Surgical Prophylaxis Guidelines Research Articles

Continuous infusion of piperacillin/tazobactam optimizes intraoperative antibiotic exposure in patients undergoing elective pelvic exenteration surgery.

Patients undergoing elective pelvic exenteration surgery who receive piperacillin/tazobactam as surgical prophylaxis are at risk of suboptimal intraoperative antibiotic exposure. With this work, we aimed to study the plasma pharmacokinetics of piperacillin and tazobactam in this population to provide dosing recommendations that optimize antibiotic exposure. We developed a prospective, observational, pharmacokinetic study of piperacillin/tazobactam in patients undergoing pelvic exenteration. Population pharmacokinetic analysis and Monte Carlo simulations were performed with Monolix and Simulx software. Probabilities of target attainment of different dosing regimens against the minimum inhibitory concentration (MIC) breakpoints (8 and 16 mg/L) were calculated. Twelve patients were included in the study, with a median age of 50.0 years [interquartile interval (45.3-57.5)] and a median weight of 79.0 kg (61.3-88.3). Median surgical time was 10.5 h (9.8-11.7). A two-compartment linear model best fitted piperacillin and tazobactam data (190 plasma samples). Monte Carlo simulations showed that a lower dose of 2 g/0.25 g loading dose followed by 4 g/0.5 g q8h by continuous infusion provided ≥90% probability of target attainment for MIC = 16 mg/L for most of the patients. For non-continuous infusion regimens, only the 2-hourly bolus re-dosing achieved intraoperative concentrations of piperacillin ≥16 mg/L. Patients with weights ≥ 100 kg and glomerular filtration rates ≥ 120 mL/min required 4 g/0.5 g q6h by continuous infusion after a loading dose. In conclusion, continuous infusion of lower doses of piperacillin/tazobactam is as adequate as the 2-hourly re-dosing recommended by the current guidelines for surgical prophylaxis in pelvic exenteration. Patients with higher weights and glomerular filtration rates are at greater risk of inadequate exposure.

Evaluation of indications and efficacy of doxycycline for surgical antibiotic prophylaxis.

Given medical advancements in global healthcare systems over the past decade, it may be reasonable to assume that the incidence of surgical site infections would have decreased; however, surveillance data indicate that these rates have held constant. Surgical prophylaxis guidelines from the United States and United Kingdom recommend cefazolin, vancomycin and clindamycin in most surgeries for no longer than 24 hours. As a result of medication shortages impacting the global supply chain, surgeons have needed to evaluate alternative perioperative antibiotics, such as doxycycline; however, research into using doxycycline for preventing surgical site infections is limited. The goal of this study is to retrospectively assess doxycycline's efficacy, safety and role in preventing surgical site infections.

A Prospective Quality Improvement Program to Reduce Prolonged Postoperative Antibiotic Prophylaxis in Ethiopia.

Introduction: Although postoperative antibiotic prophylaxis has not been shown to prevent surgical site infections, prolonged antibiotic administration is common in low- and middle-income countries. We developed a quality improvement program to reduce unnecessary postoperative antibiotics through hospital-specific guideline development and the use of a brief, multidisciplinary discussion of antibiotic indication, choice, and duration during clinical rounds. We assessed reduction in the number of patients receiving ≥24 h of antibiotic prophylaxis after clean and clean-contaminated surgery. Methods: We piloted the program at a referral hospital in Ethiopia from February to September 2023. After a 6-week baseline assessment, multidisciplinary teams adapted international guidelines for surgical prophylaxis to local disease burden, medication availability, and cost restrictions; stakeholders from surgical departments provided feedback. Surgical teams implemented a "timeout" during rounds to apply these guidelines to patient care; compliance with the timeout and antibiotic administration was assessed throughout the study period. Results: We collected data from 636 patients; 159 (25%) in the baseline period and 477 (75%) in the intervention period. The percentage of patients receiving ≥24 h of antibiotic prophylaxis after surgery decreased from 50.9% in the baseline period to 40.9% in the intervention period (p = 0.027) and was associated with a 0.5 day reduction in postoperative length of stay (p = 0.047). Discussion: This antibiotic stewardship pilot program reduced postoperative antibiotic prophylaxis in a resource-constrained setting in Sub-Saharan Africa and was associated with shorter length of stay. This program has the potential to reduce unnecessary antibiotic use in this population.

