Antibiotic Prophylaxis Guidelines Research Articles

Clinical Outcomes of Antibiotic Prophylaxis in Vaginal Delivery Women at Ramathibodi Hospital

Background: The rate of antibiotic use of vaginal delivery women in Ramathibodi Hospital is higher than expected standard criteria. The obstetrician team has developed clinical practice guidelines for rational drug use in antibiotic prophylaxis in vaginal delivery women.
 Objectives: To examine the relationships among the percentage of using antibiotic prophylaxis, the prevalence of rational drug use and the prevalence of the episiotomy wound infection rate in vaginal delivery women before and after using the clinical practice guidelines for antibiotic prophylaxis.
 Methods: The sample consisted of 983 vaginal delivery women who did not in the practice guidelines and 914 joined in practice guidelines groups. The rate of antibiotic use and episiotomy wound infection were collected before and after using the clinical practice guidelines for antibiotic prophylaxis. Data were analyzed by chi-square statistics.
 Results: The rate of antibiotic use in vaginal delivery women is significantly related to the use of the practice guidelines (P < .01), which is reduced from 25.43% to 9.85%. The prevalence of rational drug use increased from 12.40% to 34.44%. The prevalence of episiotomy wound infection of women vaginal birth before and after using the practice guidelines was not significantly different (P = .96). There was no episiotomy wound infection in both groups.
 Conclusions: The clinical practice guidelines reduces antibiotic use in postpartum women without episiotomy wound infection and promotes rational drug use.

Adherence to American Society of Health‐System Pharmacists guidelines for antibiotic prophylaxis in thoracic surgery: a prospective observational study

AbstractBackgroundSurgical antibiotic prophylaxis (SAP) decreases the incidence of surgical site infections. However, inappropriate use of prophylactic antibiotics may lead to antibiotic resistance, prolonged hospital stay and adverse drug reactions.AimThis prospective study aimed to assess the concordance of prophylactic antibiotic administration for thoracic operations in Iran with American Society of Health‐System Pharmacists (ASHP) guidelines.MethodsThe appropriateness of SAP administration in 222 thoracic operations was assessed in a respiratory referral centre over a period of 4 months. Demographic, clinical and SAP data were recorded from patient files. ASHP guidelines were used to evaluate the appropriateness of prophylactic antibiotic administration.ResultsCefazolin was correctly prescribed for approximately 70% of patients who required antibiotic prophylaxis. SAP was administered at the correct time (within 60 min before surgery) for 71.6% of surgeries. Intraoperative doses were correctly given in 27.7% of prolonged procedures. In 86.7% of surgeries, antibiotic administration was continued for more than 24 h after surgery (based on a physician's opinion or recent microbiological cultures).ConclusionThe results suggest a relatively low rate of consistency between SAP administration and ASHP guidelines in Iran. A long duration of antibiotic administration after operations is an important finding, which should be considered and re‐evaluated by thoracic surgeons in Iran.

A Practice Change to Eliminate Prophylactic Antibiotics for Elective Percutaneous Nephrostomy Tube Exchanges in Low-Risk Outpatients: A Retrospective Review on Risk for Infection

The purpose of this project was to determine if evidence-based practice change related to antibiotic administration criteria for outpatients receiving percutaneous nephrostomy tube exchanges implemented by a medical center's Vascular and Interventional Radiology department impacted hospital admission rates for infection in these patients. The 2017 practice change was based on 2010 guidelines from the Society of Interventional Radiology (SIR), stating that outpatients with a low risk of acquiring infection did not need to receive a perioperative antibiotic, as evidence has shown prophylactic therapy has no significant effect on infection rates for this population. Using a retrospective review design, 1 year of data before and after the practice change were collected and analyzed using the repeated measures generalized estimating equation (GEE) model with a binomial output by Liang & Zeger. Fisher's exact test was used to evaluate demographic variables by level of risk of infection. Data included 493 procedural events for 126 outpatients. The mean number of events per patient was 3.91 (SD: 4.15; median: 2; interquartile range: 3). Admission and infection criteria within thirty days of the event and infection risk factors were collected for each patient. Age, sex, and race were the variables that had a significant relationship with risk level of infection. Due to sample size, the GEE model could not be run using risk level (high/low) to predict admissions before or after the practice change. The relationship between the number of risk factors (0-5) and the odds of admission for infection was the same regardless of the practice change (before: odds ratio [OR] = 2.17, 95% confidence interval [CI] = 1.19-3.95; after: OR = 1.9, 95% CI = 1.12-3.22, pinteraction = .67). For every increase in a patient's number of risk factors, the odds of developing an infection would be expected to increase by almost 90% (OR = 1.9, 95% CI = 1.27-2.84). Although it was not possible to determine efficacy of the practice change, the predictive analysis indicated that risk level is a significant predictor of admission for infection regardless of antibiotic therapy. The results suggest that demographic indicators should be considered when determining appropriate therapies for this procedure; however, research studies should evaluate this relationship with larger samples to design specific recommendations. Our project results support the 2010 SIR antibiotic prophylaxis guidelines and their more recently updated antibiotic parameter guidelines from 2018.

