Timing Of Antimicrobial Prophylaxis Research Articles

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.

Time to development of surgical site infection and its predictors among general surgery patients admitted at specialized hospitals in Amhara region, northwest Ethiopia: a prospective follow-up study

BackgroundSurgical site infection is an infection occurring within 30 days after surgery. It is recently reported that evidence-based information on the specific time when the majority of surgical site infections would develop is a key to early detect the infection as well as to preventing and early intervene against their pressing and fatal complications. Therefore, the current study aimed to determine the incidence, predictors, and time to development of surgical site infection among general surgery patients at specialized hospitals in the Amhara region.MethodAn institution-based prospective follow-up study was conducted. The two-stage cluster sampling procedure was used. A systematic sampling technique with a K interval of 2 was applied to prospectively recruit 454 surgical patients. Patients were followed up for 30 days. Data were collected using Epicollect5 v 3.0.5 software. Post-discharge follow-up and diagnosis were done by telephone call follow-up. Data were analyzed using STATA™ version 14.0. Kaplan–Meier curve was used to estimate survival time. Cox proportional regression model was used to determine significant predictors. Variables with a P-value less than 0.05 in the multiple Cox regression models were independent predictors.ResultThe incidence density was 17.59 per 1000 person-day-observation. The incidence of post-discharge Surgical site infection was 70.3%. The majority of surgical site infections were discovered after discharge between postoperative days 9 to 16. Being male (AHR: 1.98, 95% CI: 1.201 – 3.277, diabetes Mellitus (AHR: 1.819, 95% CI: 1.097 – 3.016), surgical history (AHR: 2.078, 95% CI: 1.345, 3.211), early antimicrobial prophylaxis (AHR: 2.60, 95% CI: 1.676, 4.039), American Society of Anesthesiologists score ≥ III AHR: 6.710, 95% CI: 4.108, 10.960), duration of the surgery (AHR: 1.035 95% CI: 1.001, 1.070), Age (AHR: 1.022 95% CI: 1.000, 1.043), and the number of professionals in the Operation Room (AHR: 1.085 95% CI: 1.037, 1.134) were found to be the predictors of time to development of Surgical site infection.ConclusionThe incidence of surgical site infection was higher than the acceptable international range. The majority of infections were detected after hospital discharge between 9 to 16 postoperative days. The main predictors of Surgical site infection were Age, Sex, Diabetes Mellitus, previous surgical history, the timing of Antimicrobial prophylaxis, American Society of Anesthesiologists score, pre-operative hospital stay, duration of surgery, and the number of professionals in the operation room. Hence, hospitals should give great emphasis on pre-operative preparation, post-discharge surveillance, modifiable predictors, and high-risk patients, as they found in this study.

Optimal timing of antimicrobial prophylaxis before surgery: a review of recent evidence.

Optimal timing of antimicrobial prophylaxis before surgery: a review of recent evidence.

Antibiotic Prophylaxis for the Prevention of Infectious Complications following Prostate Biopsy: A Systematic Review and Meta-Analysis.

Infectious complications following prostate biopsy are increasing and fluoroquinolone prophylaxis has recently been banned by the European Commission. In this systematic review we summarize the evidence for different antibiotic prophylaxis regimens. We searched MEDLINE®, Embase® and Cochrane Database for randomized controlled trials (inception to October 2019) assessing antimicrobial interventions in prostate biopsy. Primary outcome was infectious complications. Exclusion criteria were simultaneous interfering interventions. GRADE (Grading of Recommendations, Assessment, Development and Evaluations) was used to assess the certainty of evidence. Protocol was registered with PROSPERO (CRD42015026354). Overall 59 randomized controlled trials (14,153 participants) and 7 different antimicrobial interventions were included. Antibiotic prophylaxis reduced infectious complications compared to no prophylaxis (RR 0.56, 95% CI 0.40-0.77, p=0.0005, I2=15%, participants 1,753, studies 11). A short-term prophylaxis (single shot to 3 days) was inferior to a long-term prophylaxis (1 to 7 days) with fluoroquinolone (RR 1.89, 95% CI 1.37-2.61, p=0.0001, I2=0%, participants 3,999, studies 17). Fosfomycin trometamol was an alternative to fluoroquinolone with reduced rates of infectious complications (RR 0.49, 95 CI 0.27-0.87, p=0.02, I2=54%, participants 1,239, studies 3). Empiric prophylaxis was inferior to targeted prophylaxis (RR 1.81, 95% CI 1.28-2.55, p=0.0008, I2=48%, participants 1,511, studies 6). Standard prophylaxis was inferior to augmented prophylaxis (using multiple rather than single agent) using a fixed model (RR 2.10, 95% CI 1.53-2.88, p <0.0001, I2=71%, participants 2,597, studies 9), but not using a random model (p=0.07). No difference was observed in infectious complications based on route or timing of antimicrobial prophylaxis. The certainty of evidence was rated as low/very low. In countries where fluoroquinolones are allowed as antibiotic prophylaxis, a minimum of a full 1-day administration as well as targeted therapy in case of fluoroquinolone resistance is recommended. In countries with a ban on fluoroquinolones, fosfomycin is a good alternative, as is augmented prophylaxis, although no established standard combination exists to date.

