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ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 23-27

Utilization assessment of antimicrobial prophylaxis in surgical patients at tertiary care teaching hospital


1 Department of Pharmacology, MM Medical College, Solan, Himachal Pradesh, India
2 Department of Pharmacology, MMIMSR, Mullana, Haryana, India

Date of Web Publication16-Apr-2018

Correspondence Address:
Divya Goel
Department of Pharmacology, MMIMSR, Mullana, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_86_17

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  Abstract 


Background: Surgical site infection (SSI) includes all postoperative infections occurring at surgical sites. It is one of the most common causes of the morbidity and mortality in postoperative patients. Surgical antimicrobial prophylaxis (SAP) is a brief course of an anti-microbial agent for the prevention of SSI. Judicious use of antibiotics can decrease the morbidity associated with SSI, but inappropriate antibiotic use leads to antibiotic resistance. Aims and Objectives: Inappropriate use of antibiotics is still rampant, and the present study was planned to assess the prophylactic antibiotic usage in the surgery department. Materials and Methods: A prospective study was conducted on 200 patients in the Department of General Surgery, MMIMSR, Mullana, Haryana, with prior approval from the Institutional Ethical Committee. Results: Out of 200 patients, 193 received intravenous preoperative antimicrobial dose on the day of surgery. Most commonly prescribed group was the third-generation cephalosporin (61%). Fixed-dose combinations were also frequently used, among them piperacillin-tazobactam (20.5%) was the most common combination used. Average duration of postoperative prophylactic antimicrobial administration was 8.23 days. Conclusion: This study showed antibiotics were used as prophylactic in almost every patient. Still, many patients do suffer from SSI as average duration of antibiotic usage is around 8 days. To combat inappropriate antibiotic usage, there is need to make the SAP guidelines and to adhere to these guidelines.

Keywords: Drug utilization, surgical site infection, surgical antimicrobial prophylaxis


How to cite this article:
Sharma P, Goel D. Utilization assessment of antimicrobial prophylaxis in surgical patients at tertiary care teaching hospital. Saudi J Health Sci 2018;7:23-7

How to cite this URL:
Sharma P, Goel D. Utilization assessment of antimicrobial prophylaxis in surgical patients at tertiary care teaching hospital. Saudi J Health Sci [serial online] 2018 [cited 2018 Apr 21];7:23-7. Available from: http://www.saudijhealthsci.org/text.asp?2018/7/1/23/230234




  Introduction Top


Surgical site infections (SSIs) include all postoperative infections occurring at surgical sites. In spite of advances in infection control, SSI remains major limitation of surgical horizons.[1] SSIs are the second-most common nosocomial infection accounting for approximately one quarter of 2 million hospital-acquired infections in the United States annually.[2] To combat SSI, antimicrobials are being prescribed, and the concept of prophylactic use of antimicrobials in surgery was introduced, and it is currently an essential component of the standard care in virtually all procedures and has resulted in reduced postoperative infections.[3]

Surgical antimicrobial prophylaxis (SAP) refers to very brief course of an anti-microbial agent, which is initiated just before all elective operations in the clean, clean-contaminated, and contaminated surgical wound categories.[4] It is optional for the clean surgeries, although it may be indicated for certain patients with specific risk criteria.[5] In case of emergency procedures, SAP is recommended for clean and clean-contaminated wounds only.[4] While inappropriate usage and prolonged postoperative use of antimicrobials increase the incidence of antimicrobial resistance.[6] Inappropriate use of antimicrobial agents strongly suggests the need for antimicrobial drug utilization studies as the audit of the antimicrobial therapy.[7] Assessment of current antibiotic prescribing patterns is an important step toward promoting the appropriate use of antimicrobial agents, and in India, there is inadequate information and standard guidelines for antimicrobial prophylaxis. Therefore, there is a need to generate the baseline data on the pattern of usage of antimicrobial prophylaxis before recommending any desired modifications.[2]

The present study was conducted with the aim to examine and assess the prescribing pattern of antimicrobials among patients undergoing surgical procedure in a tertiary care hospital in India.


  Materials and Methods Top


A prospective observational study was conducted from December 2013 to November 2014 in the Department of General Surgery, MMIMSR, Mullana, Haryana, with prior approval from the Institutional Ethical Committee. A total of 200 patients were enrolled in the study as per the inclusion criteria.

The inclusion criteria that were followed are as follows:

  1. All patients of either sex and of any age, who had undergone surgical procedure
  2. Patients willing to give informed consent.


