Abstract
BackgroundOpen 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.MethodsA 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.ResultsData 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.ConclusionAdherence 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.
Highlights
Surgical antimicrobial prophylaxis (SAP) accounts for one in six antibiotic prescriptions in hospitals worldwide [1], with 14% of all antimicrobials prescribed in Australian hospitals for surgical antimicrobial prophylaxis (SAP) [2]
The aim of this study was to determine how SAP is prescribed for Open reduction internal fixation (ORIF) of closed fractures at a metropolitan hospital in Melbourne, Australia and to determine how practice compares to guideline recommendations prior to, and following, guideline update
Given the proximity of the audit to the guideline release date, overall adherence with version 16 of the guidelines may have been impacted due to potentially incomplete dissemination, the small number of patients receiving single dose prophylaxis. Another potential contributor is the fact that the Therapeutic Guidelines is written primarily for general practitioners and trainee physicians [21], may not be readily accessed by senior surgical staff, resulting in suboptimal adherence to guidelines. This audit has shown that SAP prescribing for ORIF of closed fractures is relatively consistent for drug choice and route of administration with variations in dosing and duration of prophylaxis
Summary
Surgical antimicrobial prophylaxis (SAP) accounts for one in six antibiotic prescriptions in hospitals worldwide [1], with 14% of all antimicrobials prescribed in Australian hospitals for SAP [2]. Open reduction internal fixation (ORIF) procedures are a widely performed orthopaedic procedure, substantial variability exists for the choice, dose and regimen of prophylactic antibiotics. They are classified as clean procedures, with an estimated surgical site infection (SSI) rate of 1–5% [9]. Recent guidelines from the Centers for Disease Control and Prevention (CDC) and the World Health Organisation (WHO) [10,11,12] have suggested the use of a single preoperative antibiotic dose is sufficient for most clean procedures, including that of internal fixations. Open reduction internal fixation (ORIF) of closed fractures is a required indication for surgical antimicrobial prophylaxis (SAP). The aim of this study was to identify prescribing practice and to evaluate guideline adherence pre- and post-guideline update
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