Compliance with surgical antibiotic prophylaxis guidelines : a prospective descriptive study at a tertiary level hospital in Cape Town, South Africa

Abstract

Background: The aim of surgical antibiotic prophylaxis (SAP) is to prevent surgical site infection (SSI) by administering an appropriate antimicrobial agent perioperatively. However, SAP may be associated with adverse effects and incurs added costs. The primary objective of this prospective study is to establish whether clinicians are adhering to existing perioperative antibiotic prophylaxis guidelines in terms of indication, dosage and timing of SAP. Secondary objectives are to determine the proportion of patients receiving inappropriate antibiotics, and to evaluate correct practice concerning re-dosing and duration of SAP. Methods: A cross-sectional prospective audit of the anaesthetic records and prescription charts of surgical patients was conducted at Groote Schuur Hospital, a tertiary level teaching hospital in Cape Town, South Africa, over a period of one week. Data were collected by anaesthetists – blinded to the study objectives – and the investigators; then captured on Excel spreadsheets and compared to existing SAP guidelines. Descriptive statistics and binary logistic regression were used for analysis. Results: Of the 192 patients consented, 180 questionnaires were completed for data analysis. The median age of participants was 44.5 years (IQR: 31.5–58), with a preponderance of females (58.7%). SAP was administered in 149 cases (82.8%) and withheld in 31 (17.2%). This was appropriate in 91.9% (137/149) and 77.4% (24/31) respectively. Twelve patients (6.7%) received inappropriate antibiotics and in seven (3.9%) it was inappropriately withheld. Of the 156 patients who should have received SAP, choice of drug was correct in 121 (77.6%), dosage in 110 (70.5%) and timing in 87 (55.8%). Absolute compliance was achieved in 44.4% (80/180). Errors were mostly related to timing, re-dosing and duration of SAP. Conclusion: Anaesthetists and surgeons at Groote Schuur Hospital demonstrate variable adherence to surgical antibiotic prophylaxis guidelines. Interventions aimed at improving compliance are warranted.

Orthopaedic surgical antibiotic prophylaxis administration compliance with prescribing guidelines in a private hospital in North West province, South Africa

“…The SAP compliance criteria were analysed according to the following parameters: Indication: The use of SAP was deemed appropriate if prescribed in clean wounds that involve orthopaedic implantation devices as well as clean-contaminated wounds, contaminated wounds and dirty wounds. 9 The omission of SAP in clean orthopaedic procedures that did not involve orthopaedic implantation devices or prosthetic devices was considered appropriate. 6,7,9 Antibiotic choice: Orthopaedic SAP choice was deemed correct if a cephalosporin such as cefazolin, cefuroxime or ceftriaxone was prescribed with vancomycin, teicoplanin or clindamycin as indicated alternatives due to cephalosporin allergy or suspected methicillin-resistant Staphylococcus aureus (MRSA) infection.…”

“…9 The omission of SAP in clean orthopaedic procedures that did not involve orthopaedic implantation devices or prosthetic devices was considered appropriate. 6,7,9 Antibiotic choice: Orthopaedic SAP choice was deemed correct if a cephalosporin such as cefazolin, cefuroxime or ceftriaxone was prescribed with vancomycin, teicoplanin or clindamycin as indicated alternatives due to cephalosporin allergy or suspected methicillin-resistant Staphylococcus aureus (MRSA) infection. 6,9,13 Route of administration: Antibiotics indicated for orthopaedic SAP use should be administered intravenously (IV).…”

“…Antibiotic dose: Orthopaedic SAP dosage was considered correct according to the World Health Organization's global guidelines for the prevention of surgical site infections; the Scottish Intercollegiate Guidelines Network for antibiotic prophylaxis in surgery; the South African Government's Standard Treatment Guidelines and Essential Medicines List for South Africa Hospital Level of adults (2019 edition); and the Ampath National Laboratory Services' Antibiotic Prophylaxis for Surgical Procedures Guidelines, as summarised in Table I. 1,6,7,9,21,22 Weight-based dosing is only applicable to cefazolin and vancomycin. Therefore, correct cefazolin or vancomycin dosing is determined by patient weight.…”

“…6,7 Guideline development does not guarantee the successful implementation thereof, as there are documented inconsistencies between SAP guidelines and clinical practice. 9 Non-compliance with orthopaedic SAP guidelines leads to inadequate antibiotic prophylaxis, increasing the risk of SSIs, antibiotic usage, treatment cost and risk of antibiotic resistance. 2,5,7,10 In Australia, orthopaedic surgery was found to be the surgical discipline with the lowest SAP guidelines compliance rate.…”

“…10 The absolute compliance with SAP guidelines in different surgical departments at a Cape Town teaching hospital was found to be 44.4%. 9 A study conducted at a Gauteng hospital revealed a 29% compliance rate with SAP dosing recommendations among eight different surgical disciplines. 13 Furthermore, an unnecessarily prolonged duration of SAP was observed in 66% of the cases.…”