Surgical Antimicrobial Prophylaxis Research Articles

Population pharmacokinetic meta-analysis of five beta-lactams antibiotics to support dosing regimens in dogs for surgical antimicrobial prophylaxis

The Pharmacokinetic/Pharmacodynamic (PK/PD) relationship of antimicrobial drugs (AMD) for surgical prophylaxis has been poorly studied, hampering evidence-based decision making around AMD dosing and timing. Our objective is to use PK/PD principles to inform (1) the timing of administration and (2) the interval for re-administration of AMD used peri-operatively in dogs. Raw plasma concentrations of cefazolin, cefuroxime, cefalexin, amoxicillin and ampicillin were retrieved from original intravenous studies performed in dogs. E. coli and methicillin-susceptible staphylococci were identified as possible intraoperative contaminants and their epidemiological cut-offs (ECOFF) were retrieved from the EUCAST database. Individual PK data were refitted with non-linear mixed effect models (Phoenix®). We performed Monte Carlo simulation to compute i) the 95th percentile of time of peak concentration in the peripheral compartment (informing timing between administration and first incision) and ii) the duration for which at least 90% of dogs maintain a free plasma concentration above ECOFF (informing timing of re-administration: 1.5 to 4h).Cefazolin (22-25mg/kg), cefuroxime (20mg/kg), cefalexin (15mg/kg) and amoxicillin (16.7mg/kg) reached peak peripheral concentrations within 30min, but ampicillin (20mg/kg) required 82min, respectively. For methicillin-susceptible staphylococci, cefazolin and cefuroxime require re-administration every 2h, whereas cefalexin and both amoxicillin and ampicillin can be readministered every 3 and 4h, respectively. For E. coli, only cefazolin provided adequate perioperative coverage with 2-hourly administration, where cefuroxime and cefalexin failed uniformly. Alternatively, ampicillin and amoxicillin (critically ill dogs) may cover E. coli contaminations, but only if readministered every 1.5h. These PK-derived conclusions provide a rationale for perioperative AMD administration timing.

A Quality Improvement Project to Increase Compliance With a Facility Protocol on Surgical Antimicrobial Prophylaxis.

Surgical site infections (SSIs) contribute to negative outcomes for patients and health care organizations. Compliancewith clinical practice guidelines likely can help prevent SSIs. An interdisciplinary team at a regional referral center in Michigan sought to reduce SSIs by improving compliance with the facility's preoperative antibiotic selection, dosing, timing, and redosing protocol. The interventions for the quality improvement project included adding the preprocedural antibiotics and doses to the master OR schedule; holding an education session for all preoperative nurses, intraoperative nurses, and anesthesia professionals; and posting a reference guide in the preoperative and intraoperative areas. Compliance with the facility's protocol for antibiotic selection, dosing, and timing significantly improved. However, SSI rates and compliance with redosing recommendations did not change significantly. The team decided to add the antibiotic order information to the master OR schedule permanently. The team plans to consider providing education sessions on administering preprocedural antibiotics outside the OR.

Antimicrobial prophylaxis in companion animal surgery: A scoping review for European Network for Optimization of Antimicrobial Therapy (ENOVAT) guidelines

Surgical antimicrobial prophylaxis (SAP) is widely used to reduce the risk of surgical site infections (SSI), but there is uncertainty as to what the proportion of SSI reduction is. Therefore, it is difficult for surgeons to properly weigh the costs, risks and benefits for individual patients when deciding on the use of SAP, making it challenging to promote antimicrobial stewardship in primary practice settings. The objective of this study was to map the veterinary evidence focused on assessing the effect of SAP on SSI development and in order to identify surgical procedures with some research evidence and possible knowledge gaps. In October 2021 and December 2022, Scopus, CAB Abstracts, Web of Science Core Collection, Embase and MEDLINE were systematically searched. Double blinded screening of records was performed to identify studies in companion animals that reported on the use of SAP and SSI rates. Comparative data were available from 34 out of 39123 records screened including: eight randomised controlled trials (RCT), 23 cohort studies (seven prospective and 16 retrospective) and three retrospective case series representing 12476 dogs and cats in total. Extracted data described peri- or post-operative SAP in nine, and 25 studies, respectively. In the eight RCTs evaluating SAP in companion animals, surgical procedure coverage was skewed towards orthopaedic stifle surgeries in referral settings and there was large variation in SAP protocols, SSI definitions and follow-up periods. More standardized data collection and agreement of SSI definitions is needed to build stronger evidence for optimized patient care.