Timing of antimicrobial prophylaxis and infectious complications in pediatric patients undergoing appendectomy

PurposeAntibiotic administration within one hour prior to incision is a common quality metric; however, antibiotics are typically started at the time of diagnosis in pediatric patients with acute appendicitis. The purpose was to determine if antibiotic administration within one hour prior to incision reduces the incidence of surgical site infections (SSI) in pediatric patients with acute appendicitis started on parenteral antibiotics upon diagnosis. MethodsA retrospective review was performed of 478 patients aged 0–18years who underwent appendectomy for acute appendicitis from 7/2013 to 4/2015. Patients were categorized based on timing of antibiotic administration; there were 198 patients in Group A (<60min before) and 280 in Group B (>60min before). ResultsDemographics and operative time (A: 30.5±9.9 vs B: 30.8±12.2min, p=0.51) were similar. Procedures were performed laparoscopically and the groups had similar proportions of single-incision operations (A: 53% vs B: 55%, p=0.64). There was no difference in the incidence of superficial SSI (A: 2.0% vs B: 2.1%, p=1.0) or intraabdominal abscess (A: 4.0% vs B: 3.6%, p=0.81) and this remained true when stratified by intraoperative classification. ConclusionAntibiotic administration within one hour of appendectomy in pediatric patients with acute appendicitis who receive antibiotics at diagnosis did not change the incidence of postoperative infectious complications. Type of studyTreatment study. Level of evidenceIII.

Deep sternal wound infection after cardiac surgery: Evidences and controversies.

Despite many advances in prevention and perioperative care, deep sternal wound infection (DSWI) remains a pressing concern in cardiac surgery, with a still relevant incidence and with a considerable impact on in-hospital mortality and also on mid- and long-term survival. The permanent high impact of this complication is partially related to the increasing proportion of patients at high-risk for infection, as well as to the many patient and surgical risk factors involved in the pathogenesis of DSWI. The prophylactic antibiotic therapy is one of the most important tools in the prevention of DSWI. However, the choice of antibiotic, the dose, the duration, the adequate levels in serum and tissue, and the timing of antimicrobial prophylaxis are still controversial. The treatment of DSWI ranges from surgical revision with primary closure to surgical revision with open dressings or closed irrigation, from reconstruction with soft tissue flaps to negative pressure wound therapy (NPWT). However, to date, there have been no accepted recommendations regarding the best management of DSWI. Emerging evidence in the literature has validated the efficacy and safety of NPWT either as a single-line therapy, or as a "bridge" prior to final surgical closure. In conclusion, the careful control of patient and surgical risk factors - when possible, the proper antimicrobial prophylaxis, and the choice of validated techniques of treatment could contribute to keep DSWIs at a minimal rate.

Pharmacological aspects of the antibiotics used for urological diagnostic procedures