Prevention of infective endocarditis and bacterial resistance to antibiotics: A brief review.

The purpose of this statement is to debate the recommendations of the American Heart Association (AHA) for the prevention of infective endocarditis through an antibiotic prophylaxis protocol and its relation with bacterial resistance to antibiotics. Since dental infections involve biofilms that include several bacterial species (Gram-negative and Gram-positive), it is essential, from the dental point of view, to consider the frequency, magnitude, and duration of bacteremia associated with active dental infections before applying antibiotic prophylaxis. The actual guidelines for antibiotic prophylaxis should be revised according to recent evidence of bacterial resistance. Amoxicillin/clavulanic acid and moxifloxacin should be considered due to their effectiveness against bacteria associated with oral, GU, and GI infections and the low rates of antibiotic resistance associated with these antibiotics, instead of the actual protocol, which includes amoxicillin (2g) or clindamycin (600mg) administered an hour before the dental procedures. The breaking point to test the antibiotic bacterial resistance (ABR) had a wide range in the different studies that were analyzed, which could explain the widely varied ABR percentages reported for the various antibiotics used for antibiotic prophylaxis.

Comparison of Carbapenem-Resistant Microbial Pathogens in Combat and Non-combat Wounds of Military and Civilian Patients Seen at a Tertiary Military Hospital, Philippines (2013–2017)

Bacterial wound infections are a danger to both military and civilian populations. The nature of injury and infection associated with combat related wounds are important in guiding antibiotic prophylaxis and empiric treatment guidelines. The isolates were screened for drug-resistance by the MicroScan Walkaway Plus System using either the Negative Breakpoint Combo Panel (NBCP) 30 or 34 or Positive Breakpoint Combo Panel (PBPC) 20 or 23. Isolates with a minimum inhibitory concentration (MIC) of ≥8 μg/mL to imipenem and/or meropenem were tested for both carbapenemase production using the CarbaNP test and real-time PCR to determine molecular resistance mechanisms. Plasmid conjugation analysis was performed to define potential for horizontal gene transfer. We characterized 634 bacterial wound isolates collected from September 2013 to December 2017 from patients seen at a Philippine military tertiary hospital presenting with combat or non-combat injuries [354 (military) and 280 (civilians)]. Staphylococcus aureus was the most predominant bacterial species isolated from wounds in both populations (104/634, 16%). A variety of Gram-negative bacterial species comprised 442/634 (70%) of the isolates identified, with the most prevalent shown to be Pseudomonas aeruginosa, Enterobacter cloacae, Klebsiella pneumoniae, Escherichia coli, and Acinetobacter sp. Carbapenemase production was detected in 34/442 (8%) Gram-negative isolates. Testing for molecular resistance mechanisms showed 32/34 (17 military, 15 civilian) wound isolates were blaNDM positive and 2 were blaVIM positive, with the two blaVIM isolates found in the civilian population. Plasmid conjugation of 14 blaNDM and 2 blaVIM positive wound isolates representatives showed 2/16 (13%) produced E. coli J53 transconjugants (E. coli from a civilian; E. cloacae from a military). We describe in this study the wound bacterial and antibiotic resistance profile in the military (combat vs non-combat associated) and civilian population. We observed that, with the exception of Acinetobacter sp., resistance of prevalent Gram-negative bacterial species to imipenem or meropenem were not significantly different between the military and civilian populations. We also presented data on the prevalent bacterial species isolated from both combat and non-combat wounds in a military tertiary care hospital setting as well as the carbapenemase-encoding gene primarily responsible for carbapenem resistance as well as evidence of horizontal transfer via mobile genetic elements. Clinicians may use this information to guide empiric antibiotic coverage for the predominant organisms if wound culture results are not readily available.A prospective, longitudinal evaluation of the wound bacterial profile documenting the changing bacterial flora using higher resolution molecular strategies can provide a more comprehensive understanding of the diversity, composition, and abundance of bacterial composition of the wound microbial community from the time of injury, during the course of evacuation from the field to higher level of care facilities, and up to wound resolution.