Gram-negative bacterial colonizations before bilateral lung transplant. The impact of ‘targeted’ versus ‘standard’ surgical prophylaxis

BackgroundInfections are one of the most common causes of death after lung transplant (LT). However, the benefit of ‘targeted’ prophylaxis in LT recipients pre-colonized by Gram-negative (GN) bacteria is still unclear.MethodsAll consecutive bilateral LT recipients admitted to the Intensive Care Unit of the University Hospital of Padua (February 2016–2023) were retrospectively screened. Only patients with pre-existing GN bacterial isolations were enrolled and analyzed according to the antimicrobial surgical prophylaxis (‘standard’ vs. ‘targeted’ on the preoperative bacterial isolation).ResultsOne hundred eighty-one LT recipients were screened, 46 enrolled. Twenty-two (48%) recipients were exposed to ‘targeted’ prophylaxis, while 24 (52%) to ‘standard’ prophylaxis. Overall prevalence of postoperative multi-drug resistant (MDR) GN bacteria isolation was 65%, with no differences between the two surgical prophylaxis (p = 0.364). Eleven (79%) patients treated with ‘standard’ prophylaxis and twelve (75%) with ‘targeted’ therapy reconfirmed the preoperative GN pathogen (p = 0.999). The prevalence of postoperative infections due to MDR GN bacteria was 50%. Of these recipients, 4 belonged to the ‘standard’ and 11 to the ‘targeted’ prophylaxis (p = 0.027).ConclusionsThe administration of a ‘targeted’ prophylaxis in LT pre-colonized recipients seemed not to prevent the occurrence of postoperative MDR GN infections.

Surgical antimicrobial prophylaxis in Japanese hospitals: Real status and challenges

BackgroundInformation regarding the status of surgical antimicrobial prophylaxis (SAP) in Japanese hospitals is lacking. This study aimed to explore the status of SAP prescriptions for surgeries and adherence to Japanese SAP guidelines. MethodsFrom February to July 2020, a 1-day multicentre point prevalent survey was conducted at 27 hospitals in Aichi Prefecture, Japan. Patients prescribed SAP were included in this study. The appropriateness of the SAP was evaluated based on the guidelines for selection of antimicrobials and their duration. Surgery was defined as appropriate when all the items were appropriate. ResultsA total of 728 patients (7.1 %; 728/10,199) received antimicrobials for SAP. Among them, 557 patients (76.5 %, 557/728) underwent the surgeries described in the guidelines.The overall appropriateness of all surgeries was 33.9 % (189/557). The appropriate selection of antimicrobial before/during and after surgery and their durations were 67.5 % (376/557), 67.5 % (376/557), and 43.3 % (241/557), respectively. The overall appropriateness ranged from 0 % (0/37, oral and maxillofacial surgery) to 58.7 % (88/150, orthopaedic surgery) and 27.7 % (36/130, community hospitals with 400–599 beds) to 47.2 % (17/36, specific hospitals).Cefazolin was the most prevalent antimicrobial prescribed before/during (55.5 %, 299/539), and after (45.1 %, 249/552) surgery. In total, 101 oral antimicrobials were prescribed postoperatively. ConclusionsSAP adherence by specific surgical fields and hospitals was shown in this study. Intensive intervention and repeated surveillance are necessary to improve SAP prescriptions in Japanese hospitals.

Optimal time window for initiating cefuroxime surgical antimicrobial prophylaxis in spinal fusion surgery: a nested case-control study