The exclusion criteria that were followed:

  1. Patients with dirty wounds, seriously ill patients and
  2. Patients who died or referred to higher centers.


Written informed consent was taken from participants after they were explained about the purpose and nature of the study in the language understood by them.

All patients were followed from the time of admission till their discharge. Data were collected as per pro forma, prepared using WHO criteria which included patient's demographic characteristics, antimicrobial prescriptions from the date of admission to discharge as well as the operative notes were checked to note intraoperative administration of antimicrobials. To study the prescription pattern, following prescribing indicators were used: (1) the choice and average number of antimicrobial agents, (2) the percent of drugs with injections prescribed, (3) dose, (4) timing, and (5) total duration of the prophylaxis. The investigator did not intervene in patient's care in any way.

Statistical analysis

Data were entered into Microsoft excel sheet. It was analyzed and presented as percentage, mean, and standard deviation. Statistical analysis was done using SPSS version 20 (IBM, Ambala, Haryana, India).


  Results Top


A total of 200 cases (88 females and 112 males) were studied from the time of their admission till their discharge. The mean age of the patient was 45.33 ± 19.01 years. The average stay in the hospital was 11.9 ± 6.92 days with a minimum stay of 3 days and a maximum stay of 25 days.

Patients underwent various surgical procedures during the study period, and according to surgical wound classification most of the patients (107) had clean-contaminated surgical wounds, and very few patients (16) had contaminated surgical wounds [Figure 1].
Figure 1: Types of surgical wounds

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Almost, all the patients (193) receive intravenous preoperative antimicrobial dose on the day of surgery. No intraoperative antimicrobial was administered to any patient. Majority of the patients (55%) were prescribed single antimicrobial drug, out of which 27 (13.5) patients were given the fixed-dose combination of antimicrobial. While 28 (14%) patients were prescribed three antimicrobial drugs [Table 1]. Most commonly prescribed 162 (81%) antimicrobials were third-generation cephalosporins, followed by aminoglycosides 79 (39.5%). Ceftriaxone was the most frequently prescribed antimicrobial in 155 (77.5%) patients [Table 2]. Out of which 26 patients were prescribed ceftriaxone as fixed-dose combination of ceftriaxone-sulbactam.
Table 1: Number of antibiotics prescribed preoperatively

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Table 2: Groups and types of antibiotics prescribed preoperatively

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Postoperatively, various other antibiotics like amikacin and metronidazole were added. All the patients were prescribed intravenous postoperative antimicrobials and variations were seen in the number as well type of antimicrobials being prescribed to the patients. Majority of the patients (49%) were prescribed three antimicrobial drugs [Table 3]. Among these, the most commonly prescribed group was the third-generation cephalosporin (61%). While individually amikacin (58.5%) was the most commonly prescribed individual AMA followed by ceftriaxone (44.55%) and metronidazole (55%). Fixed-dose combinations were also frequently used; among them piperacillin-tazobactam (20.5%) was the most common combination used followed by the ceftriaxone-sulbactam (13%) and amoxy-clavulanic acid (7.5%) [Table 4]. Cephalosporin plus an aminoglycoside plus an anti-anaerobic agent was the preferred prescribed postoperative antimicrobial combination.
Table 3: Number of antibiotics prescribed postoperatively

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Table 4: Antibiotics prescribed postoperatively

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The duration of postoperative prophylaxis ranges from 24 h or more in all patients during their hospital stay. AMAs were given throughout their stay in hospital; average duration of postoperative prophylactic antimicrobial administration was 8.23 days. Assessment of surgical site was done by surgeons; out of 200 patients, 19 (9.5%) patients had SSIs.