Surgical antimicrobial prophylaxis is the use of an antibiotic before, during, or shortly after a urological procedure to prevent postoperative infections such as urinary tract or wound infection. The optimal antimicrobial drug must be microbiologically active against the most frequent potential pathogens and have good pharmacological properties.Correct timing of antimicrobial prophylaxis is the first critical issue in determining treatment efficacy. The antibiotic must be administered before the start of the surgical procedure in order to ensure a high tissue level at the time of microbial contamination. If using an oral antibiotic, this must be administered 1–3 hours before the operation and a parenteral antibiotic should be administered at the induction of anaesthesia.The antibiotics potentially useful for antimicrobial prophylaxis are the beta-lactams, cotrimoxazole, fluoroquinolones, and fosfomycin trometamol. The criteria for choosing the optimal antibiotic include an appropriate antimicrobial spectrum, favourable pharmacokinetic parameters (especially good tissue penetration), and elevated safety or tolerability. The use of cotrimoxazole must be restricted due to increasing chemoresistance. Unfortunately fluoroquinolone-based regimens, once the mainstay of prophylaxis guidelines, are increasingly ineffective due to a constant increase in multidrug-resistant (MDR) Gram-negative bacteria. The same concerns apply with regard to the second and third generation cephalosporins that have problems of resistance and, if administered orally, do not sufficiently penetrate prostatic tissue. An appropriate beta-lactam could be an aminopenicillin combined with a beta-lactamase inhibitor.Fosfomycin trometamol can also be a good potential choice due to its elevated activity against MDR Gram-negative bacteria and its favourable pharmacokinetic parameters, including an elevated penetration into prostatic tissue.

Use and Outcomes of Extended Antibiotic Prophylaxis in Urological Cancer Surgery

Although perioperative antibiotic prophylaxis prevents postoperative infectious complications, national guidelines recommend cessation of antibiotics within 24 hours after the procedure. Extended antibiotic prophylaxis beyond 24 hours may contribute to hospital acquired infections such as Clostridium difficile colitis. We evaluated practice patterns of antibiotic prophylaxis in genitourinary cancer surgery and assessed the impact of antibiotic prophylaxis on hospital acquired C. difficile infections. We identified 59,184 patients treated with radical prostatectomy, 27,921 who underwent partial or radical nephrectomy, and 5,425 treated with radical cystectomy for prostate, kidney and bladder cancers, respectively, from the Premier Perspective Database (Premier Inc., Charlotte, North Carolina) from 2007 to 2012. We constructed hierarchical linear regression models to identify patient and hospital factors associated with extended antibiotic prophylaxis. We evaluated the association between extended antibiotic prophylaxis and C. difficile infections for patients who underwent partial or radical nephrectomy and radical cystectomy with multivariate logistic regression. Surgery specific models demonstrated that hospital identity was associated with a substantial proportion of the variation in extended antibiotic prophylaxis (20% to 35% for radical prostatectomy, partial or radical nephrectomy, and radical cystectomy). Postoperative C. difficile colitis occurred in 0.02% of patients treated with radical prostatectomy, 0.23% of those treated with partial or radical nephrectomy and 1.7% of those treated with radical cystectomy. On multivariate analysis extended antibiotic prophylaxis was associated with higher odds of C. difficile infection after partial or radical nephrectomy (OR 3.79, 95% CI 2.46-5.84) and radical cystectomy (OR 1.64, 95% CI 1.12-2.39). Antibiotics may be overused after genitourinary cancer surgery and this overuse is associated with hospital acquired C. difficile colitis. Efforts are needed to encourage greater compliance with evidence-based approaches to postoperative care.

Prevention of Surgical Site Infection: Beyond SCIP

Surgical site infections (SSIs) are a leading cause of patient morbidity and mortality. Each SSI that occurs is associated with approximately seven to 10 additional postoperative hospital days,1,2 and patients with SSIs have a two to 11 times higher risk of death compared to surgical patients without SSIs.3,4 Surgical site infections have now emerged as the most common and most costly cause of health care–associated infection.5,6 Thus, hospitals and health care providers must constantly pursue and improve adherence with evidence-based strategies for preventing these devastating infections. Several core SSI prevention strategies have been promoted by the Surgical Care Improvement Project (SCIP), including the appropriate choice and timing of antimicrobial prophylaxis, avoiding shaving surgical site hair, maintaining perioperative patient normothermia, and controlling perioperative blood glucose.7 During the past decade, many, if not most, providers associated with quality improvement and surgical improvement programs in the United States have become familiar with the SCIP recommendations. In fact, health care providers are placing great effort on improving staff member compliance with these recommendations because rates of performance on SCIP measures now affect hospital payment under the Centers for Medicare & Medicaid Services Value-Based Purchasing Program.8,9 Compliance with some of the SCIP recommendations is now close to 100%; thus, some of these quality measures have been retired (eg, avoiding surgical site hair shaving). If hospitals are near 100% compliance with some of the basic SCIP recommendations, yet SSIs still occur and harm patients, the question then becomes, “What else can be done?” This column will summarize several additional evidence-based strategies that go beyond SCIP recommendations to prevent SSIs: optimizing antimicrobial prophylaxis dosing, preparing the colon with mechanical bowel preparation and oral antibiotics, optimizing tissue oxygenation, and using a surgical safety checklist.