Antimicrobial stewardship capacity and antibiotic utilisation practices in the Cape Coast Teaching Hospital, Ghana: A point prevalence survey study.

Antimicrobial resistance (AMR) is a global threat that necessitates coordinated strategies to improve antibiotic prescribing and reduce AMR. A key activity is ascertaining current prescribing patterns in hospitals to identify targets for quality improvement programmes. The World Health Organisation point prevalence survey methodology was used to assess antibiotic prescribing in the Cape Coast Teaching Hospital. All core variables identified by the methodology were recorded. A total of 78.8% (82/104) patients were prescribed at least one antibiotic, with the majority from adult surgical wards (52.14%). Significantly longer hospital stays were associated with patients who underwent surgery (p = 0.0423). "Access" antibiotics dominated total prescriptions (63.8%, 132/207) with ceftriaxone, cefuroxime, and ciprofloxacin being the most prescribed "Watch" antibiotics. The most common indications were for medical prophylaxis (59.8%, 49/82) and surgical prophylaxis (46.3%, 38/82). Over one-third of surgical prophylaxis (34.2%, 13/38) indications extended beyond one day. There was moderate documentation of reasons for antibiotic treatment in patient notes (65.9%, 54/82), and targeted therapy after samples were taken for antimicrobial susceptibility testing (41.7%, 10/24). Guideline compliance was low (25%) where available. There was high use of antibiotics within the hospital which needs addressing. Identified quality targets include developing surgical prophylaxis guidelines, reviewing "Watch" antibiotic prescribing, and assessing antibiotic durations for patients on two or more antibiotics. Organizational-level deficiencies were also identified that need addressing to help instigate ASPs. These can be addressed by developing local prescribing protocols and antibiotic stewardship policies in this hospital and wider in Ghana and across Africa.

Comparative antibiogram of annual antimicrobial susceptibility trend in a tertiary care institution in Telangana with ICMR annual AMR report for the year 2021

Introduction: Antibiogram data can improve hospital antibiotic formulary decisions and local protocols such as surgical prophylaxis or empirical treatment guidelines. This study aims to compare the antimicrobial resistance (AMR) trends observed in our institution with the national data published by the Indian Council of Medical Research (ICMR). Methods: The annual antibiogram of all common clinical isolates received in the hospital in 2021 was constructed as per the consensus guidelines developed by the Clinical and Laboratory Standards Institute, and the antimicrobial susceptibility trends were compared with the Indian Council of Medical Research annual Antimicrobial Resistance Report for 2021. Results: A total of 719 first isolates (excluding duplicate isolates) of common organisms viz., Escherichia coli (n = 198), Klebsiella pneumoniae (n = 164), Pseudomonas aeruginosa (n = 70), methicillin-sensitive Staphylococcus aureus (MSSA) (n = 174), methicillin-resistant Staphylococcus aureus (MRSA) (n = 39), Enterococcus species (n = 74) were analyzed and described as in charts. Discussion: The percentage susceptibility of gram-positive isolates to vancomycin, linezolid, tetracycline, nitrofurantoin, and fosfomycin was comparable to the national ICMR AMR report, whereas there were differences in the susceptibility rates to other antimicrobial agents such as penicillin, ampicillin, erythromycin, clindamycin, and co-trimoxazole. The percentage susceptibility of P. aeruginosa isolates was comparable to the national ICMR AMR report for all anti-pseudomonal agents tested and analyzed. The gram-negative isolates showed better susceptibility rates to the beta-lactam antibiotics, fluoroquinolones, and carbapenems in comparison to the national ICMR AMR report. Conclusion: Analysis of antibiograms from different regions of our country would show us the trends and patterns of antimicrobial resistance.

Antibiotic use in spine surgery: A narrative review based in principles of antibiotic stewardship

BackgroundA growing emphasis on antibiotic stewardship has led to extensive literature regarding antibiotic use in spine surgery for surgical prophylaxis and the treatment of spinal infections. PurposeThis article aims to review principles of antibiotic stewardship, evidence-based guidelines for surgical prophylaxis and ways to optimize antibiotics use in the treatment of spinal infections. MethodsA narrative review of several society guidelines and spine surgery literature was conducted. ResultsAntibiotic stewardship in spine surgery requires multidisciplinary investment and consistent evaluation of antibiotic use for drug selection, dose, duration, drug-route, and de-escalation. Developing effective surgical prophylaxis regimens is a key strategy in reducing the burden of antibiotic resistance. For treatment of primary spinal infection, the diagnostic work-up is vital in tailoring effective antibiotic therapy. The future of antibiotics in spine surgery will be highly influenced by improving surgical technique and evidence regarding the role of bacteria in the pathogenesis of degenerative spinal pathology. ConclusionsIncorporating evidence-based guidelines into regular practice will serve to limit the development of resistance while preventing morbidity from spinal infection. Further research should be conducted to provide more evidence for surgical site infection prevention and treatment of spinal infections.

