Managing infections no longer as simple as selecting another antibiotic

Surgical site infection is a potential risk of surgery that needs to be managed effectively as part of good patient care.  The advent of antibiotics in the 20^th century and their associated use as surgical antibiotic prophylaxis, often along with other interventions such as oxygenation, glycaemic control and surgical anti-sepsis and advances in practice, has enabled us to minimise this procedural burden. However, the march of antimicrobial resistance across the globe is limiting the ability of the antibiotics we have at our disposal to provide safe and effective care for our patients. 

Many current infections are no longer responsive to first line antibiotic choices. The overuse and misuse of antibiotics, wherever this occurs, impacts the efficacy of surgical antibiotic prophylaxis. This, compounded by the decreased antibiotic development pipeline, means that managing infections is no longer as simple as just selecting another antibiotic. 

Complex infections are now being treated with more toxic, costly and complicated regimens than in the past, due to the reality of antimicrobial resistance.  This creates additional risks for our patients, including adverse outcomes from the antibiotic choices and increased length of stay due to a paucity of oral therapeutic choices. Patients with unnecessary exposure to long courses of antibiotic prophylaxis are also at higher risk of morbidity and mortality if they develop an infection, as it is more likely the organism will be resistant.

The Australian Commission on Safety and Quality in Health Care coordinates the Antimicrobial Use and Resistance in Australia (AURA) program which provides a platform for voluntary standardised audits of surgical prophylaxis within the Hospital National Antimicrobial Prescribing Survey (NAPS) framework.  Data from participating hospitals in 2017 demonstrates that 30.5 per cent of surgical prophylaxis prescriptions for inpatients extended 24 hours beyond the time of surgery. This is despite guidelines generally recommending surgical prophylaxis durations of less than 24 hours.  Commonly, surgical antibiotic prophylaxis was found to be too broad or too narrow for the likely organisms; were inconsistent with guidelines (with no indication of patient characteristics that would require variation), or the wrong dose was prescribed. 

In reality, variation in surgical antibiotic prophylaxis prescription is often because of our own individual prophylaxis preferences. There may be the perception of reduced adverse outcome with longer and broader spectrum intravenous courses, and topical or deep surgical site administration has been reported.  Despite evidence to the contrary, some of these perceptions remain.^1,2 The documented increased healthcare-associated complications of prolonged or novel intra-operative antibiotic use, also need to be considered, particularly where the evidence base for alternative practices is poor. As antibiotic prophylaxis is important in reducing complications for our patients, attention should be paid to relative benefits of these considerations.

Process issues still account for many variations from guidelines-based practice.  Improved standardisation could harmonise our practice towards more consistent and reliable delivery of antibiotic prophylaxis.  There are many opportunities for improvement including:

• Consistency in documentation of fixed antibiotic duration

• Development and adherence to evidence or consensus-based guidelines

• Optimising administration timing for optimal concentration during the procedure.

Simple changes such as elevating the importance of correct surgical antimicrobial prophylaxis for every procedure, rather than as a peripheral consideration to the surgery at hand, could also increase consistent administration and improve choice practices. Clarity in the ownership of the choice of antibiotic between the anaesthetic and surgical specialties may aid in more consistent administration practices within organisations.³ 

Under the National Safety and Quality Health Service (NSQHS) Standards, every hospital is required to have a local antimicrobial stewardship program to optimise use of antimicrobials and improve the use of surgical antimicrobial prophylaxis within hospitals.   They may also be able to facilitate peer group or individual audit and feedback procedures or dedicated quality improvement projects.  We all want the same outcome - the provision of safe and effective care to our patients. To achieve this, we need to understand how to balance the risks and benefits of antimicrobial use by utilising specialty knowledge. 

The Commission is working with RACS to provide you with resources to assist in this.

Visit the Commission web page and download a useful presentation and other resources to help you improve surgical antibiotic prophylaxis in your organisation.

1. Harbarth S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation. 2000 Jun 27;101(25):2916-21

2. Improvisation versus guideline concordance in surgical antibiotic prophylaxis: a qualitative study, Broom, J., Broom, A., Kirby, E. et al. Infection (2018) 46: 541).

3. Understanding antibiotic decision making in surgery-a qualitative analysis, Clinical Microbiology and Infection , Volume 23 , Issue 10 , 752 - 760, Charani, E. et al.