Vincent’s University Hospital (SVUH), as part of the hospital antimicrobial stewardship programme. Compliance of surgical services was measured against the recommended regimens described in the SVUH Antimicrobial Guidelines. Method Data on duration and choice of prophylaxis were prospectively gathered on inpatients undergoing elective surgery during a three-week period between August-September 2020. Patients undergoing transplant procedures, inpatients in the intensive care unit, and patients who moved off-site postoperatively were excluded. Results Eighty-one patients were included. Sixty-four (79%) were compliant with prophylaxis duration, while seventeen (21%) were not. Reasons for extended prophylaxis included three (18%) cases where there were intra-operative complications and five (29%) cases of routine prescribing of an additional 24-hour coverage. Nine (53%) did not document the reason for extended cover. Conclusions Compliance with recommended duration of prophylaxis improved in comparison to prior audits. Among patients receiving extended prophylaxis, documentation of the indication was poor. Patients with evidence of post-operative infection may be better served with targeted antimicrobial therapy rather than extended prophylaxis. One reason for extended prophylaxis may be due to difficulty accessing guidelines on recommended prophylaxis duration, hence a targeted smartphone application was introduced to improve accessibility.

Surgical Antimicrobial Prophylaxis—Where Do We Stand?

Introduction Surgical site infection (SSI) is the commonest preventable health care–associated infection among postoperative cases. Several guidelines are available for surgical antimicrobial prophylaxis (SAP) and other measures which prevent SSI. National Center for Disease Control (NCDC), India, has also provided a guideline for prevention of SSI in 2016. In this study we have compared the NCDC, India, guideline with WHO (World health organization) and American Society of Health System Pharmacists (ASHP) guidelines. The timing of antimicrobial agent administration is the only parameter which is included in all the three guidelines. As per NCDC and ASHP it should be within 60 minutes of incision while as per WHO it is within 120 minutes of incision. Material and Methods This was a prospective observational study—104 patients undergoing surgery in general surgical ward between January 2016 and June 2017 were included in this study. The NCDC guideline was compared with WHO and ASHP guidelines. Real data comparison was done for those parameters which were included in all the three guidelines. Statistical Analysis Data were analyzed using descriptive methods and chi-square test. Results None of the patients in our study received SAP within 60 minutes of incision. In 70% cases it was administered within 2 hours of incision and in the remaining 30% it was administered after more than 2 hours. There was no significant difference in the incidence of SSI among these two groups. Conclusion NCDC SAP guideline helps in rational use of antimicrobials. Increasing the duration for SAP may be added in the NCDC guidelines. Inclusion of certain additional parameters like weight-based doses and consideration for other comorbidities will help in patient- and procedure-specific SAP. Antimicrobial stewardship should be encouraged in all the hospitals and should follow local antimicrobial resistance pattern. This will assist in therapy decision, policy making, and evidence-based treatment.

Review of the Appropriateness of Surgical Antimicrobial Prophylaxis

Aim: This review aims to describe the appropriateness of surgical antimicrobial prophylaxis during the last decade. Methodology: The review included a searching web of science for articles focused on “the appropriateness of surgical antimicrobial prophylaxis”. The searching process was conducted on 29 Nov 2020 and included original articles so the review articles were excluded. Results: The review included 57 articles; 38 articles were published after 2015 and the rest before 2015. Most of the articles that were included in the review showed a high rate of inappropriate surgical prophylaxis and showed inappropriate duration and time of the antibiotics used. Conclusion: It can be concluded that the rate of surgical prophylaxis inappropriateness was high and the main cause for this result was inappropriate timing and duration. Numerous interventions including educational interventions such as one-time seminars and online e-learning modules are needed to improve the adherence to the guidelines.

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.

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

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.

Impact of a Critical National Shortage of Cefazolin on Antimicrobial Practice at a Tertiary-Care Center in Japan

Background: Shortages of essential medicines, a long-standing issue in healthcare, apply equally to antimicrobial agents, a group of essential drugs necessary for sustainable healthcare. The WHO categorized essential medicines into the access, watch, and reserve groups. Older antimicrobials, in particular, were categorized into the access group, meaning that these drugs are in theory widely available at an affordable cost. The shortage of essential antimicrobial agents like cefazolin leads to increased consumption of alternative antimicrobial agents with broad-spectrum activity, which often has the undesirable consequence of defeating antimicrobial stewardship efforts in inpatient settings and potentially promoting antimicrobial resistance. In Japan, cefazolin has been in critically short supply since March 2019. Cefazolin is a first-line agent against common infectious diseases and in surgical antimicrobial prophylaxis, and its shortage has substantially impacted inpatient care. The aim of the present study was to investigate changes in antimicrobial practice at a tertiary-care center in Japan following the emergence of the national cefazolin shortage in March 2019. Methods: Data on each antimicrobial use are logged as days of therapy (DOT) per 1,000 patient days (PD) for antimicrobial stewardship purposes at the study institution. We extracted weekly data from September 2018 to September 2019 to evaluate the impact of the national cefazolin shortage on antimicrobial use at our tertiary-care center. Changes in weekly antimicrobial use and the weekly incidence of Clostridium difficile infections were analyzed by interrupted time series analysis. We also investigated changes in antimicrobial practice at selected situations. Results: As weekly cefazolin use significantly declined after the emergence of the national shortage, use of third-generation cephalosporin (+18.9 DOT per 1,000 PD for intercept [P < .001] and +0.65 DOT per 1,000 PD per week for trend [P = .037]) and clindamycin (18 DOT per 1,000 PD for intercept [P = .008] and 0.12 DOT per 1,000 PD per week for trend [P = .003]) significantly increased. Significant changes in antimicrobial practice were also observed in surgical antimicrobial prophylaxis: third-generation cephalosporin use increased from 1.0% (31 of 3,032) to 62.9% (2,237 of 3,554) (P < .001). However, no significant change in the incidence of Clostridium difficile infection was observed during the study period: +1.72 per 10,000 PD for intercept (P = .12) and 0.12 per 10,000 PD per week for the trend (P = .09). Conclusions: The national cefazolin shortage had a significantly negative impact on patient care and led to increased use of alternative, broader-spectrum antimicrobials, which are not ideal choices either for prophylaxis or treatment.Funding: NoneDisclosures: None