Enterobacter cloacae infection characteristics and outcomes in battlefield trauma patients.

Enterobacter cloacae is a Gram-negative rod with multidrug-resistant potential due to chromosomally-induced AmpC β-lactamase. We evaluated characteristics, antibiotic utilization, and outcomes associated with battlefield-related E. cloacae infections (2009-2014). Single initial and serial E. cloacae isolates (≥24 hours from initial isolate from any site) associated with a clinical infection were examined. Susceptibility profiles of initial isolates in the serial isolation group were contrasted against last isolate recovered. Characteristics of 112 patients with E. cloacae infections (63 [56%] with single initial isolation; 49 [44%] with serial isolation) were compared to 509 patients with bacterial infections not attributed to E. cloacae. E. cloacae patients sustained more blast trauma (78%) compared to non-E. cloacae infections patients (75%; p<0.001); however, injury severity scores were comparable (median of 34.5 and 33, respectively; p = 0.334). Patients with E. cloacae infections had greater shock indices (median 1.07 vs 0.92; p = 0.005) and required more initial blood products (15 vs. 14 units; p = 0.032) compared to patients with non-E. cloacae infections. Although E. cloacae patients had less intensive care unit admissions (80% vs. 90% with non-E. cloacae infection patients; p = 0.007), they did have more operating room visits (5 vs. 4; p = 0.001), longer duration of antibiotic therapy (43.5 vs. 34 days; p<0.001), and lengthier hospitalizations (57 vs. 44 days; p<0.001). Patients with serial E. cloacae had isolation of infecting isolates sooner than patients with single initial E. cloacae (median of 5 vs. 8 days post-injury; p = 0.046); however, outcomes were not significantly different between the groups. Statistically significant resistance to individual antibiotics did not develop between initial and last isolates in the serial isolation group. Despite current combat care and surgical prophylaxis guidelines recommending upfront provision of AmpC-inducing antibiotics, clinical outcomes did not differ nor did significant antibiotic resistance develop in patients who experienced serial isolation of E. cloacae versus single initial isolation.

National surgical antibiotic prophylaxis guideline in Singapore

Institutional surgical antibiotic prophylaxis (SAP) guidelines are in place at all public hospitals in Singapore, but variations exist and adherence to guidelines is not tracked consistently. A national point prevalence survey carried out in 2020 showed that about 60% of surgical prophylactic antibiotics were administered for more than 24 hours. This guideline aims to align best practices nationally and provides a framework for audit and surveillance. This guideline was developed by the National Antimicrobial Stewardship Expert Panel's National Surgical Antibiotic Prophylaxis Guideline Development Workgroup Panel, which comprises infectious diseases physicians, pharmacists, surgeons and anaesthesiologists. The Workgroup adopted the ADAPTE methodology framework with modifications for the development of the guideline. The recommended duration of antibiotic prophylaxis was graded according to the strength of consolidated evidence based on the scoring system of the Singapore Ministry of Health Clinical Practice Guidelines. This National SAP Guideline provides evidence-based recommendations for the rational use of antibiotic prophylaxis. These include recommended agents, dose, timing and duration for patients undergoing common surgeries based on surgical disciplines. The Workgroup also provides antibiotic recommendations for special patient population groups (such as patients with β-lactam allergy and patients colonised with methicillin-resistant Staphylococcus aureus), as well as for monitoring and surveillance of SAP. This evidence-based National SAP Guideline for hospitals in Singapore aims to align practices and optimise the use of antibiotics for surgical prophylaxis for the prevention of surgical site infections while reducing adverse events from prolonged durations of SAP.

WHO Point Prevalence Survey to Describe the Use of Antimicrobials at a Tertiary Care Center in Pakistan: A Situation Analysis for Establishing an Antimicrobial Stewardship Program.