Surgical site infections (SSI) are one of the common complications following spinal fusion surgery. Unfortunately, several studies had shown conflicting results regarding optimal timing of surgical antimicrobial prophylaxis (SAP) administration. Due to limitations in population homogeneity and sample size, these studies have not provided significant statistical correlations or clear practical recommendations. The purpose of the study was to investigate the impact of timing of cefuroxime SAP on the risk of SSI in patients undergoing spinal fusion surgery, and to determine the optimal timing of administration. Retrospective nested case-control study. We retrospectively analyzed consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021. In the current study, the primary outcome measure was SSI. This was a retrospective nested case-control study. All consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021 formed a retrospective cohort. For each SSI case, two controls free of SSI at the time of the index date of their corresponding case were selected, matched by age, sex, and calendar year. Electronic record and radiographic data were reviewed retrospectively in electronic database. SAP related data included timing of administration, preoperative dose, intraoperative second dose, and postoperative use. To examine the effects of mismatched variables, we further adjusted for possible confounding factors using conditional logistic regression models. Subsequently, subgroup analyses were conducted to assess the robustness of the statistical associations. According to the pre-planned statistical scheme and matching factors, we matched 236 controls for these SSI cases, and the subsequent statistical analysis was performed on these 354 patients. After adjusting for confounding factors, the results indicated that the risk of SSI was 70% higher in the group receiving SAP 31-60 minutes before incision compared to the group receiving SAP 0-30 minutes before incision (OR=1.732, 95%CI 1.031-2.910, P=0.038). Additionally, the risk of SSI was 150% higher in the group receiving SAP 61-120 minutes before incision compared to the group receiving SAP 0-30 minutes before incision (OR=2.532, 95%CI 1.250-5.128, P=0.010). In subgroup analysis, this statistical trend persisted for both deformity surgeries and different SSI classifications. Administering cefuroxime SAP within 30 minutes before skin incision significantly reduces the risk of SSI, whether they are deep or superficial, in spinal fusion surgery. This pattern remains consistent among spinal deformity patients.

ANTIMICROBIAL PROPHYLAXIS IN SURGERY: A CROSS-SECTIONAL STUDY IN THE SURGICAL WARD OF A TERTIARY CARE CENTRE IN CENTRAL NEPAL

Background: Surgical Antimicrobial Prophylaxis is administration of a short course of antimicrobial agent prior to surgery. It has long been recommended for routine use in preventing occurrence of surgical site infections. The choice of drug, dosage, route, duration and timing of antimicrobial prophylaxis has been specified in the clinical practice guideline issued by American Society of Health-System Pharmacists. In the present study, we aim to seek the practice of antibiotic prophylaxis at a tertiary care centre in central Nepal and report the adherence to American and National Antimicrobial Treatment Guideline where applicable. Methods: This hospital-based cross-sectional study was conducted between January to June 2023 among 232 patients undergoing surgery at Chitwan Medical College Teaching Hospital. Data collection tool prepared with slight modification from previous studies recorded the demographic details, surgical data, surgical antimicrobial prophylaxis usage data and assessment of Prophylaxis data. Data analysis was done using SPSS-20. Results: We observed compliance to selection of drug, route of administration, dosage of antimicrobial prophylaxis with American guideline. All (100%) prophylaxis was administered parenterally for more than 72 hours in over 40% cases. Choice of drug was appropriate in over 84% of cases and dosage adequacy was observed in over 61% cases. Surgical antimicrobial prophylaxis was administered most frequently 30 minutes before surgery (52.59%). Conclusions: All the surgical patients were found to receive surgical antimicrobial prophylaxis. Ceftriaxone was the most commonly administered drug followed by combination of piperacillin and tazobactam. The duration of treatment post-surgery was found to be unnecessarily broader than recommended guideline.

Effective Antimicrobial Prophylaxis in Surgery: The Relevance and Role of Pharmacokinetics-Pharmacodynamics.

Appropriate surgical antimicrobial prophylaxis (SAP) is an important measure in preventing surgical site infections (SSIs). Although antimicrobial pharmacokinetics-pharmacodynamics (PKPD) is integral to optimizing antibiotic dosing for the treatment of infections, there is less research on preventing infections postsurgery. Whereas clinical studies of SAP dose, preincision timing, and redosing are informative, it is difficult to isolate their effect on SSI outcomes. Antimicrobial PKPD aims to explain the complex relationship between antibiotic exposure during surgery and the subsequent development of SSI. It accounts for the many factors that influence the PKs and antibiotic concentrations in patients and considers the susceptibilities of bacteria most likely to contaminate the surgical site. This narrative review examines the relevance and role of PKPD in providing effective SAP. The dose-response relationship i.e., association between lower dose and SSI in cefazolin prophylaxis is discussed. A comprehensive review of the evidence for an antibiotic concentration-response (SSI) relationship in SAP is also presented. Finally, PKPD considerations for improving SAP are explored with a focus on cefazolin prophylaxis in adults and outstanding questions regarding its dose, preincision timing, and redosing during surgery.

