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Antibiotic prophylaxis audit and questionnaire study: Traffic Light Poster improves adherence to protocol in gastrointestinal surgery
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International Journal of Surgery xxx (2015) 1e4
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Q6
Antibiotic prophylaxis audit and questionnaire study: Traffic Light Poster improves adherence to protocol in gastrointestinal surgery
Q5
Michaella Cameron a, *, Stacey Jones a, Olufunso Adedeji b a
Q1
b
Foundation Year Two Doctor, University Hospital Lewisham, London, United Kingdom University Hospital Birminghma, United Kingdom
h i g h l i g h t s
Q2
We present the results of a closed loop audit and questionnaire survey, which measured adherence to antibiotics prophylaxis in gastrointestinal surgery. There is poor compliance to antibiotic protocols in gastrointestinal survey, in part to general lack of awareness. A survey of current practice revealed only 30% of respondents would not give antibiotic as recommended. 45% would use appropriate antibiotics prophylaxis for clean contaminated wounds. An educational intervention in the form of a ‘Traffic Light Poster’ improved adherence two fold with improved rationalizing of antibiotics.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 February 2015 Received in revised form 24 April 2015 Accepted 6 May 2015 Available online xxx
Objective: To measure adherence to antibiotic prophylaxis (AP) protocol amongst surgeons and anesthetists and explore their understanding of AP prescribing in practice. Design: A prospective audit of AP in gastrointestinal surgery and re-audit after intervention. A questionnaire survey of practice. Results: 58 (38%- clean; 62%- clean contaminated) operations were audited and 73 (48%-clean; 51%-clean contaminated) operations were re-audited after intervention with “Traffic Light Poster” (TFP) .55 colleagues (32 consultants and 23 trainees) were recruited for questionnaire survey in three West Midlands hospitals. Audit and Re-Audits. Only 31% of procedures followed the protocol correctly in the initial audit and this increased to 73% in the re-audit. 73% of patients undergoing clean procedures received AP inappropriately in the initial audit but reduced significantly to 20% (p < 0.002) in the re-audit. In the initial audit, 62% of clean contaminated procedures did not receive the appropriate first line AP but this fell to 35% (p < 0.05) in the re-audit. Questionnaire Survey- Only 30% of respondents would not give AP in clean surgery as recommended. 45% would use appropriate AP for clean-contaminated wounds. 73% of respondents will give AP at induction, 20% 1 h pre op and 7% just before incision. Conclusion: There is poor compliance with AP protocols in gastrointestinal surgery in part due to general lack of awareness. An educational intervention in the form of a ‘Traffic Light Poster’ improved adherence to AP protocol two fold. There was improved rationalizing of AP. Clean procedures, in particular, had less inappropriate prescribing. © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Keywords: Antibiotics Prophylaxis Traffic light chart Audit cycle
1. Introduction Antibiotic prophylaxis (AP) is an important measure used to decrease surgical site infections (SSI) incidence and it reduces
* Corresponding author.
contaminated inoculations perioperatively [1e5]. SSIs are common cause of hospital acquired infections [6,7] and appropriate AP can reduce the incidence fourfold [8] without increasing the incidence of C. Diff colitis [9,10]. Scottish Intercollegiate Guidelines Network (SIGN) have designed evidence-based guidelines, which advocate the rationalization of AP [11] and the National Institute for Clinical Excellence (NICE) also produced a similar AP guideline [12]. Despite
http://dx.doi.org/10.1016/j.ijsu.2015.05.008 1743-9191/© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: M. Cameron, et al., Antibiotic prophylaxis audit and questionnaire study: Traffic Light Poster improves adherence to protocol in gastrointestinal surgery, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.05.008
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published evidence for AP, there is low adherence to hospital AP protocols [13e16]. There are multiple reasons for low adherence to hospital protocols and lack of awareness is a common one [14e17]. Cabana et al. (1999) [18] identified 4 main reasons for poor compliance wit: lack of awareness of the evidence for the suggested guidelines, lack of familiarity, lack of agreement with guidelines and inertia of previous practice which means there is resistance to change. Eskicioglu et al. (2012) explains that broad reaching initiatives are key to narrowing the gap between evidence and practice [12]. Effective dissemination of AP guidelines is necessary in order to improve adherence. Prado et al. (2002) implemented a prophylaxis guideline as well as an educational intervention and measured an improvement in adherence from 56.4% to 100% [19]. Imai- Kamata and Fushimi (2011) also advocated the use of education which improved previous suboptimal AP prescribing specifically in terms of drug selection [17]. Alexiou et al. (2010) surveyed AP usage and found that strategies can differ significantly not just locally but internationally and suggested that uniform practice based on evidence is needed to improve the general adherence to protocols [20]. However, this is difficult especially when surgeons are accustomed to following their own protocol, which has always ‘worked’ for them [14,21]. Pontenza et al. (2009) observed that surgeons' resistance to change is often due to misunderstandings of the planning process involved [16]. This paper assesses the adherence to AP protocol with the following aims: 1) To audit the adherence to AP protocols in a tertiary hospital in West Midlands, UK 2) A cross-sectional survey of surgical and anaesthetic teams in three West Midlands Hospitals in order to assess their understanding of AP. 3) To re-audit adherence to AP protocols after the introduction of an educational ‘Traffic Light” poster.