Antimicrobial stewardship is a systematic approach for promoting and monitoring responsible antimicrobial use globally. We conducted a prospective point prevalence survey of antimicrobial utilization among hospitalized adult patients during September 2021. The survey instrument was adapted from the WHO methodology for point prevalence surveys, and it was conducted at The Indus Hospital and Health Network, Karachi. Among the 300 admitted patients, 55% were males and the mean age was 44 (±18) years. At least 67% of the patients received one antimicrobial agent and the most common indication was surgical prophylaxis (40%). The most frequently used were antibacterial agents (97%) among all antimicrobials. Amoxicillin/Clavulanic acid and Ceftriaxone were the most frequently used antibacterial agents, i.e., 14% each. At least 56% of the antibacterial agents were amenable to antimicrobial stewardship when reviewed by infectious disease (ID) experts. Reasons for stewardship were: antibacterial not indicated (n = 39, 17.0%), unjustified prolonged duration of antibacterial (n = 32, 13.9%), extended surgical prophylaxis (n = 60, 26.2%), non-compliance to surgical prophylaxis guidelines (n = 30, 13.1%), and antibacterial not needed on discharge (n = 27, 11.7%). Median days of therapy (DOT) per agent was 3 days (IQR 2-4), while median DOT per patient was 2 days (IQR 1-4). These data have described the pattern of antimicrobial utilization in our institute. We found a higher prevalence of antimicrobial use overall as compared to the global figures, but similar to other low- and middle-income countries. Two important areas identified were the use of antimicrobials on discharge and extended surgical prophylaxis. As a result of these data, our institutional guidelines were updated, and surgical teams were educated. A post-intervention survey will help us to further determine the impact. We strongly recommend PPS at all major tertiary care hospitals in Pakistan for estimating antimicrobial utilization and identifying areas for stewardship interventions.

Antibiotic point prevalence survey at a tertiary healthcare hospital in India: Identifying strategies to improve the antibiotic stewardship program immediately after a COVID-19 wave

BackgroundThe COVID-19 pandemic has substantially affected the antibiotic stewardship activities in most hospitals of India.AimsWe conducted an antibiotic point-prevalence survey (PPS) immediately after the decline of a major COVID-19 wave at a dedicated COVID-19 hospital. By doing so we aimed to identify the antibiotic prescription patterns, identify factors influencing the choice of antibiotics, and identify/develop strategies to improve the antibiotic stewardship program in such setups.MethodsThe PPS was single-centred, cross-sectional, and retrospective in nature. Patients admitted in various wards and intensive care units (ICUs) between September 2021 to October 2021 were included in our PPS.ResultsOf the included 460 patients, 192 were prescribed antibiotics. Of these 192 patients, ICU-admitted patients had the highest number of antibiotics prescribed i.e. 2.09 ± 0.92. Only a minor fraction (7.92 %) of antibiotics prescriptions were on the basis of culture reports. Most of the antibiotics were prescribed empirically by the parenteral route. The most common group of antibiotics prescribed were third-generation cephalosporins. Carbapenems were the most common designated antibiotics prescribed. A large number of patients (22.40 %) were prescribed double anaerobic cover.ConclusionThe strategies that we identified to improve the antibiotic stewardship program at our institute included reviving the culture of sending culture reports to prescribe antibiotics, improving surgical prophylaxis guidelines, training resident doctors to categorize antibiotic prescriptions appropriately, closely monitoring prescriptions providing double anaerobic cover, and improving the electronic medical record system for improving prescription auditing.

Antibiotic Usage in Surgical Prophylaxis: A Retrospective Study in the Surgical Ward of a Governmental Hospital in Riyadh Region.

Antibiotic prophylaxis is used to decrease the bacterial load in the wound to assist the natural host defenses in preventing the occurrence of surgical site infections. The present study aimed to investigate trends in using antibiotic prophylaxis in the surgical ward of a governmental hospital in the Riyadh Region and included collecting data concerning the use of antibiotic prophylaxis from medical electronic records. During 2020, most of the surgical patients received systemic antibiotics (82.40%). The most prescribed antibiotics were ceftriaxone (28.44%) and metronidazole (26.36%). The study also found that most of the patients received antibiotics for seven days or for five days, and only 1.08% of the patients received antibiotics appropriately for a maximum of one day. The present study showed that there was a major problem in selecting the correct antibiotic and in the duration of its use compared with the recommendations of the surgical prophylaxis guideline that was issued by the Saudi Ministry of Health. Thus, there is an urgent need to improve the adherence to the recommendations of surgical antibiotic prophylaxis guidelines in order to reduce the occurrence of negative consequences.