Appropriateness of Surgical Antimicrobial Prophylaxis in a tertiary care hospital: A prospective observational study

Surgical site infections (SSIs) are a significant concern in global healthcare, particularly in middle and low-income countries, leading to increased hospitalizations, morbidity, mortality, and financial strain. Ranked third in the CDC's National Nosocomial Infections Surveillance System, SSIs have prompted a focus on preventive measures, notably surgical antimicrobial prophylaxis (SAP). However, SAP is often used inappropriately, contributing to the rise of Antimicrobial Resistance (AMR). Addressing this, a six-month prospective observational study was conducted in a tertiary care hospital to assess the adherence to SAP guidelines among 386 patients undergoing surgeries in various specialties. The study aimed to evaluate the appropriateness of SAP practices and identify factors leading to non-compliance. Results showed that only 58.3% of patients fully adhered to the guidelines. While 100% compliance was observed in SAP indication, lower adherence was noted in the timing of administration (97.7%), choice of SAP (85%), and duration of prophylaxis (70.2%). These findings underscore a significant gap between recommended SAP practices and actual implementation. This gap highlights the need for stronger Institutional Antimicrobial Stewardship (AMS) programs and the critical role of clinical pharmacists in regularly evaluating SAP and prescribing practices. To combat the rise of antibiotic resistance while ensuring patient safety, enhancing SAP practices in line with national and international recommendations is essential. The study advocates for more active interventions at the time of order to optimize antibiotic use, thereby addressing the challenge of compliance in SAP guidelines.

Withdrawal: "Surgical site infection and antimicrobial prophylaxis prescribing pattern, and its determinants among hospitalized patients in northeast Ethiopia: a hospital based cross-sectional study" by Habteweld HA, Yimam M, Tsige AW, Teshome Y, Endalifer BL, Dires K.

The above article from Journal of Clinical Pharmacology, published online on 1 September 2023 in Wiley Online Library (http://wileyonlinelibrary.com) has been withdrawn by agreement among the authors, the Journal Editor-in-Chief Joseph S. Bertino Jr. and Wiley Periodicals, Inc. on behalf of the American College of Clinical Pharmacology. The withdrawal has been agreed because a dispute over authorship.

Evaluation of local guideline introduction on surgical antimicrobial prophylaxis prescribing for open reduction internal fixations at an Australian tertiary hospital

AbstractBackgroundGuidelines advocate for the use of single‐dose prophylaxis in open reduction internal fixation (ORIF) procedures. The presence of local (institutional) guidelines may assist in the uptake of evidence‐based recommendations.AimTo determine the impact of local guideline introduction on prescribing practice for ORIF procedures at a metropolitan hospital in relation to our previous audit investigating adherence to national guidelines, which found that only 20.4% of ORIF patients received single‐dose prophylaxis.MethodAntibiotic prescribing was audited for patients undergoing ORIF of closed fractures from July–December 2021 at a metropolitan, tertiary hospital following guideline introduction in April 2021. Data on perioperative prescribing regimens were collected, with results compared to recommendations in local guidelines. Descriptive statistics, chi‐squared test, and Fisher's exact test were used to report categorical variables. Ethics approval was granted by Northern Health Office of Research, Ethics, and Governance (Reference no: NLR 72459) and registered with the RMIT University College Human Ethics Advisory Network (Reference no: RM 24642).ResultsData were collected for 165 patients. Almost all patients (93.5%) received cefazolin preoperatively as per guidelines. Only 22.6% of patients received single‐dose prophylaxis as per local guideline recommendations, with overall adherence to guidelines only 16.4%.ConclusionLittle change was observed in the proportion of patients who received single‐dose prophylaxis as compared to our previous audit. There is a need to understand why guidelines are not adhered to despite the availability of national and local guidelines. An evaluation of local barriers may assist with informing future implementation strategies.

Knowledge and practice of surgical antimicrobial prophylaxis at a tertiary academic hospital in a low-middle income country

Knowledge and practice of surgical antimicrobial prophylaxis at a tertiary academic hospital in a low-middle income country

Surgical site infection prophylaxis: what have we learned and are we making progress?

