Post-surgical infections can be prevented through the effective use of antimicrobial prophylaxis (AP) (Goede et al, 2013; Foroutan and Foroutan, 2014; Wartiti et al, 2016; Berrios-Torres et al, 2017; Alemkere, 2018). About 20–30% of the overall consumption of antimicrobials in hospital are as prophylactics in surgery (Groselj Grenc et al, 2006; Alemkere, 2018). It is evident that the excessive prescribing of antimicrobials is responsible for the emergence of antimicrobial resistance; therefore, rational use is crucial for the reduction of problems related to resistance (Bisht et al, 2009; Foroutan and Foroutan, 2014; Berríos-Torres et al, 2017). Despite the availability of evidence-based guidelines for surgical prophylaxis, studies have reported unnecessary use of broad-spectrum agents and inappropriate timing of administration of antimicrobials worldwide (Groselj et al, 2006; Hosoglu et al, 2009; Vessal et al, 2011; Elbur et al, 2013; Goede et al, 2013; Pollmann et al, 2017; Alemkere, 2018; Karamachandani et al, 2019). Adherence to evidence-based guidelines is an essential element of hospital policy and patient safety (Wartiti et al, 2016).
The proportion of older people in the total population is increasing in most countries (World Health Organization (WHO), 2018a). Most older adults are vulnerable to the adverse events of inappropriate antimicrobial usage (Pollmann et al, 2017). Very little is known about antimicrobial prophylaxis use in older patients. Therefore, this study was carried out to evaluate the quality of antimicrobial prescribing and adherence to recommended protocols in different surgical procedures among older patients at a 600-bed teaching hospital in Islamabad, Pakistan.
Methods
An audit-based retrospective study was carried out in the surgical wards of the main referral teaching hospital PIMS, Islamabad, Pakistan. This is a government-funded tertiary care teaching hospital and is made up of different departments and wards such as medical wards, outpatient departments (OPD), pediatrics, general surgical wards, gynecology, and obstetrics. The study was approved by the hospital's ethical review board.
The study retrospectively examined surgical procedures in elderly patients ages 65 years and older. A total of 264 patients were admitted to four surgical wards; abdominal (n=71), orthopaedic (n=61), urological (n=63) and neurosurgery (n=69) during 2016 (from January 1 to December 30). Sixty cases were enrolled for each of the four surgical wards through a random systematic sampling technique. Indication, selection, dose, route, and timing of antimicrobial administration were the main evaluated parameters in this study. Observed practices were compared with Clinical practice guidelines for antimicrobial prophylaxis in surgery (Bratzler et al, 2013) and the American College of Surgeons and Surgical Infection Society's Surgical site infection guidelines (Ban et al, 2017).
A summary of the antibiotic prophylaxis recommendations according to surgery type using international clinical practice guidelines are presented in Table 1.
Table 1. Summary of the antibiotic prophylaxis recommendations according to surgery type using international clinical practice guidelines
| Procedures | Antimicrobial use and route | Dose | Timing (minutes) |
|---|---|---|---|
| Abdominal surgeries | |||
| First line | Cefazolin IV | 2 g | 0–30 |
| Alternative | Clindamycin IV | 900 mg | 0–30 |
| Vancomycin | 15 mg/kg | 120 | |
| Gentamicin IV | 5 mg/kg | 30–60 | |
| Aztreonam IV | 2 g | 0–30 | |
| Fluroquinolones (Ciprofloxacin or Moxifloxacin) | 400 mg | 0–30 | |
| Urological surgeries | |||
| First line | Cefazolin IV | 2 g | 0–30 |
| Fluroquinolones (Ciprofloxacin or Moxifloxacin) | 400 mg | 0–30 | |
| Trimethoprim-sulfamethoxazole | 8–10 mg/kg/day | 0–30 | |
| Alternative | Clindamycin IV | 900 mg | 0–30 |
| Gentamicin IV | 5 mg/kg | ||
| Vancomycin | 15 mg/kg | 120 | |
| Aztreonam IV | 2 g | 30–60 | |
| Orthopaedic surgeries | |||
| First line | Cefazolin | 2 g | 0-30 |
| Alternative | Clindamycin IV | 900 mg | 0–30 |
| Vancomycin | 15 mg/kg | 120 | |
| Neurosurgeries | |||
| First line | Cefazolin | 2 g | 0–30 |
| Alternative | Clindamycin IV | 900 mg | 0–30 |
| Vancomycin | 15 mg/kg | 120 | |
The required information was retrospectively collected from anesthesiologic, medical and nursing records, using a standardised collection form – The World Health Organization anatomical classification code (WHO-ATC) system (WHO, 2018b). Finally, the data were entered into SPSS 22.0; the statistical software package for descriptive statistics (frequency, percentages) and chi-square analysis.