Adherence and outcomes of a surgical prophylaxis guideline promoting cephalosporin use among patients with penicillin allergy

BackgroundThe study purpose was to assess adherence to a local surgical prophylaxis guideline in patients with reported penicillin allergies, which recommends cephalosporins as first-line prophylaxis. MethodsAdult patients with penicillin allergies admitted for a surgical procedure from July 2020 to June 2021 were retrospectively screened, and the first surgery per admission was included. The primary outcome was the proportion of surgeries using β-lactam prophylaxis. Additional outcomes included prophylaxis timing, hypersensitivity reactions, acute kidney injury, infectious complications, duration of stay, and 30-day mortality or readmission. ResultsAmong 597 procedures, 504 patients (84.4%) received a β-lactam for surgical prophylaxis, including 494 (82.3%) who received a cephalosporin. Patients in the non–β-lactam group were more likely to have a type I IgE–mediated penicillin allergy (48.4% vs 31.7%, P = .002); however, the majority with type I reactions still received β-lactams (78.0%), including in the setting of anaphylaxis or angioedema to penicillin (67.7%). Zero allergic reactions to prophylaxis antibiotics were reported in either group, and there were no significant differences in the proportion of patients receiving drugs associated with the management of allergic reactions. Receipt of non–β-lactams was associated with inappropriate prophylaxis timing (9.7% vs 3.2%, P = .005) and postprocedural acute kidney injury (7.5% vs 0.6%, P < .001). All other outcomes were nonsignificant between the groups. ConclusionAmong surgical patients with a documented penicillin allergy, most received cephalosporin prophylaxis as recommended by institutional guidelines, with zero allergic reactions. Receipt of non–β-lactam prophylaxis was associated with worsened outcomes. Cephalosporin prophylaxis should be preferred for surgical patients, including in the setting of true penicillin allergy.

1125. Decreasing Concomitant Vancomycin and Piperacillin-Tazobactam Use in Children to Reduce Incidence of Acute Kidney Injury

Abstract Background Concomitant use of vancomycin (V) and piperacillin-tazobactam (PT) is associated with increased incidence of acute kidney injury (AKI). AKI develops 3 times faster on this combination compared to alternative vancomycin combinations. We sought to reduce AKI in our patients by reducing concomitant use of V/PT using a QI framework. Methods We implemented several PDSA cycles to reduce concomitant V/PT use at a 415-bed quaternary children’s hospital in Boston, MA. Interventions included substitution of PT with other agents in surgical prophylaxis guidelines and order sets starting in February 2020 and in the hospital-wide sepsis order set in March 2021. The Antimicrobial Stewardship Program reinforced these changes during daily audit-and-feedback reviews. In November 2020, we implemented an electronic alert that apprises clinicians of the AKI risk when V/PT are ordered and recommends an alternative regimen. We measured the monthly number of patients on combination V/PT, new exposures to nephrotoxic medications, AKI events, and the percentage of days with serum creatinine monitoring for patients on ≥2 nephrotoxic medications. Results From 02/01/20 to 05/31/21, the number of patients exposed to combination V/PT decreased from 23 to 6 per month (Figure 1). New nephrotoxic medication exposures declined from 17.1 to 7.7 per 1,000 patient days, and AKI events dropped from 2.8 to 0.6 per 1,000 patient days (Figures 2 and 3). The percentage of days with serum creatinine monitoring increased from 60% to 66%. Rate of New Exposures to Nephrotoxic Medications per 1000 Patient Days Conclusion Revising guidelines and electronic order sets and implementing an order alert led to marked decreases in exposures to V/PT and nephrotoxic medications overall and was associated with reduced AKI events. Use of electronic health record tools is an effective way to drive safer antimicrobial use. Disclosures Gabriella S. Lamb, MD, MPH, Nothing to disclose

137. Impact of Antimicrobial Stewardship Interventions on Post-Elective Caesarean Antibiotic Prophylaxis and Surgical Site Infections