This review aims to discuss the current state of surgical antimicrobial prophylaxis (SAP) evidence for surgical site infection prevention. Despite decades of research, knowledge gaps persist in identifying optimal SAP regimens. Recent randomised controlled trials highlight ongoing heterogeneity in study design. Key new findings support the use of oral preoperative SAP for colorectal surgery and advise against the use of SAP for transperineal prostate biopsy. There is growing evidence for culture-based SAP over empiric use for transrectal prostate biopsy.Contentious issues remain regarding topical antimicrobials for cardiac procedures involving sternotomy, the necessity of SAP for wire lumpectomy and laparoscopic cholecystectomy for both mild or moderate acute cholecystitis. Procedures where SAP is not indicated, yet research is still being conducted on this topic include dental implants and clean orthopaedic procedures. Research efforts continue with numerous trials published and registered to determine optimal SAP regimens. However, many efforts are suboptimal due to poor statistical design and redundant questions already answered by existing literature. To improve practice and influence surgeons prescribing behaviour future RCTs should be well powered, with large sample sizes across multiple sites, focusing on clinically relevant questions.

A Process Improvement Project to Increase Compliance With Cephalosporin-based Surgical Antimicrobial Prophylaxis in Children With Non-severe Penicillin Allergies

Background/purposeCephalosporins are considered safe and first-line prophylaxis in children with non-severe penicillin allergies. However, use of second-line agents is common and is primarily driven by poor allergic response documentation and misunderstanding of cross-reactivity risk. The goal of this project was to improve compliance with cephalosporin prophylaxis through improved documentation and targeted educational efforts. MethodsA multidisciplinary working group including representatives from allergy, surgery, infectious disease, and pharmacy developed staged interventions to facilitate compliance with cephalosporin prophylaxis. These included: (1) caregiver outreach to clarify incomplete allergy documentation, (2) a decision-support algorithm for prophylaxis use in penicillin-allergic patients, (3) standardized educational resources for surgical faculty and rotating trainees, (4) email reminders with prophylaxis recommendations sent out prior to scheduled cases, and (5) EMR-based decision support during antibiotic ordering. Rates of complete allergy documentation and cephalosporin utilization were compared for general surgery procedures between a 12-month pre-intervention and 14-month post-intervention period. Results578 patients with penicillin allergies recorded in the EMR were included (301 pre-intervention and 277 post-intervention), 54.0% of which received prophylaxis. Compared to the pre-intervention period, complete documentation of allergic reactions increased from 57.1% to 84.2% (p < 0.001) following implementation of all interventions. Appropriate prophylaxis utilization increased from 34.5% to 88.5% following implementation of all interventions (p < 0.001), and evidence of a stepwise increase in appropriate utilization was evident with each intervention stage. Persistent compliance failures during the post-implementation period were most commonly associated with urgent and emergent add-on cases. No adverse events or allergic responses were reported before or after project implementation. ConclusionsCompliance with cephalosporin prophylaxis significantly improved following a multidisciplinary effort targeting education, allergy documentation, and clinical support at the point of care. Ongoing efforts include postoperative audits within 24 h for noncompliant cases in order to identify barriers and improve compliance for urgent and emergent add-on cases. Level of EvidenceIII. Type of StudyProspective.

Surgical site infection and antimicrobial prophylaxis prescribing profile, and its determinants among hospitalized patients in Northeast Ethiopia: a hospital based cross-sectional study

The inappropriate use of surgical antimicrobial prophylaxis is a common cause for increased risk of morbidity and mortality from surgical site infection in patients who underwent surgical procedures. The study aimed to evaluate surgical antimicrobial prophylaxis prescribing patterns, Surgical Site Infection (SSI), and its determinants in the surgical ward of Debre Berhan Comprehensive Specialized Hospital, northeast Ethiopia. A prospective cross-sectional study was conducted from October 1st 2022 to January 31st, 2023. Data collected from patient medical record cards and patient interviews were entered and analyzed using SPSS V26.0. The determinants of surgical site infection were determined from the multivariable logistic regression. P-value ≤ 0.05 was considered statistically significant. Ceftriaxone (70.5%) followed by a combination of ceftriaxone with metronidazole (21.90%) was the most frequently used prophylactic antibiotic. One hundred fifty-nine (78%) of patients were exposed to inappropriately used prophylactic antimicrobials and 62.2% of these were exposed to inappropriately selected antibiotics. One hundred twenty-six (61.9%) patients developed Surgical Site Infection (SSI). Duration of procedure longer than an hour and inappropriate use of antimicrobial prophylaxiswere the independent predictors for the occurrence of surgical site infections. Patients whose operation was lasted in longer than an hour were 3.39 times more likely to develop SSI compared to those whose operation was completed in less than an hour, AOR = 3.39 (95% CI: 1.24–9.30). Similarly, controlling the effect of other covariate variables, individuals who were given inappropriate antimicrobial prophylaxis were 6.67 times more likely to develop SSI compared to those given appropriate prophylaxis, AOR = 6.67 (95% CI: 1.05–42.49). The high rate of SSI requires due attention from clinicians as well as health policymakers. Duration of surgical procedure greater than an hour and inappropriate antimicrobial prophylaxis use was the independent predictor of surgical site infections.