Evaluation of Antibiotic Prophylaxis and Discharge Prescriptions in the General Surgery Department.

IntroductionAlthough there are international guidelines for surgical antibiotic prophylaxis (SP), the use of inappropriate SP is still a common problem. Most studies investigated SP applications in clean and clean-contaminated cases. However, antibiotics in the discharge prescriptions of these cases have not been adequately investigated. In this study, we aimed to examine the antibiotics in SP applications and discharged prescriptions together and to find out the causes of inappropriate use.Materials and methodsWe retrospectively evaluated the data of patients admitted to our general surgery wards between 2014 and 2015. Patients with clean or clean-contaminated wound category operations were included. The patients were evaluated in terms of convenience of SP (choice of antibiotics, compliance with an indication for SP, timing of the first dose, SP>24 hours, and discharge prescription). In addition, to interpret the results, a questionnaire has been performed for the surgeons in the same clinics.ResultsA total of 1205 patients with clean and clean-contaminated wound class operation were enrolled in this study. The total accuracy rate of SP was 7.1%. SP application with the correct indication and timing of the first dose was compatible with guidelines: 55.6% and 81.9%, respectively. SP was applied >24 hours at 60.2% and antibiotic prescribing carried out after discharge at 80.6% of patients. According to questionnaire results, the use of SP over 24 hours and the prescription of antibiotics during discharge were: drain usage, hyperthermia, leukocytosis, surgeons feeling of comfort, avoidance of patients, and their relatives' reactions.ConclusionThe total accuracy rate of SP rate was low in the present study and in surgeons prescribing the SP after discharge. In light of the present study, we suggest that discharge prescriptions should also be reviewed in clinics who have a high inappropriate surgical antibiotic prophylaxis rate.

Adherence to surgical antibiotic prophylaxis guidelines in children: A cohort study.

Surgical antimicrobial prophylaxis (SAP) is an important measure to reduce post-operative infections. Guidelines exist, but their efficacy and performance in children is poorly understood compared with adults. To review adherence to SAP guidelines, this study assesses risk factors for non-adherence and rate of early post-surgical infections. A retrospective cohort study of paediatric surgical cases (0-<18 years) at a tertiary children's hospital was performed. Patient characteristics, surgical factors and antimicrobial details were evaluated against hospital guidelines for overall adherence and domains of: antimicrobial choice, dose, re-dosing, timing and duration. Multiple regression analysis was used to determine risk factors for non-adherence. Hospital records were reviewed for post-operative infections at 7 and 30 days. Among 326 cases, overall guideline adherence was 39.6% but varied by domain and surgical subspecialty. Incorrect wound classification was associated with overall non-adherence on multivariate regression (odds ratio (OR): 2.59; P < 0.001). Incorrect antimicrobial choice was more likely in children with penicillin hypersensitivity (OR 138.34, P = 0.004) and incorrect dosing more likely in adolescent patients (OR 4.33; P = 0.004). Presence of invasive devices was associated with prolonged duration of antimicrobials (OR 2.92, P = 0.016). Only two post-operative infections were documented by 30 days, but data were insufficient to exclude mild infections managed in the community. SAP was suboptimal in children, with areas for improvement including better guidance on wound classification, allergy management and care for adolescent patients. Documented infections were rare, but mild infections were unable to be excluded due to limited post-discharge information.