BackgroundAntimicrobial stewardship programs (ASP) aim to improve appropriate antimicrobial use. Post-operative antibiotics are generally not necessary, especially those without surgical site infections risk factors (e.g. obesity). Few studies have described the impact of ASP interventions on patient outcomes especially in unique populations such as obstetrics. This study aims to evaluate the impact of ASP interventions on post-elective caesarean (eLSCS) oral antibiotic prophylaxis use and patient outcomes including SSI rates.MethodsThis pre-post quasi-experimental study was conducted over 9 months (2 months pre- and 7 months post-intervention) in all women admitted for eLSCS in our institution. Interventions included eLSCS surgical prophylaxis guideline dissemination, where a single antibiotic dose within 60 minutes before skin incision was recommended. Post-eLSCS oral antibiotics was actively discouraged in those without SSI risk factors. This was followed by ASP intervention notes (phase 1) for 3 months, and an additional phone call to the ward team for the next 7 months (phase 2). Phase 3 (next 6 months) constituted speaking to the operating consultant. The primary outcome was post-operative oral antibiotics prescription rates. Secondary outcomes included rates of 30-day post-operative SSI.ResultsA total of 1751 women was reviewed. Appropriateness of pre-operative antibiotic prophylaxis was 98% in our institution. There were 244 women pre-intervention, 274 in post-intervention phase 1, 658 in phase 2 and 575 in phase 3. Pre-intervention post-eLSCS antibiotic prescribing rates was 82% (200), which reduced significantly post-intervention to 54% (148) in phase 1, 50% (331) in phase 2 and 39% (226) in phase 3 (p< 0.001). There was no significant difference in patients who developed post-operative SSI pre-post intervention (0.8%, 2 of 242 vs. 1.9%, 28 of 1479, p=0.420) and among who received post-operative oral antibiotics compared to those without (1.9%, 17 of 905 vs. 1.5%, 13 of 846, p=0.582).ConclusionASP interventions can reduce post-eLSCS antibiotic prophylaxis rates without adversely impacting patient safety.Disclosures All Authors: No reported disclosures

Perceptions of surgeons on surgical antibiotic prophylaxis use at an urban tertiary hospital in Tanzania.

Surgical Site Infections are a major cause of morbidity and mortality among operated patients. In spite of the accessibility of universal and national guidelines for surgical prophylaxis, recent studies surveying the present routine of prophylaxis have demonstrated overutilization of a wide range antibacterial medication for a single patient. Few studies have shown qualitatively factors influencing this and perceptions of surgeons on surgical antibiotic prophylaxis use. Unfortunately, none of these studies have been done in Tanzania. To describe the perceptions of surgeons on surgical antibiotic prophylaxis use at an urban tertiary hospital. A qualitative study involving in-depth interviews with surgeons was conducted in English by the primary investigator. The interviews were audio-recorded and transcribed verbatim. Systematic text condensation by Malterud was used for data analysis. Fourteen surgeons and obstetrics and gynaecologists participated. Their perceptions were summarized into three main categories: Inadequate data to support practice; one who sees the patient decides the antibiotic prophylaxis; prolonged antibiotic use for fear of unknown. The participants perceived that choice of antibiotic should be based on local hospital data for bacterial resistance pattern, however the hospital guidelines and data for surgical site infection rates are unknown. Fear of getting infection and anticipating complications led to prolonged antibiotics use. The study provides an understanding of surgical antibiotic prophylaxis use and its implementation challenges. This was partly expressed by unavailability of local data and guidelines to enhance practice. To improve this, there is a need of guidelines that incorporates local resistance surveillance data and enhanced antibiotic stewardship programmes. A strong consideration should be placed into ways to combat the fears of surgeons for complications, as these significantly affect the current practise with use of surgical antibiotic prophylaxis.

Antimicrobial prescribing in the surgical and medical wards at a private hospital in KwaZulu-Natal, South Africa, 2019.