Results
There were more male patients (136/240; 56.6%) than female patients (104/240; 43.4%). Cholecystectomy (16/60; 26.6%) was the most common abdominal surgical procedure while pyeloplasty (18/60; 30%) were common among urological procedures. Knee replacement (19/60; 31.6%) and craniotomy (21/60; 35%) were frequently performed, as were orthopaedic and neurosurgical surgical procedures. Most of the procedures were ‘clean surgical wounds’ (n=104; 43.3%) followed by ‘clean contaminated’ (n=97; 40.4%), ‘contaminated’ (n=15; 6.2%) and ‘dirty infected wounds’ (n=24; 10%) (Box 1). There were more elective surgical procedures (n=226; 94 %) than urgent ones (n=14; 6%). The surgical procedures considered in the study are presented in Table 2.
Box 1.Definitions of operative infections
- Clean: An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. Clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow non-penetrating (blunt) trauma should be included in this category if they meet the criteria.
- Clean-contaminated: Operative wounds in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.
- Contaminated: Open, fresh, accidental wounds. Operations with major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, non-purulent inflammation is encountered including necrotic tissue without evidence of purulent drainage (eg, dry gangrene) are included in this category.
- Dirty or infected: Includes old traumatic wounds with retained devitalised tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing post-operative infection were present in the operative field before the operation.
From: Centers for Disease Control and Prevention (2017)
Table 2. Details of surgical procedures and wound classification (n=240)
| Types of surgeries | Number | Percentage | A/B/C/D | E/U |
|---|---|---|---|---|
| Abdominal procedure | ||||
| Cholecystectomy | 16 | 26.6 | B | E |
| Appendectomy | 14 | 23.3 | B | U |
| Hernia surgery | 11 | 18.3 | A | E |
| Colonic resection | 3 | 5 | B | E |
| Sigmoidectomy | 7 | 11.6 | C | E |
| Splenectomy | 5 | 8.3 | A | E |
| Esophagectomy | 4 | 6.6 | B | E |
| Total | 60 | 100 | - | - |
| Urological surgeries | ||||
| Pyeloplasty | 18 | 30 | B | E |
| Hydrocelectomy | 13 | 21.6 | B | E |
| Transurethral resection of the prostate (TURP) | 15 | 25 | B | E |
| Ureteroscopy (URS) surgery | 11 | 18.3 | B | E |
| Percutaneous nephrolithotomy (PCNL) | 3 | 5 | B | E |
| Total | 60 | 100 | - | - |
| Orthopaedic | ||||
| Knee replacement surgery | 19 | 31.6 | A | E |
| Hip replacement surgery | 12 | 20 | A | E |
| Knee arthroscopy | 9 | 15 | A | E |
| Shoulder arthroscopy | 5 | 8.3 | A | E |
| Ankle repair | 4 | 6.6 | A | E |
| Joint fusion | 8 | 13.3 | A | E |
| Tibia fibula surgery | 2 | 3.3 | A | E |
| Femur surgery | 1 | 1.6 | A | E |
| Total | 60 | 100 | - | - |
| Neurosurgeries | ||||
| Craniotomy | 21 | 35 | D | E |
| Laminectomy | 13 | 21.6 | A | E |
| Microdiscectomy | 10 | 16.6 | A | E |
| Peripheral nerve surgery | 5 | 8.3 | A | E |
| Ventriculostomy | 8 | 13.3 | C | E |
| Ventriculoperitoneal shunt | 3 | 5 | D | E |
| Total | 60 | 100 | - | - |
A - clean wounds; B - clean contaminated wounds; C - contaminated wounds; D-dirty, inflamed wounds; E-elective surgery; U-urgent surgery
Indication
According to protocols, antimicrobials were indicated for all surgical procedures in this study; however, non-use was observed several times in this study. A total of 25 patients (10.4%) out of 240 did not receive antimicrobial prophylaxis (AP): 8 patients in abdominal, 16 in urological surgeries and one in orthopaedic surgery. AP was prescribed to 215 patients (89.6%) (Appendix). Statistical significance was observed between antimicrobial practices and surgical procedures (P<0.001).