Clinical spectrum of post‐streptococcal reactive arthritis (PSRA) revisited: Juvenile versus adult‐onset disease

Dear Editor, The term post-streptococcal reactive arthritis (PSRA) refers to a form of reactive arthritis which is characterized by a streptococcal sore throat, a symptom-free interval of approximately 10 days followed by aseptic inflammation involving one or more joints. In the year 1959, post-streptococcal arthritis without cardiac involvement was first reported.1 The term PSRA was first suggested by Goldsmith and Long in 1982.2 The presentation may be like that of acute septic arthritis with sudden onset of fever and severe joint pain. The joint pain is usually out of proportion to the degree of physical findings. The pattern of joint involvement may be monoarticular or polyarticular, migratory, additive or chronic; arthritis is usually non-destructive and self-limiting, but the symptoms may last for months. The treatment response to aspirin is less dramatic than that with acute rheumatic fever. There may be no clear evidence of a preceding streptococcal infection and the throat culture can be sometimes negative.3 We tried to analyze the clinical profile of these patients (adult vs juvenile onset) in our tertiary level referral hospital during the period from 1998 to 2008. Retrospective case records of 25 cases of PSRA attending various outpatient services (Clinical Immunology and Rheumatology clinic, Early arthritis clinic and Pediatrics Rheumatology Clinic) of Christian Medical College and Hospital, Vellore, India were studied. The diagnosis of PSRA was based on criteria proposed by Ayoub et al in 1997.4 Out of 25 cases, 7 (28%) were female and 18 (72%) were male. Nine patients (36%) had juvenile-onset disease, whereas 16 (64%) had onset after the age of 16 years. The mean duration of disease at presentation was 3.6 ± 2.66 weeks. Ten patients (40%) had polyarticular onset and 15 patients (60%) had onset in large joints of the lower limbs. Concomitant axial joint involvement was seen in 4 patients (16%). Thirteen patients (52%) had fever and leucocytosis. Juvenile-onset patients had fever along with leucocytosis more frequently (78% vs 22%) as compared to those having disease onset after the age of 16 years (P = 0.058).The mean duration of persistent joint pain was longer in the later / adult age group patients as compared to juvenile-onset disease (29.25 ± 18.51 vs 16.78 ± 14.85 weeks; P = 0.049). None had any residual joint damage or deformity. No extra-articular feature such as carditis was seen, a findings similar to that described by Sato et al from Japan.5 As per decription in literature, PSRA is a rare but benign disease with varied clinical manifestations. In our study, we noted that the arthritis tends to persist for longer duration in later /adult onset PSRA as compared to juvenile-onset disease. PSRA should be considered in the differential diagnosis of a young adult with arthritis involving the lower limbs.6 Although substantial controversy still exists regarding the optimal therapy for patients with PSRA, there is concern about the risk of other non-suppurative complications upon recurrence.7 As streptococcal infections in the adult population are increasingly being reported, it is a timely opportunity to revisit PSRA and develop comprehensive treatment and antibiotic prophylaxis guidelines.8 In the adult-onset PSRA, it may be prudent to give antibiotic prophylaxis as the arthritis is prolonged; one such option include use of sulfasalazine as a disease-modifying agent, even though PSRA is classified by some as nonclassical reactive arthrits. None.

346 - Adherence to the AUA penile prosthesis antibiotic prophylaxis guidelines in diabetic patients is associated with significantly higher risks of device infection

346 - Adherence to the AUA penile prosthesis antibiotic prophylaxis guidelines in diabetic patients is associated with significantly higher risks of device infection

A standardized guideline for antibiotic prophylaxis in surgical neonates,

Infection following surgical procedures leads to increased morbidity and mortality in all populations. Guidelines to aid providers in the proper use of prophylactic antibiotics exist for adults, but are rare in the neonatal surgical population. A recent emphasis on appropriate antibiotic stewardship had led to the development of more guidelines without a coincident increase in surgical site infection. Robust data from randomized, controlled trials, however, remain sparse.