  Discussion Top


The main objective of this study was to study the usage pattern of antimicrobials in the patients undergoing surgery in the general surgery department of the MMIMSR. In our study, most of the patients had clean-contaminated surgical wounds; similar results were shown in the study conducted in Dutch hospitals.[8] Clean-contaminated wounds have more chances of getting infected as compared to clean wounds and contaminated ones have the highest rate of infection.[4] No universal SAP guideline can be implemented basis solely on the type of surgical wound as the occurrence of SSIs is also influenced by other factors such as site and length of the procedure, overall health of the patient, i.e., glucose levels, weight of the patients, etc.[9] In our study, majority of the patients (193 = 96.5%) received preoperative prophylactic antimicrobials which is similar to study done in Greece,[10] but contrary to the study done in Ahmedabad [11] and Kerala,[7] where all patients were given preoperative prophylactic antimicrobials. In our study, few of the patients with clean wound were not given SAP as recommended by guidelines.[4] In all patients, preoperative antibiotic dose was administrated by intravenous route as recommended by SAP guidelines.[4] Most of the patients (55%) were prescribed single preoperative antimicrobial, drug it is in accordance with SAP guidelines as single intravenous dose of single antimicrobial is sufficient to prevent SSIs.[4] Most commonly prescribed AMA group was cephalosporins followed by the aminoglycosides and anti-anaerobic agent, i.e., metronidazole. This corresponds to the results obtained by other studies, which also showed cephalosporins as most commonly prescribed antimicrobials.[7],[8],[12] Among the cephalosporins, ceftriaxone was the most commonly prescribed AMA in our study contrary to that in another study done in Delhi found Cefotaxime as the most commonly used cephalosporin,[12] while a study done in Czech had shown cefazolin as most commonly prescribed cephalosporins.[13] The recent guidelines recommend the use of first-generation cephalosporins such as Cefazolin as SAP,[4],[9] but local resistance pattern and surgeon's own experience at hospital setting might influence the choice of antimicrobial.

Use of two antimicrobial and three antimicrobials is very high in our study. They were merely used as blanket therapy to prevent any kind of infection. The three AMA combinations of cephalosporin, amikacin, and metronidazole were most commonly used, although there is paucity of data that shown that addition of aminoglycoside gives any additional benefit.

Timing plays an important role in SAP, ideally should be given within 1 h of incision to achieve sufficient minimum inhibitory concentration plasma concentration. All the patients were given antimicrobials on the day of surgery, but documentation was incomplete regarding timings of the administration of antimicrobials. It might be because of the same time of antimicrobial administration in wards irrespective of the timing of surgery; this can be resolved by the administration of antimicrobial drugs in the operating room by anesthetists.

In our study, none of the patients received any antimicrobial doses intraoperatively, as the duration of the surgery did not exceed 4 h and there was no significant blood loss during the surgery.

Existing guidelines recommend that single dose of antimicrobial with long enough plasma half-life is sufficient as SAP, and it should not be given longer than 24 h.[4] In our study, number of antimicrobials prescribed postoperatively were much more as compared to preoperatively. Postoperatively, 93% of patients were prescribed two or more antimicrobials, majority of the patients (49%) were given three antimicrobials. Unlike preoperative antimicrobial of choice, aminoglycosides were commonly prescribed followed by cephalosporins. Amikacin was given to 58.5% of patients usually in combinations with other antimicrobials and ceftriaxone to 44.5% of patients. Piperacillin-tazobactam was given to 41% of patients. Most of the patients were given antimicrobials through parenteral and oral route, and average duration of antimicrobial use was 8.23 days, which is much more than recommended guidelines. Many other studies have also documented the prolonged use of postoperative prophylaxis of antimicrobials.[8],[12] In addition, postoperative use of newer AMA such as meropenem, imipenem, linezolid, were also noticed, findings are similar in terms of overuse of antibiotics in other studies.[7],[12] Nineteen (9.5%) patients had SSI. Various studies done in India have shown the incidence varying from 8.95% to 17.8%, which shows that merely giving the blanket prophylaxis for preventions not enough.[14],[15]

This study shows that prophylactic use of antimicrobials especially postoperatively is inappropriate in majority of the patients. Reducing the infections after surgery is important but prolonged administration of antimicrobials not only leads to the emergence of resistant microbial strain but also increases the incidence of antimicrobials associated adverse effects and also the cost of the treatment.[16] Widespread use of AMAs may lead to emergence of multidrug-resistant microorganisms, which is the biggest health-care issue, we are facing globally. Based on our findings, we recommend that

  1. To promote appropriate prophylactic antimicrobial, use each hospital should formulate its own SAP guidelines based on standards guidelines like SIGN, for that local antibiograms should be updated periodically with regular update on hospital resistance pattern
  2. Educational interventions focusing on rational drug use, importance of complete documentation with periodic prescription auditing can help to curb the inappropriate antimicrobial prescribing
  3. Implement the antimicrobial stewardship programs in hospitals by making multidisciplinary antimicrobial stewardship teams – a group of health professionals, including a pharmacologists and microbiologist, who review the use of antibiotics by that organization.



