Identifying targets for improvement using a nationally standardized survey: Surgical antimicrobial prophylaxis in orthopedic surgery

Abstract

Background: Surgical antimicrobial prophylaxis (SAP) is commonly administered in orthopedic procedures. Research regarding SAP appropriateness for specific orthopedic procedures is limited and is required to facilitate targeted orthopedic prescriber behavior change. Objectives: To describe SAP prescribing and appropriateness for orthopedic procedures in Australian hospitals. Design, setting, and participants: Multicenter, national, quality improvement study with retrospective analysis of data collected from Australian hospitals via Surgical National Antimicrobial Prescribing Survey (Surgical NAPS) audits from January 1, 2016, to April 15, 2019, were analyzed. Methods: Logistic regression identified hospital, patient and surgical factors associated with appropriateness. Adjusted appropriateness was calculated from the multivariable model. Additional subanalyses were conducted on smaller subsets to calculate the adjusted appropriateness for specific orthopedic procedures. Results: In total, 140 facilities contributed to orthopedic audits in the Surgical NAPS, including 4,032 orthopedic surgical episodes and 6,709 prescribed doses. Overall appropriateness was low, 58.0% (n = 3,894). This differed for prescribed procedural (n = 3,978, 64.7%) and postprocedural doses (n = 2,731, 48.3%). The most common reasons for inappropriateness, when prophylaxis was required, was timing for procedural doses (50.9%) and duration for postprocedural prescriptions (49.8%). The adjusted appropriateness of each orthopedic procedure group was low for procedural SAP (knee surgery, 54.1% to total knee joint replacement, 74.1%). The adjusted appropriateness for postprocedural prescription was also low (from hand surgery, 40.7%, to closed reduction fractures, 68.7%). Conclusions: Orthopedic surgical specialties demonstrated differences across procedural and postprocedural appropriateness. The metric of appropriateness identifies targets for quality improvement and is meaningful for clinicians. Targeted quality improvement projects for orthopedic specialties need to be developed to support optimization of antimicrobial use.

Surgical antimicrobial prophylaxis in open reduction internal fixation procedures at a metropolitan hospital in Australia: a retrospective audit

“…Surgical antimicrobial prophylaxis (SAP) accounts for one in six antibiotic prescriptions in hospitals worldwide [1], with 14% of all antimicrobials prescribed in Australian hospitals for SAP [2]. Inappropriate prescribing and poor adherence to SAP guidelines has been noted across all surgical disciplines, including orthopaedic surgery [3][4][5]. The inappropriate use of SAP has multiple consequences, including the development of antimicrobial resistance, an increase in adverse events, length of hospital stay as well as costs to the healthcare system [6].…”

How is surgical antibiotic prophylaxis prescribed for open reduction internal fixation procedures by Australian orthopaedic surgeons?

“…Australian studies have also shown that postoperative antibiotics are frequently prescribed in orthopaedic surgery. [5][6][7] As postoperative SAP prescribing remains commonplace, it is important to understand the circumstances or factors that influence multidose prescribing. As stated by one of the surgeons in this study, procedural and patient factors can contribute to the use of postoperative doses.…”

“…illustrates that although orthopaedic surgeons are aware of the lack of benefits postoperative antibiotics provide, they continue to prescribe antibiotics, with 59% of respondents indicating they prescribe at least one postoperative dose. Australian studies have also shown that postoperative antibiotics are frequently prescribed in orthopaedic surgery 5–7 . As postoperative SAP prescribing remains commonplace, it is important to understand the circumstances or factors that influence multidose prescribing.…”

“…New recommendations advocate for single‐dose prophylaxis for internal fixations, with no antibiotics to be administered once surgery is complete 2 . Although the recommendation for single‐dose prophylaxis aligns with global guidelines, 3,4 it has been observed that postoperative antibiotics are often prescribed in the orthopaedic setting 5–7 …”

“…2 Although the recommendation for single-dose prophylaxis aligns with global guidelines, 3,4 it has been observed that postoperative antibiotics are often prescribed in the orthopaedic setting. [5][6][7] In this study, we evaluated self-reported prescribing practices of SAP for ORIF of closed fractures by a small cohort of Australian orthopaedic surgeons and how they compare to current Therapeutic Guidelines recommendations (Appendix S1).…”