Antimicrobial Prophylaxis for Cesarean Delivery Before Skin Incision

To estimate the effect of a hospital-wide change in the timing of antimicrobial prophylaxis in cesarean deliveries on maternal and neonatal infections. In November 2004, our institution instituted guidelines recommending that the administration of antimicrobial prophylaxis for cesarean delivery be administered before skin incision rather than after umbilical-cord clamping. We reviewed all cesarean deliveries from two time periods. Group 1 received antibiotics after umbilical-cord clamping (July 2002 to November 2004). Group 2 received antibiotics before skin incision (June 2005 to August 2007). Rates of maternal and neonatal infectious complications were compared between groups. There were 4,229 cesarean deliveries in group 1 and 4,781 cesarean deliveries in group 2. Compared with women receiving antimicrobial prophylaxis after umbilical-cord clamping, those administered antimicrobial prophylaxis before skin incision had lower rates of postpartum endometritis (2.2% compared with 3.9%) and wound infection (2.5% compared with 3.6%). After multivariable logistic regression, antimicrobial prophylaxis before skin incision remained associated with lower rates of endometritis (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.47-0.79) and wound infection (OR 0.70, 95% CI 0.55-0.90). Antimicrobial prophylaxis before skin incision had no adverse effect on neonatal infection rates or on the evaluation of the neonate. Antimicrobial prophylaxis before skin incision, compared with after cord clamping, resulted in lower rates of maternal infections and had no effect on neonatal infections. Antimicrobial prophylaxis for cesarean delivery should occur before skin incision, consistent with basic tenets of surgical antimicrobial prophylaxis. II.

Timing of Antimicrobial Prophylaxis and the Risk of Surgical Site Infections

The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP). National AMP guidelines should be supported by evidence from large contemporary data sets. Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac, hip/knee arthroplasty, and hysterectomy cases. Surgical site infections (SSIs) were ascertained through routine surveillance, using National Nosocomial Infections Surveillance system methodology. The association between the prophylaxis timing and the occurrence of SSI was assessed using conditional logistic regression (conditioning on hospital). One-hundred thirteen SSI were detected in 109 patients. SSI risk increased incrementally as the interval of time between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 0.04). When antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded, the infection risk following administration of antibiotic within 30 minutes prior to incision was 1.6% compared with 2.4% associated with administration of antibiotic between 31 to 60 minutes prior to surgery (OR: 1.74; 95% confidence interval, 0.98-3.04). The infection risk increased as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision. Intraoperative redosing (performed in only 21% of long operations) appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 3.08 with no redosing; 95% confidence interval 0.74-12.90), but only when the preoperative dose was given correctly. These data from a large multicenter collaborative study confirm and extend previous observations and show a consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision.

Protocol for Administration of Prophylactic Antibiotics within One Hour before the Surgical Incision in Total Hip and Knee Replacement

Purpose: We aimed that compliance could be improved by new protocol ensuring the adequate timing of intravenous antibiotic delivery onto an already existing time out system used to ensure exact surgical site. Materials and Methods: A group of 150 patients was administered prophylactic antibiotics just before entering operation room and performed only time-out protocol. Other group of 150 patients was administered prophylactic antibiotics directly after anesthetic induction and perfomed new protocol inclusive of checklist ensuring appropriate timing of antimicrobial prophylaxis. We compared mean time from prophylactic administration to surgical incision and compliance. Results: The average time from administration of the antimicrobial prophylaxis to the surgical incision for patients who was performed only time-out protocol was 43 minutes and compliance was 60.6%. The average time from administration of the antimicrobial prophylaxis to the surgical incision for patients who was performed new protocol was 18 minutes and compliance was 100%. There was a significant difference in compliance of two groups. Conclusion: New protocol ensuring the adequate timing of intravenous antibiotic delivery combined with administration of the antimicrobial prophylaxis directly after anesthetic induction were effective and easily adaptable method to ensure compliance with appropriate timing of prophylactic antibiotics.