Selection of antimicrobial
The selection of antimicrobial medicine adhered to local guidelines in 70 (32.5%) of 215 patients who received antimicrobials. The correct selection of AP was more common in abdominal surgeries (46%) compared to other surgeries; P=0.001. However, 145 patients (67.5%: 36 abdominal, 44 urological, 39 orthopaedic and 51 neurosurgical procedures) received antimicrobials different from the recommended choice according to standard guidelines (Appendix).
Timing
The timing of administration within an optimal range (30–60 minutes before surgical incision) was noted in more than half of patients (55.3%). The timing was most appropriate in neurosurgeries (n=41; 68.3%) compared to other procedures P=0.001. The timing was ‘too late’ in 96 patients (44.7%: 33 abdominal, 17 urological, 27 orthopaedic and 19 neurosurgeries) (Appendix).
Dose and route
Patients who did not receive antimicrobial medication according to guidelines were not included in the computation of correct dose and route. The dose and route of antimicrobial adhered with the guidelines in all patients (n=70; 100%) who received correct antimicrobials according to protocols (Appendix).
Utilisation pattern of antimicrobials
The most frequently prescribed antimicrobials were ceftriaxone (n=63; 29.3%) followed by cefazolin (n=39, 18.1%) and ciprofloxacin (n=21, 9.8%). The combination of amoxicillin plus clavulanic acid (n=16; 7.4%), cefoperazone plus sulbactam (n=15, 6.9%) and piperacillin plus sulbactam (n=11; 5.1%) were also prescribed as APs. The remaining patients were managed with different regimens. The antimicrobial use between surgical wards is summarised in the Appendix.
Discussion
Most of the patients received surgical AP according to the results of this audit-based study. However, APs were not used in 10.4% (25 out of 240) cases, despite being recommended. Lack of AP prescribing leads to increased chances of wound development, increased length of stay, morbidity and mortality (Heineck et al, 1999; Abubakar et al, 2018). Of the 86% of patients who received AP, only 32.5% received them according to the receommended guidelines. The poor compliance rate with international guidelines was also reported in different studies (Groselj Grenc et al, 2006; Hosoglu et al, 2009; Elbur et al, 2013; Goede et al, 2013; Foroutan and Foroutan, 2014; Wartiti et al, 2016; Abubakar et al, 2018). The lack of awareness of international guidelines and the absence of local clinical guidelines were demonstrated in this study and has been seen elsewhere (Pollmann et al, 2017; Alemkere, 2018). The dose and route of surgical AP; however, adhered with the guidelines in all patients who received correct antimicrobials according to guidelines in this study. Similar results were also reported in a Turkish study (Hosoglu et al, 2009).
The use of narrow-spectrum antimicrobials is advocated by international guidelines for all of the surgical procedures (Bratzler et al, 2013; Berrios-Torres et al, 2017). Cefazolin is the most commonly recommended first choice and provides adequate protection against surgical infections (Bratzler et al, 2013). Cefazolin is easily available in the authors' hospital, but the results of this audit suggest that third-generation cephalosporins (specifically ceftriaxone) were frequently used for prophylaxis. The studies conducted in Ethiopia (Alamkere, 2018), Sudan (Elbur et al, 2013) and Turkey (Hosoglu et al, 2009) also reported higher use of broad-spectrum cephalosporins. This agent is not recommended for prophylaxis purposes due to the emergence of bacterial resistance, less coverage against Staphylococcus and higher cost (Elbur et al, 2013; Alemkere, 2018).
