Antibiotic prophylaxis and surgical site infection
Myron Yaster MD, Genie Heitmiller MD, and Jayant K. Deshpande MD
Many years ago, Dr. Genie Heitmiller, as the chief Hopkins Quality and Safety officer, beat some sense into me (and my colleagues) about the importance of antibiotic prophylaxis to prevent surgical site infections in our patients. The antibiotic, the dose to give, the timing and route of administration (bolus and/or continuous infusions) became quality benchmarks. When I read today’s article I thought of Genie and asked her to edit and cowrite the PAAD with me and Jay. But first a word from Dr. Glaucomflecken on antibiotics, the pharmacy, and Infectious Disease stewardship of these drugs. Myron Yaster MD
Original article
Katherine He;Raageswari B Nayak;Alexander C Allori;Brian K Brighton;Robert A Cina;Jonathan S Ellison;Michael J Goretsky;Kris R Jatana;Mark R Proctor;Catherine Grant;Vanessa M Thompson;Marie Iwaniuk;Mark E Cohen;Jacqueline M Saito;Bruce L Hall;Jason G Newland;Clifford Y Ko;Shawn J Rangel. Correlation Between Postoperative Antimicrobial Prophylaxis Use and Surgical Site Infection in Children Undergoing Nonemergent Surgery. JAMA Surg. 2022;157(12):1142-1151. PMID: 36260310
“Appropriate use of intravenous antimicrobial prophylaxis is essential to mitigate surgical site infection (SSI) risk, however, overuse of prophylaxis has been associated with antimicrobial resistance and adverse events, including allergic reaction, acute kidney injury, and antibiotic-associated colitis”.1, 2 “Noncompliance with the recommended spectrum of coverage for surgical antibiotic prophylaxis is common in pediatric surgery, with both over and undertreatment being common themes. Improved compliance is needed to optimize both antibiotic stewardship and infection prevention”.3 Indeed, “despite available guidelines, continuation of intravenous prophylaxis following incision closure is common in pediatric surgery, with postoperative use reported in up to 86% of cases”.1, 2 He et al. sought to determine if continuation of intraoperative prophylaxis postoperatively would correlate to SSI in children undergoing non emergent surgery. Cutting to the chase it didn’t. Indeed, there was no correlation found between use of postoperative prophylaxis and SSI rates overall (r = 0.13; P = .20), and when stratified by SSI type and surgical specialty.
“SSIs, including incisional SSI and organ space SSI, were identified by NSQIP-Pediatric surgical clinical reviewers through medical record review using standardized NSQIP-Pediatric definitions and medical record review methodology. For the purpose of this analysis, superficial and deep incisional SSIs were combined into a single incisional SSI category. The primary outcome for the correlation analysis included occurrence of any SSI (incisional or organ space SSI), and secondary outcomes included incisional and organ space infections that were analyzed separately”.1
The overall rate of any SSI in this study was low, 1.8% (range 0-7.3%). There was no association between postoperative prophylaxis use and SSI outcomes. The authors conclude that “the results of this analysis provide a call to arms for stewardship efforts to reduce postoperative prophylaxis use, particularly for hospitals that are relatively high users compared with their peers”.1 Further, the results of this study will be used “to develop a benchmarking report card to provide comparative performance data for both postoperative use and SSI rates for participating collaborative hospitals”.1
Know when to start, and when to stop! Perioperative teams have learned that properly timed preoperative antibiotics can impact the rate of surgical site infections. Good antibiotic practices also include knowing when to stop. Continuing ineffective or unnecessary antibiotic treatment exposes a patient to unnecessary risks (e.g., drug allergy, medication errors, IV infiltration) and costs, as well as adding to the general spiral of drug resistance from overuse of antibiotics. The hard part of updating guidelines based on evidence (and these are 2017 guidelines) is breaking old habits and unlearning old teaching. The CDC 2017 guidelines state “1E. In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room, even in the presence of a drain. (Category IA–strong recommendation; high-quality evidence.)”4
So, at the end of a case, overcome the temptation to give “just one more dose” of an antibiotic. What do you think? Send your thoughts and comments to Myron who will post on the Friday “reader response”.
References
1. He K, Nayak RB, Allori AC, et al. Correlation Between Postoperative Antimicrobial Prophylaxis Use and Surgical Site Infection in Children Undergoing Nonemergent Surgery. JAMA surgery. Dec 1 2022;157(12):1142-1151. doi:10.1001/jamasurg.2022.4729
2. Branch-Elliman W, O’Brien W, Strymish J, Itani K, Wyatt C, Gupta K. Association of Duration and Type of Surgical Prophylaxis With Antimicrobial-Associated Adverse Events. JAMA surgery. 2019;154(7):590-598. doi:10.1001/jamasurg.2019.0569
3. Anandalwar SP, Milliren C, Graham DA, et al. Trends in the use of surgical antibiotic prophylaxis in general pediatric surgery: Are we missing the mark for both stewardship and infection prevention? J Pediatr Surg. Jan 2020;55(1):75-79. doi:10.1016/j.jpedsurg.2019.09.057
4. Sandra I. Berríos-Torres, MD; Craig A. Umscheid, MD, MSCE; Dale W. Bratzler, DO, MPH; Brian Leas, MA, MS; Erin C. Stone, MA; Rachel R. Kelz, MD, MSCE; Caroline E. Reinke, MD, MSHP; Sherry Morgan, RN, MLS, PhD; Joseph S. Solomkin, MD; John E. Mazuski, MD, PhD; E. Patchen Dellinger, MD; Kamal M. F. Itani, MD; Elie F. Berbari, MD; John Segreti, MD; Javad Parvizi, MD; Joan Blanchard, MSS, BSN, RN, CNOR, CIC; George Allen, PhD, CIC, CNOR; Jan A. J. W. Kluytmans, MD; Rodney Donlan, PhD; William P. Schecter, MD; for the Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784-791. doi:10.1001/jamasurg.2017.0904