Appropriate antimicrobial use is imperative owing to the misuse of antimicrobials, which has resulted in a growing burden of antimicrobial resistance. Evidence-based guidelines should be adhered to in order to ensure the sustainability of effective antimicrobials. To assess the appropriateness of antimicrobial prescribing at a private hospital in Durban, KwaZulu-Natal, South Africa. The records of patients admitted to the surgical and medical wards over a 2-month period were reviewed to assess the choice, dose and duration of prescribed antimicrobials. The guidelines used to determine the appropriateness of the prescriptions were: the Standard Treatment Guidelines and Essential Medicines List for South Africa - Hospital Level Adults, 2015 edition, the antimicrobial indications and prescribing instructions in the South African Medicines Formulary, the South African Antibiotic Stewardship Programme guidelines and the evidence-based surgical prophylaxis guidelines adopted by the hospital group where the research was conducted. During the study period, 466 patients were admitted and prescribed an antimicrobial, of whom 220 (47.2%) were admitted to the surgical ward and 246 (52.8%) to the medical wards. A total of 779 antimicrobials were prescribed. Of the 660 antimicrobials prescribed for empirical treatment, 305 (46.2%) were appropriately prescribed based on drug choice, dose and duration. Of the 38 antimicrobials that were classified as targeted, 36 (94.7%) were prescribed at the correct dose and 33 (86.8%) for the correct duration. Of the 81 antimicrobials prescribed for surgical prophylaxis, only 32 (39.5%) met the criteria for appropriateness in terms of drug choice, dose and duration. Our findings suggest that compliance with evidence-based guidelines for the use of antimicrobials is not optimal in hospitals in the private sector. Antimicrobials are prescribed inappropriately for empirical treatment and for surgical prophylaxis. Private hospital groups should consider adopting antimicrobial prescribing guidelines that are mandatory for doctors to adhere to in order to promote rational antimicrobial prescribing, and thereby reduce the burden of antimicrobial resistance.

Incidence of Surgical-Related Infections in Temporary Mechanical Circulatory Support Patients Using Narrow Spectrum versus Broad Spectrum Peri-Operative Antibiotic Prophylaxis

Purpose To date, there are no studies evaluating the effects of prophylactic antibiotic regimens in patients receiving temporary Impella® mechanical circulatory support (MCS). The purpose of this study was to compare the incidence of surgical-related infections within 30 days of temporary MCS implantation in patients receiving narrow versus broad spectrum peri-operative antibiotics. Methods 89 Patients receiving Impella® 5, 5.5, and CP devices in a surgical setting at Cedars-Sinai Medical Center from January 2017 to August 2020 were included for analysis which was IRB approved. This study period includes devices implanted before and after the implementation of MCS Antibiotic Selection for Surgical Prophylaxis Guideline. This protocol recommends cefazolin or ceftriaxone for pre-op surgical prophylaxis, with gentamicin for additional gram-negative coverage and vancomycin for beta-lactam allergy. 34/89 (38.2%) patients were identified as Stewardship (protocol adherence), while 27/89 (30.3%) were identified as Conventional (protocol non-adherence) another 28/89 (31.5%) patients were identified as Pre-existing (admitted with prior antimicrobial). The primary endpoint was the incidence of surgical site infections (SSI) and surgical-related bacteremia (SRB) within 30-day post-implant period. The secondary endpoint was protocol adherence. Results 72%, 26% and 2% of patients were bridged to heart transplant, durable MCS or no device, at 30 days respectively. There were no cases of SSI within 30 days post-operatively in any group, except for one case of SRB with Streptococcus mitis bacteremia in the Conventional group. Patients were screened for Methicillin-resistant Staphylococcus aureus (MRSA) colonization before incision in 72.2% of cases (mean, 2.6 days prior to device implantation). Reasons for non-adherence included incorrect duration of post-operative antibiotic(s) (44.4%), no pre-operative antibiotic given prior to incision (25.9%), and incorrect pre-operative antibiotic(s) given (22.2%). Conclusion The absence of SSI and SRB among Stewardship group supports narrow spectrum pre-op antibiotic prophylaxis over broad-spectrum agents for Impella® non-durable MCS.

Antibiotic Prophylaxis in Plastic Surgery Correlation Between Practice and Evidence.