The Impact of an Antimicrobial Stewardship Clinical Pharmacy Specialist on Antimicrobial Days of Therapy through Education Driven Policies, Procedures, and Interventions.

The primary goal of antimicrobial stewardship is to improve patient outcomes and minimize the consequences of antibiotic use. Prospective audit and feedback cannot always be performed by an antimicrobial stewardship program member which is where policies, procedures and education can aid interventions. The purpose of this study was to evaluate the impact on antimicrobial days of therapy due to a dedicated clinical pharmacy specialist primarily responsible for developing policies and procedures and providing education. A pre-intervention and post-intervention retrospective analysis of antimicrobial days of therapy from September 2019-May 2020 and July 2020-March 2021 was performed. Inclusion criteria consisted of adults receiving IV vancomycin, azithromycin, meropenem, ciprofloxacin, and/or levofloxacin. Excluded criteria consisted of documented interventions that were not related to implemented policies and procedures or performed education and patients receiving antimicrobial surgical prophylaxis. The primary outcome was antimicrobial days of therapy. An average of 3.47 ± 2.46 days (pre-intervention, n = 203) and 3.21 ± 2.52 days (post-intervention, n = 203) were observed for the primary outcome (p < 0.04182). Pharmacists performed 75 interventions pre-intervention and 102 interventions post-intervention (p = 0.0092). The implementation of a dedicated antimicrobial stewardship clinical pharmacy specialist responsible for developing policies, procedures, and education successfully reduced antimicrobial days of therapy and documented interventions.

Pediatric Moderate and Severe Traumatic Brain Injury: A Systematic Review of Clinical Practice Guideline Recommendations.

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Many clinical practice guidelines (CPGs) have addressed pediatric TBI in the last decade but significant variability in the use of these guidelines persists. Here, we systematically review CPGs recommendations for pediatric moderate-to-severe TBI, evaluate the quality of CPGs, synthesize the quality of evidence and strength of included recommendations, and identify knowledge gaps. A systematic search was conducted in MEDLINE®, Embase, Cochrane CENTRAL, Web of Science, and Web sites of organizations publishing recommendations on pediatric injury care. We included CPGs developed in high-income countries from January 2012 to May 2023, with at least one recommendation targeting pediatric (≤ 19 years old) moderate-to-severe TBI populations. The quality of included clinical practice guidelines was assessed using the AGREE II tool. We synthesized evidence on recommendations using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We identified 15 CPGs of which 9 were rated moderate to high quality using AGREE II. We identified 90 recommendations, of which 40 (45%) were evidence based. Eleven of these were based on moderate to high quality evidence and were graded as moderate or strong by at least one guideline. These included transfer, imaging, intracranial pressure control, and discharge advice. We identified gaps in evidence-based recommendations for red blood cell transfusion, plasma and platelet transfusion, thromboprophylaxis, surgical antimicrobial prophylaxis, early diagnosis of hypopituitarism, and mental health mangement. Many up-to-date CPGs are available, but there is a paucity of evidence to support recommendations, highlighting the urgent need for robust clinical research in this vulnerable population. Our results may be used by clinicians to identify recommendations based on the highest level of evidence, by healthcare administrators to inform guideline implementation in clinical settings, by researchers to identify areas where robust evidence is needed, and by guideline writing groups to inform the updating of existing guidelines or the development of new ones.