Antibiotic Prophylaxis in Cardiac Implantable Electronic Device Procedures: A Tale of Two Western Australian Hospitals

Australian guidelines recommend antibiotic prophylaxis (AP) for CIED procedures, however the level of adherence to these guidelines is currently unknown. This study aimed to investigate guideline adherence and the CIED infection rate in the two largest Western Australian public teaching hospitals. In a retrospective, observational study, medical records of patients who underwent CIED procedures at the two hospitals from January to December 2017 were reviewed. Adherence to the AP guidelines was assessed with respect to drug, dose, timing, route and frequency. CIED infection was identified using patient follow-up documentation. AP was administered in 589 (98.5%) of 598 procedures reviewed (Hospital A: n = 400, B: n = 198). Full guideline adherence was observed in 33.9% of procedures and differed significantly between the hospitals (A: 47.3% vs. B: 7.1%, p < 0.001). The most common reasons for non-adherence were timing of administration (A: 42.3% vs. B: 60.6% non-adherent, p < 0.001) and repeat dosing (A: 19.3% vs. B: 78.8% non-adherent, p < 0.001). Twenty infections were identified over 626.6 patient-years (PY) of follow-up (mean [SD] follow-up: 1.0 [0.3] years). The infection rate was 3.19 per 100 PY (p = 0.99 between the two hospitals). Two devices were removed; no patients died from CIED infection. There were no statistically significant associations between infection and any patient, procedure or AP-related factors. Infection occurred in 2.0% of AP guideline adherent and 4.1% of non-adherent cases (p = 0.27). Although the rate of serious infection was low, there was evidence of suboptimal antibiotic use, and notably potential overuse of AP in CIED procedures. Practices varied significantly between hospitals.

Physicians’ knowledge and practice attitudes toward infective endocarditis antibiotic prophylaxis guidelines in Saudi Arabia

ObjectivesTo assess the physicians’ knowledge and practice attitudes toward the infective endocarditis antibiotics prophylaxis guidelines in Saudi Arabia. Moreover, to determine whether there is knowledge-to-practice discrepancy. MethodsA cross-sectional study was performed using a self-administered questionnaire. A questionnaire was distributed among physicians dealing with congenital heart disease patients in Saudi Arabia, from January 7, 2016 to August 30, 2016. The questionnaire designed to calculate three scores: a knowledge score, a practice score, and a knowledge-to-practice discrepancy score. A t test was used for a mean comparison between the three scores and a Pearson correlation coefficient for correlation. ResultsA total of 121 physicians completed the survey. The respondents were predominantly pediatric cardiologists (84%). The mean knowledge score for infective endocarditis prophylaxis in various cardiac lesions was 8.6 ± 3.2 SD out of 14, and the mean practice score was 7.6 ± 3 SD out of 14. The mean discrepancy score was 1.1 ± 3 SD. There was a positive significant correlation between knowledge and discrepancy scores, r = 0.533, n = 121, p = 0.001, using Pearson correlation analysis. Almost 39% of our population had a discrepancy score of +1 or more. ConclusionsThe knowledge about antibiotics prophylaxis of infective endocarditis in various cardiac lesions was less than optimal. Even in the presence of knowledge, there is a practice-to-knowledge discrepancy, with an overprescribing attitude for low-risk cardiac lesions that correlates significantly with more knowledgeable physicians. We recommend that physicians be up-to-date and follow the most recent guidelines.

Non-specialist pharmacists as stewardship champions

While experts agree that antibiotic stewardship programmes should ideally be led by a multidisciplinary professional team with specialist training in antibiotics and infectious diseases, resources to constitute these teams, especially in low-and middle-income countries(LMICs) remain a challenge[1]. The use of non-specialist pharmacist as stewardship champions has shown important progress and impact across multiple hospitals in 3 South Africa studies and may offer potential solutions for other LMICs. The first study, aimed to reduce consumption of antibiotics across 47 hospitals, focused on prospective audit of process measures (prolonged duration, multiple antibiotics, and redundant antibiotic coverage) with pharmacist's interventions[2]. Overall antibiotic consumption reduced by 18,1% over 104 weeks using standardised measurement and feedback. The second intervention across 33 hospitals improved compliance to timeliness of antibiotic administration and built important collaboration with nursing colleagues[3]. In the third study, a pharmacist-led strategy involving change management and improvement principles across 34 hospitals reviewed perioperative antibiotic prophylaxis (PAP) guideline compliance and a post-implementation phase of audit, intervention and monthly feedback, facilitated improvements in compliance[4]. There was significant improvement in composite compliance with all process measures from 66.8% to 83.3% representing a 24.7% increase and the SSI rate decreased by 19.7%. Additional studies across public and private sector hospitals are underway to further test this strategy as a model for progressing antibiotic stewardship programmes in lower resource settings.

