Antibiotic prophylaxis in cesarean section and other surgical procedures: a Korean national assessment system

Abstract

Prophylactic antibiotic management is a major issue in surgical patients, as the postoperative risk of infection is very high, especially in vulnerable populations. Westen et al. reported that a single dose of prophylactic ampicillin and metronidazole is as effective as a multiple-day regimen of these antibiotics, which would allow a significant dose reduction while decreasing healthcare costs 1. Between 2005 and 2006, the Korean Ministry of Health and Welfare began assessment of antibiotic prescriptions for surgical patients. In 2007 it extended the assessment program to include antibiotic prophylaxis in patients undergoing hysterectomy and cesarean section 2. Since then, prophylactic antibiotic monitoring has been extended annually and now includes gastric, heart, knee, thyroid, and breast operations, as well as neurosurgery, and more. As of 2014, 15 types of surgery were covered by the assessment program 2. Among the 12 parameters evaluated in the program are prophylactic antibiotics administration one hour before the first indication, dose of antibiotics, rates of aminoglycoside administration, rates of third-generation cephalosporin administration, rates of co-administered prophylactic antibiotics, antibiotic prescription rates at discharge, total average number of days of prophylactic antibiotic administration, and history of antibiotic allergy 2. The exclusion criteria are based on clinical symptoms and diagnosis. Thus, patients with three days of high fever postoperatively, infection, transfusion of >4 units of blood within 24 h postoperatively, drainage of an abscess at the surgical site, pneumonia, sepsis, and/or disruption of the surgical wound or other evidence of serious infection are excluded from the assessment. Based on the results, hospitals are ranked in five levels, which are reported annually on the website of the Korean Ministry of Health and Welfare and in Korean newspapers. Korea has a national insurance system that contributes to the cost of surgical procedures. In 2014, the government started a hospital incentive system based on the above-mentioned rankings. Thus, the government pays more to high-ranking and less to low-ranking hospitals. In 2014, 11 hospitals qualified for the incentive program 2. In view of the legal problems that confront surgeons whose patients experience postoperative infectious complications, a surgeon cannot initiate a reduction in prophylactic antibiotics. The primary goal of the assessment is to reduce antibiotic abuse and medical costs while improving the quality of surgical care. According to a health insurance review, in 2009, total antibiotics use per operation had decreased by 36.4% compared with 2006 2. The program to reduce prophylactic antibiotic use in surgical patients was initiated by the government health system, not by surgeons. However, the Korean data have made an important contribution to surgical practice and to the development of government health insurance policies.