Surgical antimicrobial prophylaxis: Current standards of care

SummaryAntimicrobial drug resistance is a critical problem in human and veterinary medicine. Antimicrobial drug use and particularly overuse or misuse drive resistance. Surgical antimicrobial prophylaxis (SAP) is one area where misuse and overuse (particularly prolonged SAP) is documented to be at a high level. Infection‐related complications can be devastating to the patient, harm the client/patient–surgeon relationship and damage the reputation of the surgeon. Consequently, surgeons tend to be reluctant to change their antimicrobial prescribing behaviour. There is a plethora of data from human surgery and emerging data from veterinary surgery describing appropriate SAP and supporting the use of shorter duration of SAP. Antimicrobial stewardship programs (ASPs) have been developed and evaluated in human hospitals and this type of collaborative approach would likely have benefit in veterinary hospitals.

Assessment of the quality of antimicrobial prescribing among hospitalized patients in a teaching hospital in Ghana: findings and implications

ABSTRACT Objective There is a need to assess the quality of antimicrobial prescribing in hospitals as a first step toward improving future prescribing to reduce antimicrobial resistance (AMR). This is in line with Ghana's National Action Plan. Methods A point prevalence survey of antimicrobial use was undertaken at the adult medical, surgical, and pediatric wards of Tamale Teaching Hospital using the standardized Global Point Prevalence Survey (GPPS) tool. Key target areas include adherence to current guidelines, limiting the prescribing of ‘Watch’ antibiotics with their greater resistance potential, and limiting the prescribing of antibiotics post-operatively to prevent surgical site infections (SSIs). Results Out of 217 patients' medical records assessed, 155 (71.4%) patients were prescribed antimicrobials. The rates were similar among children (73.9%) and adults (70.3%). Most of the antibiotics prescribed were in the WHO ‘Watch’ group (71.0%) followed by those in the ‘Access’ group (29%). Out of the 23 cases indicated for surgical antimicrobial prophylaxis to prevent SSIs, the majority (69.6%) were given doses for more than 1 day, with none receiving a single dose. This needs addressing to reduce AMR and costs. Guideline compliance with the current Ghanaian Standard Treatment Guidelines (GSTG) for managing infections was also low (28.7%). The type of indication was the only independent predictor of guideline compliance (aOR = 0.013 CI 0.001–0.127, p-value = 0.001). Conclusion Given current concerns with antimicrobial prescribing in this hospital, deliberate efforts must be made to improve the appropriateness of prescribing to reduce AMR via targeted antimicrobial stewardship programs.

Barriers and facilitators of inappropriate surgical antimicrobial prophylaxis in endourological procedures: a qualitative study from Jordan

Background: Inappropriate surgical antimicrobial prophylaxis (SAP) practice increases patients’ morbidity, healthcare cost, and antimicrobial resistance. Several guidelines have been published to set guidance for SAP before endourological procedures. Such guidelines include the American Urological Association (AUA, 2019) and the European Association of Urology (EAU, 2020). Literature reported that compliance with the recommendations of these guidelines has been suboptimal.&#x0D; Aims: to investigate healthcare professionals’ (HCPs) perspectives on the barriers to international guideline adherence regarding SAP for endourological procedures and the potential strategies to optimize adherence to guidelines recommendations.&#x0D; Methodology: This study was a qualitative study based on face-to-face semi-structured interviews conducted with urologists in multiple medical centers across Jordan using a preformulated interview guide regarding barriers and facilitators to the adherence to international guidelines of preoperative SAP during endourological procedures.&#x0D; Results: Nineteen urologists were interviewed. Interviews identified many barriers influencing HCP adherence to guidelines, these included factors related to patients, HCPs, the healthcare system, or other external barriers. Also, during the interviews, HCPs suggested many strategies to enhance SAP practice which included increasing patients’ awareness about their actual need for antibiotics, providing training sessions for HCPs about appropriate SAP before endourological procedures, developing national guidelines and conducting local clinical studies, and promoting awareness of the clinical pharmacist's role. In addition to imposing national policy to control antibiotic use and prevent over-the-counter (OTC) prescriptions.&#x0D; Conclusion: Factors related to nonadherence to guidelines were determined. Such knowledge will constitute the backbone for planning appropriate antimicrobial stewardship programs that involve all stakeholders and address all those aspects to optimize SAP prescribing and reduce antibiotic misuse.