The inappropriate timing of prophylaxis administration was another important indicator and has been reported in a number of studies,(Heineck et al, 1999; Groselg et al, 2006; Hosoglu et al, 2009; Abubakar et al, 2018; Alemkere, 2018). According to guidelines, the correct time of administration is 30 minutes before the surgical incision (Bratzler et al, 2013; Berrios-Torres et al, 2017). In this study, only 119 (55.3%) patients were administered an antimicrobial prophylaxis within the optimal recommended time frame. The studies carried out in Turkey (59.2%) (Hosoglu et al, 2009) and Ethiopia (52.3%) (Alemkere, 2018) presented similar findings. The protection received by patients who did not receive the antimicrobial at the optimal time was reduced, as described in the literature (Hosoglu et al, 2009; Bratzler et al, 2013; Berrios-Torres et al, 2017; Abubakar et al, 2018; Alemkere, 2018).
The importance of guidelines in relation to improving the quality of antimicrobial use was indicated in several studies (Groselg et al, 2006; Hosoglu et al, 2009; Elbur et al, 2013; Foroutan and Foroutan, 2014; Wartiti et al, 2016; Alemkere, 2018). The consensus among surgeons is an influencing factor in the development and implementation of standard guidelines that have the potential to ultimately reduce inappropriate antimicrobial usage (Hosoglu et al, 2009; Alemkere, 2018). Currently, there are no national standards or guidelines in Pakistan. There is also a lack of guidelines in the study setting. The infection control staff and therapeutic drug committees of any hospital are responsible for the periodic audit of antimicrobial use. Unfortunately, despite the presence of these committees in the study hospital, there were no data available about the actual administration of antimicrobials.
Non-availability of standard local guidelines and a lack of awareness among the surgical team about international evidence-based guidelines for antibiotic prophylaxis could be a reason for non-compliance in this study as similar reasons have been reported in previous studies (Hosoglu et al, 2009; Alemkere, 2018; Khan et al, 2019). Furthermore, delayed administration of surgical AP is associated with a two times greater risk of SSIs as compared to timely administration (Abubakar et al, 2018). Appropriate time of administration of AP can also reduce the duration of stay and hospitalisation cost (Bratzler et al, 2013).
Limitations
Prescribing practice is a complex phenomenon. This study had access to well-reported data on AP; however, some limitations must be acknowledged. The study did not monitor the post-surgical infection rate; therefore, we do not know if the non-adherence to guidelines had any clinical consequences. This study also has low sample size so it is difficult to generalise the results. As there were no local consensus guidelines available, international clinical practice guidelines for antimicrobial prophylaxis in surgery were used. However, it is possible that recommendations given by the guidelines were not practicable in our patients or for the situation in Pakistan. These findings do, however, provide a useful insight to the issue of antimicrobial resistance, particularly around appropriate medicines use, adherence with standard guidelines and health systems in developing countries.
Conclusion
Of the older patients who underwent surgical procedures in the authors' Trust in 2016, 89% received antimicrobials. The selection of prophylactic antimicrobial administration and the preoperative timing were the main non-adherent parameters. The dose and route of administration were appropriate in patients who received the correct antimicrobials. Awareness and availability about antimicrobials and standard guidelines are the crucial intervention for judicial use of antimicrobials in surgery. Therefore, implementation of an antimicrobial stewardship programme is required at local and international levels for the better quality and care of patients.
Key Points
- Adherence with standard antimicrobial prophylaxis protocols is an essential element of hospital policy and patient safety
- Little is known about antimicrobial prophylaxis for prevention of surgical site infections in older patients in Pakistan, as well as globally
- The frequency of inappropriate antimicrobial choice and sub-optimal timing of administration were high in the setting studied
- The findings this study should be of use to policy makers in terms of improving the process and ensuring efficient distribution of rational services in older patients
- The authors recommend the implementation of antimicrobial stewardship programme as an urgent agent for improvement of antimicrobial use and patient outcomes across the globe
CPD reflective questions
- Consider antimicrobial prophylaxis prescribing in your Trust, how does it differ to prescribing in Pakistan? Are there any similarities?
- Consider the international guidance in Table 1. Does the care offered by yourself and your colleagues reflect this guidance? If not, consider what could be done to improve care
- After reading this article, how do you think your practice can be improved?