The Timing of Surgical Antimicrobial Prophylaxis

To obtain precise information on the optimal time window for surgical antimicrobial prophylaxis. Although perioperative antimicrobial prophylaxis is a well-established strategy for reducing the risk of surgical site infections (SSI), the optimal timing for this procedure has yet to be precisely determined. Under today's recommendations, antibiotics may be administered within the final 2 hours before skin incision, ideally as close to incision time as possible. In this prospective observational cohort study at Basel University Hospital we analyzed the incidence of SSI by the timing of antimicrobial prophylaxis in a consecutive series of 3836 surgical procedures. Surgical wounds and resulting infections were assessed to Centers for Disease Control and Prevention standards. Antimicrobial prophylaxis consisted in single-shot administration of 1.5 g of cefuroxime (plus 500 mg of metronidazole in colorectal surgery). The overall SSI rate was 4.7% (180 of 3836). In 49% of all procedures antimicrobial prophylaxis was administered within the final half hour. Multivariable logistic regression analyses showed a significant increase in the odds of SSI when antimicrobial prophylaxis was administered less than 30 minutes (crude odds ratio = 2.01; adjusted odds ratio = 1.95; 95% confidence interval, 1.4-2.8; P < 0.001) and 120 to 60 minutes (crude odds ratio = 1.75; adjusted odds ratio = 1.74; 95% confidence interval, 1.0-2.9; P = 0.035) as compared with the reference interval of 59 to 30 minutes before incision. When cefuroxime is used as a prophylactic antibiotic, administration 59 to 30 minutes before incision is more effective than administration during the last half hour.

Antibiotic prophylaxis and preoperative colorectal cleansing: Are they useful?

The utility of antibiotic prophylaxis for colorectal surgery has been assessed and largely confirmed worldwide. There is homogeneous consensus that the antibiotic chosen for prophylaxis must cover both aerobic and anaerobic bacteria, that the toxicity should be minimal and it should be cost effective. Recent studies have questioned the role of preoperative bowel cleansing, which is considered by many surgeons as a widely established practice prior to elective colorectal procedures. New clinical trials are needed to resolve these key questions such as the efficacy of bowel preparation and how to obtain effective timing of antimicrobial prophylaxis.

Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting

Objective: Our objective was to identify risk factors for deep sternal site infection after coronary artery bypass grafting at a community hospital. Methods: We compared the prevalence of deep sternal site infection among patients having coronary artery bypass grafting during the study (January 1995–March 1998) and pre-study (January 1992–December 1994) periods. We compared any patient having a deep sternal site infection after coronary artery bypass graft surgery during the study period (case-patients) with randomly selected patients who had coronary artery bypass graft surgery but no deep sternal site infection during the same period (control-patients). Results: Deep sternal site infections were significantly more common during the study than during the pre-study period (30/1796 [1.7%] vs 9/1232 [0.7%]; P = .04). Among 30 case-patients, 29 (97%) returned to the operating room for sternal debridement or rewiring, and 2 (7%) died. In multivariable analyses, cefuroxime receipt 2 hours or more before incision (odds ratio = 5.0), diabetes mellitus with a preoperative blood glucose level of 200 mg/dL or more (odds ratio = 10.2), and staple use for skin closure (odds ratio = 4.0) were independent risk factors for deep sternal site infection. Staple use was a risk factor only for patients with a normal body mass index. Conclusions: Appropriate timing of antimicrobial prophylaxis, control of preoperative blood glucose levels, and avoidance of staple use in patients with a normal body mass index should prevent deep sternal site infection after coronary artery bypass graft operations. (J Thorac Cardiovasc Surg 2000;119:108-14)

Improving the Timing of Antimicrobial Prophylaxis through a Total Quality Management Approach

Studies have shown that the optimal time to give preoperative prophylactic antibiotics is within 2 hours prior to the incision. An initial study of perioperative antibiotic use at our institution revealed significant deficiencies both in the timing and the charting of preoperative antibiotics. In response to these findings, a multidisciplinary total quality management team was formed. This team identified several key problems related to the timing and documentation of preoperative antibiotics. Accordingly, our institution's method of prophylactic antibiotic delivery and administration was revised, and a program to educate appropriate staff was formulated. Following these interventions, a second study found that the number of preoperative antibiotic doses given at the proper time improved from 86% in the previous study to 98%, and that the number of doses properly charted improved from 84% to 94%.