  Conclusion Top


The present study revealed that there is poor compliance to SAP-stranded guidelines especially in terms of long postoperative use of antimicrobials, though this study had some inherent limitations regarding study population and sample size. More studies are needed to know the antibiotic use in all surgical cases, i.e., orthopedics, obstetrics, and gynecology. This study emphasizes there is dire need to make local SAP guidelines and dissemination of that among all health-care workers as antibiotic resistance is a global problem.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barnali K, Kumar A, Gupta P, Sachan PK, Thakuria B. Surgical site abdominal wound infection: Experience at a North Indian tertiary care hospital. JIACM 2013;14:13-9.  Back to cited text no. 1
    
2.
Martone WJ, Nochols RL. Recognition, prevention, surveillance and management of surgical site infections. Introduction to the problem and symposium overview. Clin Infect Dis 2001;33:67-8.  Back to cited text no. 2
    
3.
Belagali Y, Mc A, Thejeswi P, Sheetal DU, Bhagwath V, Shenoy KA, et al. Acritical evaluation and comparison of antimicrobial prophylaxis in elective surgeries across three hospitals. J Clin Diagn Res 2013;7:1073-7.  Back to cited text no. 3
    
4.
Scotish Intercollegiate Guidelines Network. Updated April 2014 Antibiotic Prophylaxis in Surgery – A National Clinical Guideline; 2008. Available from: http://www.sign.ac.uk/pdf/sign104. [Last accessed on 2017 Nov 10].  Back to cited text no. 4
    
5.
Henry FC. General principle of antimicrobial therapy. In: Brunton LL, Chabner BA, Knollmann BC, editors. Goodman & Gilman's the Pharmacological Basis of Therapeutics. 10th ed. New York: McGraw Hill; 2011. p. 1143-70.  Back to cited text no. 5
    
6.
Lampiris HW, Maddix DS. Clinical use of antimicrobial agents. In: Katzung BG, Masters SB, Trevor AJ, editors. Basic and Clinical Pharmacology. 11th ed. New Delhi: Tata McGraw-Hill Education Private Limited; 2009. p. 1029-49.  Back to cited text no. 6
    
7.
Khan AK, Mirshad PV, Rashed MR, Banu G. A study on the usage pattern of antimicrobial agents for the prevention of surgical site infections (SSIs) in a tertiary care teaching hospital. J Clin Diagn Res 2013;7:671-4.  Back to cited text no. 7
    
8.
van Kasteren ME, Kullberg BJ, de Boer AS, Mintjes-de Groot J, Gyssens IC. Adherence to local hospital guidelines for surgical antimicrobial prophylaxis: A multicentre audit in Dutch hospitals. J Antimicrob Chemother 2003;51:1389-96.  Back to cited text no. 8
    
9.
World Health Organization. Guidelines for Safe Surgery: Safe Surgery Saves Lives. Geneva: World Health Organization; 2009. Available from: http://www.who.int/patientsafety/safesurgery/tools_resources/9789241598552/en/. [Last accessed on 2017 Nov 12].  Back to cited text no. 9
    
10.
ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health Syst Pharm 1999;56:1839-88.  Back to cited text no. 10
    
11.
Tourmousoglou CE, Yiannakopoulou EC, Kalapothaki V, Bramis J, St. Papadopoulos J. Adherence to guidelines for antibiotic prophylaxis in general surgery: A critical appraisal. J Antimicrob Chemother 2008;61:214-8.  Back to cited text no. 11
    
12.
Rehan HS, Kakkar AK, Goel S. Surgical antibiotic prophylaxis in a tertiary 30 care teaching hospital in India. Int J Infect Control 2010;6:34-9.  Back to cited text no. 12
    
13.
Rana DA, Malhotra SD, Patel VJ. Inappropriate surgical chemoprophylaxis and surgical site infection rate at a tertiary care teaching hospital. Braz J Infect Dis 2013;17:48-53.  Back to cited text no. 13
    
14.
Choi WS, Song JY, Hwang JH, Kim NS, Cheong HJ. Appropriateness of antibiotic prophylaxis for major surgery in Korea. Infect Control Hosp Epidemiol 2007;28:997-1002.  Back to cited text no. 14
    
15.
Negi V, Pal S, Juyal D, Sharma MK, Sharma N. Bacteriological profile of surgical site infections and their antibiogram: A Study from resource constrained rural setting of Uttarakhand state, India. J Clin Diagn Res 2015;9:DC17-20.  Back to cited text no. 15
    
16.
Al-Azzam SI, Alzoubi KH, Mhaidat NM, Haddadin RD, Masadeh MM, Tumah HN, et al. Preoperative antibiotic prophylaxis practice and guideline adherence in Jordan: A multi-centre study in Jordanian hospitals. J Infect Dev Ctries 2012;6:715-20.  Back to cited text no. 16
    


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    Tables

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