The effect of applying and sustaining trust level antibiotic prophylaxis guidelines on the surgical site infection (SSI) Rate after level 2 therapeutic mammoplasty in a single tertiary institute

The effect of applying and sustaining trust level antibiotic prophylaxis guidelines on the surgical site infection (SSI) Rate after level 2 therapeutic mammoplasty in a single tertiary institute

Modifying pre-operative antibiotic overuse in gynecologic surgery

PurposePrevious studies indicate adherence to pre-operative antibiotic prophylaxis guidelines has been inadequate. The purpose of this paper is to determine adherence rates to current perioperative antibiotic prophylaxis guidelines in gynecologic surgery at a tertiary care, academic institution. As a secondary outcome, improving guidelines after physician re-education were analyzed.Design/methodology/approachA retrospective chart review (2,463 patients) was completed. The authors determined if patients received perioperative antibiotic prophylaxis in accordance with current guidelines from the America College of Obstetricians and Gynecologists. Data were obtained before and after physician tutorials. Quality control was implemented by making guideline failures transparent. Statistical analysis used Fisher’s exact and agreement tests.FindingsIn total, 23 percent of patients received antibiotics not indicated across all procedures. This decreased to 9 percent after physician re-education and outcome transparency (p<0.0001). Laparoscopy was the procedure with the lowest guideline compliance prior to education. The compliance improved from 52 to 92 percent (p<0.0001) after re-education.Practical implicationsGynecologic surgeons overuse antibiotics for surgical prophylaxis. Physician re-education and transparency were shown to enhance compliance.Originality/valueEducational tutorials are an effective strategy for encouraging physicians to improve outcomes, which, in turn, allows the healthcare system a non-punitive way to monitor quality and mitigate cost.

Antibiotic Prophylaxis in Surgical Sterilization: Following the Recommendations [29G

INTRODUCTION: Surgical site infections are the most common surgical complication. Antibiotic administration perioperatively has been shown to reduce associated morbidity, however, indiscriminate use has been associated with adverse outcomes. Selective antibiotic prophylaxis guidelines have been published by the American College of Obstetricians and Gynecologists (ACOG) for gynecologic procedures. Little is known regarding adherence to these recommendations. The primary objective was to determine adherence to ACOG recommendations for antibiotic prophylaxis in surgical sterilization. The secondary objective was to evaluate the patterns and predictors of appropriate antibiotic prophylaxis. METHODS: A retrospective chart review of preoperative antibiotics for laparoscopic and hysteroscopic sterilization procedures was performed at a single institution, Banner University Medical Center - Phoenix (BUMCP), from 01/01/2014 to 12/31/2014. Descriptive data were analyzed using chi-squared for categorical variables and Student t-test for continuous variables. P-values &lt;.05 were considered significant. RESULTS: Of 165 women who met inclusion criteria, 50.9% received antibiotic prophylaxis outside of ACOG guidelines. Patient age, race and insurance status were not predictive of inappropriate prophylaxis. Women who underwent hysteroscopic sterilization were less likely to receive inappropriate prophylaxis compared to laparoscopic sterilization (18.6% vs 68.9%, P&lt;.001). Antibiotic administration was less likely in cases assisted by lower-level residents compared to cases assisted by upper-level residents (46.4% vs 69.4%, P=.02). The number of years of attending experience was not predictive of adherence. CONCLUSION: There is widespread misuse of perioperative antibiotics for surgical sterilizations. Increased education and quality improvement is needed within BUMCP (our institution) to align practice patterns with evidence based recommendations.