Background:The use of appropriate preoperative antibiotic prophylaxis decreases the risk of surgical site infections (SSI); however, the breadth of plastic surgery procedures makes it challenging to ensure appropriate use for each unique procedure type. Currently, plastic surgeons lack a cohesive and comprehensive set of evidence-based guidelines (EBG) for surgical prophylaxis. We sought to profile the perioperative antibiotic prescribing patterns for plastic surgeons in British Columbia to investigate if they are congruent with published recommendations. In doing so, we aim to determine risk factors for antibiotic overprescribing in the context of surgical prophylaxis.Methods:A literature review identifying EBG for antibiotic prophylaxis use during common plastic surgery procedures was performed. Concurrently, a provincial survey of plastic surgery residents, fellows, academic and community plastic surgeons was used to identify their antibiotic prophylaxis prescribing practices. These findings were then compared to recommendations identified from our review. The compliance of the provincial plastic surgery community with current EBG was determined for 38 surgical scenarios to identify which clinical factors and procedure types were associated with unsupported antibiotic use.Results:Within the literature, 31 of the 38 categories of surveyed plastic surgery operations have EBG for use of prophylactic antibiotics. When surgical procedures have EBG, 19.5% of plastic surgery trainees and 21.9% of practicing plastic surgeons followed recommended prophylaxis use. Average adherence to EBG was 59.1% for hand procedures, 24.1% for breast procedures, and 23.9% for craniofacial procedures. Breast reconstruction procedures and contaminated craniofacial procedures were associated with a significant reduction in adherence to EBG resulting in excessive antibiotic use.Conclusion:Even when evidence-based recommendations for antibiotic prophylaxis exist, plastic surgeons demonstrate variable compliance based on their reported prescribing practices. Surgical procedures with low EBG compliance may reflect risk avoidant behaviors in practicing surgeons and highlight the importance of improving education on the benefits of antibiotic prophylaxis in these clinical situations.

Current Status of Antimicrobial Stewardship Programs in São Paulo Hospitals

OBJECTIVES:Antimicrobial stewardship programs (ASPs) comprise coordinated interventions designed to improve antimicrobial use. Understanding the current structure of ASP hospitals will support interventions for the improvement of these programs. This study aimed to describe the status of ASPs in hospitals in São Paulo, Brazil.METHODS:A cross-sectional survey was conducted on the ASPs of hospitals in the state of São Paulo from March to July 2018. Through interviews by telephone or e-mail, we queried which components of the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America and Centers for Disease Control and Prevention guidelines were implemented.RESULTS:The response rate was 30% (28/93 hospitals), and 26 hospitals (85%) reported having a formal ASP. The most frequently implemented strategies were antimicrobial surgical prophylaxis guidelines (100%), empiric sepsis guidelines (93%), and the presence of ASP team members during bedside rounds (96%). The least commonly implemented strategies included prior authorization for all antimicrobials (11%), pharmacokinetic monitoring, and an adjustment program for patients on IV aminoglycosides (3%). Regarding the metrics of the ASP, the most common indicator was the rate of antimicrobial resistance (77%). Eighteen hospitals evaluated antimicrobial consumption using defined daily dose, and only 29% evaluated the days of therapy; 61% of hospitals reported their results to the hospital administration and 39% to the prescribers.CONCLUSIONS:Most hospitals have a formal and active ASP, but with timely actions. We observed inconsistencies between what program leaders understand as the main objective of ASP and the metrics used to evaluate it. Part of the effort for the next few years should be to improve program evaluation metrics and to provide feedback to physicians and hospital leadership.

69. Impact of antimicrobial stewardship interventions on post-elective caesarean antibiotic prophylaxis and surgical site infections

BackgroundAntimicrobial stewardship programs (ASP) aim to improve appropriate antimicrobial use. This study aims to evaluate the impact of ASP interventions on post-elective caesarean (eLSCS) oral antibiotic prophylaxis use. In a subgroup of those without surgical site infection (SSI) risk factors, 30-day SSI rates was compared in those who received post-eLSCS oral antibiotics vs. those without.MethodsThis pre-post quasi-experimental study was conducted over 9 months (2 months pre- and 7 months post-intervention) in all women admitted for eLSCS in our institution. Interventions included eLSCS surgical prophylaxis guideline dissemination, where a single antibiotic dose within 60 minutes before skin incision was recommended. Post-eLSCS oral antibiotics was discouraged in those without SSI risk factors (e.g. obesity). This was followed by ASP intervention notes (phase 1) for 3 months, and an additional phone call to the ward team for the next 4 months (phase 2).ResultsA total of 894 women were reviewed. There were 244 women in the pre-intervention phase, 274 in post-intervention phase 1 and 376 in phase 2. Pre-intervention post-eLSCS antibiotic prescribing rates was 82% (200), compared to 54% (148) in phase 1 and 49% (180) in phase 2 (p< 0.001). There were 560 women without SSI risk factors. Of these, only 4 of 301 (1.3%) who received oral antibiotics, and 3 of 259 (1.2%) without oral antibiotics developed post-op SSI (p=1.000).ConclusionASP can reduce post-eLSCS antibiotic prophylaxis. In those without SSI risk factors, use of post-eLSCS oral antibiotics did not impact SSI rates.Disclosures All Authors: No reported disclosures