Use and Effectiveness of Peri-Operative Cefotetan versus Cefazolin Plus Metronidazole for Prevention of Surgical Site Infection in Abdominal Surgery Patients.

Current practice guidelines for antimicrobial prophylaxis in surgery recommend a cephamycin or cefazolin plus metronidazole for various abdominal surgeries. In February 2016, cephamycin drug shortages resulted in a change in The Johns Hopkins Hospital's (JHH) recommendation for peri-operative antibiotic prophylaxis in abdominal surgeries from cefotetan to cefazolin plus metronidazole. The primary objective of this study was to quantify the percentage of abdominal surgeries adherent to JHH peri-operative antibiotic prophylaxis guidelines. A sub-group analysis investigated whether prophylaxis with cefazolin plus metronidazole was associated with a lower rate of surgical site infections (SSIs) versus cefotetan. This retrospective cohort study included adult inpatients who underwent an abdominal surgery at JHH in September 2015 (Study Period I: cefotetan) or February to March 2016 (Study Period II: cefazolin plus metronidazole). Two hundred abdominal surgery cases were included in the primary analysis. A subset of 156 surgical cases were included in the sub-group analysis. The overall adherence rate to JHH guidelines was 75% in Study Period I versus 17% in Study Period II (p < 0.001). The largest difference in adherence was attributed to pre-operative administration time (87% vs. 23%, p < 0.001), primarily because of the longer infusion time required for metronidazole. Surgical site infections occurred in 14% (12/83) of surgeries with cefotetan versus 8.2% (6/73) with cefazolin plus metronidazole for prophylaxis (p = 0.19). Adherence to an institution-specific peri-operative antibiotic prophylaxis guideline for abdominal surgeries was limited primarily by the longer infusion time required for pre-operative metronidazole. A higher percentage of SSIs occurred among abdominal surgeries with cefotetan versus cefazolin plus metronidazole for prophylaxis.

Antimicrobial Prophylaxis with Combat-Related Open Soft-Tissue Injuries.

All Department of Defense (DoD) guidance documents recommend cefazolin or clindamycin as post-trauma antibiotic prophylaxis for open soft-tissue injuries. Although not advocated, some patients with open soft-tissue injuries also received expanded Gram-negative coverage (EGN) prophylaxis based on the judgment of front-line trauma providers. During the study period, revised guidelines in 2011/2012 re-emphasized recommendations for using cefazolin or clindamycin, and stewardship efforts in the DoD trauma community aimed to reduce the practice of adding EGN to guideline-recommended antibiotic prophylaxis. Our objective was to examine antibiotic utilization among wounded military personnel with open extremity soft-tissue injuries over a 5-yr period and assess the impact on infectious outcomes in patients who received EGN prophylaxis versus guideline-directed prophylaxis. The study population included military personnel with open extremity soft-tissue injuries sustained in Iraq and Afghanistan (2009-2014) who transferred to participating hospitals in the USA following medical evacuation. The analysis was restricted to patients who were hospitalized for at least seven days at a U.S. facility and excluded those who sustained open fractures. Post-trauma antibiotic prophylactic regimens were defined as narrow if they followed recommended guidance (e.g., IV cefazolin or clindamycin) or EGN coverage when the narrow regimen also included fluoroquinolones and/or aminoglycosides. Intravenous amoxicillin-clavulanate, which is commonly used at non-U.S. coalition theater hospitals, was also classified as narrow because it conformed to coalition antibiotic prophylaxis guidelines. This study was approved by the Infectious Disease Institutional Review Board of the Uniformed Services University of the Health Sciences. A total of 287 wounded personnel with open soft-tissue injuries were assessed, of which 212 (74%) received narrow prophylaxis and 75 (26%) received EGN coverage (p < 0.001). Among patients in the narrow prophylaxis group, 81% were given cefazolin and/or clindamycin, while 19% received amoxicillin-clavulanate. In the EGN group, 88% and 12% received a fluoroquinolone and aminoglycoside, respectively. Use of EGN coverage significantly declined during the study period from 39% in 2009-2010 to 11% in 2013-2014 (p < 0.001). Approximately 3% of patients who received a narrow regimen developed an extremity skin and soft-tissue infection, while there were no skin and soft-tissue infections among patients in the EGN coverage group. Nonetheless, this was not a significant difference (p = 0.345). In addition, the proportion of non-extremity infections was not significantly different between narrow and EGN regimen groups (11% and 15%, respectively). There were also no significant differences between the narrow and EGN regimen groups related to duration of hospitalization (median of 19 versus 20 d). Use of non-guideline directed EGN-based post-trauma antibiotic prophylaxis does not improve infectious outcomes nor does it shorten hospital stay.

Management of pregnancy loss in the first trimester: a retrospective audit

BackgroundEarly pregnancy loss occurs in 10% of all clinically recognised pregnancies. 80% of pregnancy losses occur in the first trimester. Offering choice and participation in the management decisions is essential to patient-centred care. The aim of this study was to assess the management of first trimester pregnancy loss at the Emirati Hospital in Rafah, Gaza Strip. MethodsIn this retrospective audit, we compared the management of first trimester pregnancy loss at Emirati Hospital using the American College of Obstetricians and Gynecologists guidelines (ACOG, No. 150, May 2015). Data were obtained from patients' medical records. Findings50 cases were identified in November and December, 2015. 32 (64%) cases were missed miscarriages (an ultrasound finding of a non-viable pregnancy in an asymptomatic patient), 13 (26%) were incomplete miscarriages, and five (10%) were complete miscarriages. All cases were haemodynamically stable. Only seven (14%) cases were managed medically (200 μg misoprostol four times sublingually without repetition). 43 (86%) cases were treated surgically. Of these, two (4%) cases were treated without prior medical management because of acute presentation with bleeding, and 41 (82%) cases were treated after failure of medical management, when expulsion of conception products did not occur after the full dose of medical management regimen. 43 (86%) women received antibiotic prophylaxis after surgery without specific indication, which is not recommended. Seven (14%) women received no antibiotics, whereas others received a variety of different antibiotic regimens. Expectant management did not require admission, and these cases were not recorded in this audit. InterpretationThis audit showed a high percentage of failure in the medical management regimen and poor adherence to antibiotic prophylaxis guidelines in surgical management. Furthermore, all patients not presenting with acute bleeding were treated with medical management first, without an opportunity to choose surgical management. To improve outcomes of medical management and offer patients a real choice of management methods, clear local guidelines need to be developed with an evidence-based medical management regimen (the ACOG regimen reports an expulsion rate of up to 84%). Regular audit and team feedback could further improve guideline adherence also in the use of antibiotic prophylaxis. FundingNone.

Adherence to surgical antibiotic prophylaxis guidelines in an Indian tertiary care hospital

Introduction: The surgical antibiotic prophylaxis guidelines are developed to provide surgeons with a standardised approach to the rational, safe and effective use of antimicrobial agents for the prevention of surgical-site infections based on international, national and local recommendations. However, despite the availability of these guidelines, the adherence to the set protocols is a challenge. This study was carried out to evaluate the adherence to presurgical antibiotic prophylaxis in a tertiary care hospital. Materials and Methods: The antibiotic audit was prospectively carried out for 29 months January 2014—May 2016 for randomly selected clean and clean-contaminated surgeries. Measurable parameters for each selected case were choice of antibiotic, timing of administration and duration. The results were statistically analysed (Minitab 17.0 software). Results: A total of 1549 surgeries were audited. Out of this, 1501 (96.9%) surgeries fulfilled the inclusion criteria and 76.8% were clean. Mean age of the patients was 42.9 ± 18 years with the majority being females 52.5%. The most commonly used antibiotics were amikacin 32.5%, cefuroxime 29.5% and cefazolin 22.9%. The three parameters tested for adherence showed individual compliance of 87.3% for appropriate selection of antibiotic, 85.3% for appropriate administration and 34.9% for appropriate duration of antibiotic, respectively. Overall adherence to presurgical antibiotic prophylaxis guidelines by the surgeons showed significant results (69.2%, P Conclusion: The present study highlights the adherence and challenges faced in transforming hospital-specific guidelines into practice. The adherence to SAP protocols by surgeons was found comparable with that of the developed countries. This is due to their involvement in the formulation of antibiotic guidelines.