2.3.2. Questionnaire The questionnaire survey comprised of 10 questions, which included multiple choice and free text questions (See Appendix 1, web only). Responses were analysed using Microsoft Excel software programme. 3. Intervention The data on AP administration obtained from the initial audit was presented at a surgical Mortality and Morbidity Meeting. A ‘Traffic Light’ Poster (See Appendix 2, web only) was produced and approved by the Microbiology Department. Data of the re-audited AP prescribing analysed and efficacy of the poster intervention was presented. 4. Results 4.1. Audit 38% (22/58) of the procedures were clean and 62% (36/58) were clean-contaminated. Inguinal hernia repair was the most common clean procedure and bowel resection was the most common clean contaminated procedure. In the initial audit, the hospital protocol for AP was followed for 31% (18/58) of patients. Table 1. Displays the adherence to AP protocol for clean and clean contaminated surgeries (Table 2). Q3 3 different AP regimens were used in the clean procedure. The most frequently prescribed antibiotic was co-amoxiclav. In the clean-contaminated procedures, 9 different AP regimens were used as an alternative to the recommended antibiotics. The most frequently prescribed alternative antibiotic combination was coamoxiclav and metronidazole. 4 (12.5%) patients who underwent clean-contaminated procedures did not receive antibiotics. 4.2. Re-audit
AP use was audited for 21 days between October 2011eJanuary 2012. Questionnaires were randomly distributed concurrently during initial audit. An intervention in the form of a ‘Traffic Light’ poster was displayed in seven theatres thereafter. A re-audit commenced after intervention in May 2012 for 28 days. Differences in frequency were compared using chi-square with Fisher's exact test with a two-tailed p value.
48% (35/73) of the procedures were clean and 51% (37/73) were clean contaminated (See Table 1). The hospital protocol for AP was followed 73% of cases. Inguinal hernia repair was the most common clean procedure and co-amoxiclav was the most common AP choice. Bowel resection was the most common clean contaminated procedure and co-amoxiclav and metronidazole was the most common alternative AP for this procedure. There were 8 different AP regimens used as an alternative to the recommended antibiotics. 2 (5.4%) patients who underwent clean-contaminated procedures did not receive AP. Most patients received antibiotics at induction (51%), contrary to guidelines, with the remaining patients mostly receiving AP just before first incision (40%) and 4% receiving AP 1 h pre op.
2.2. Participants
5. Questionnaire survey
Three West Midlands Hospitals were included in the study population. Consultant general surgeons and anesthetists and their trainees were randomly selected for questionnaire. All protocols across the three hospitals were based on SIGN guidelines [11]. Both audits were undertaken in one large teaching hospital.
In the three hospitals, 32 consultants and 23 trainees in surgery and anaesthetics completed the AP questionnaire. Their responses are seen below: The questionnaire survey mirrored the clinical practice observed in the initial audit. Most responders would give antibiotic prophylaxis at induction (73%) but 20% would give AP at 1-h pre op and 7% would give AP just before incision. When asked to provide specific circumstances warranting postoperative antibiotic prophylaxis, 5% stated that they were unsure of indication and 67% of responders gave appropriate situations (high infection risk in faecal contamination and specific co-morbidities like infective endocarditis), which would indicate postoperative antibiotics. Antibiotic choice for specific procedures revealed a variety of
2. Methods 2.1. Design
2.3. Data collection 2.3.1. Audit Antibiotic prescribed and time administered was recorded. Penicillin allergy status, MRSA status and duration of surgery were recorded. Data was cross-referenced with anaesthetic charts and hospital electronic records.
Please cite this article in press as: M. Cameron, et al., Antibiotic prophylaxis audit and questionnaire study: Traffic Light Poster improves adherence to protocol in gastrointestinal surgery, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.05.008
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3
Table 1 Shows Adherence to Hospital Protocol Before and After ‘Traffic Light’ Poster Intervention. Wound classification
Definition according to SIGN
Hospital protocol criterion
Initial audit n (%)
Re-audit n (%)
Fishers p
Clean
Operation in which no respiratory, alimentary tract or genitourinary tracts are entered Operation in which the respiratory, alimentary or genitourinary tracts are entered but without significant spillage
No AP
6/22 (27)
28/35 (80)
<0.0002
Co- amoxiclav
12/32 (38)
24/37(65)
<0.05
Clean contaminated
responses for both the clean and clean contaminated procedures. The majority of responders would give antibiotics inappropriately for inguinal hernia (77%). 44% of responders correctly chose coamoxiclav in colonic resections and 29% will combine this antibiotic with metronidazole. 42% of responders would use coamoxiclav alone for closure of duodenal ulcers, 57% would use co amoxiclav for non-perforated appendectomies while 55% opting to use this antibiotic for gastrectomies. Only 25% of responders would use co-amoxiclav alone in perforated diverticular and with 15 different antibiotic prophylaxis regimes being noted. Finally, there was a relatively low awareness of SSI rates in the literature for clean and clean-contaminated procedures. Most responders underestimated the SSI rate in clean procedures with many opting to quote a less than 2% risk. 36% of responders did not know the SSI rates for clean contaminated procedures or estimated a less than 5% risk. 6. Discussion There is a poor awareness of antibiotic prophylaxis amongst surgeons and anaesthetists. This audit showed a low adherence with recommended guidelines for both clean and clean contaminated procedures. AP is being prescribed for clean procedures similarly to clean contaminated procedures. 73% of the clean procedures audited received antibiotics incorrectly and the questionnaire further depicted the general attitude that procedures such as inguinal hernia repair should receive antibiotics. This practice is similar to other studies where surgeons give AP in clean surgery [22,23]. There is ambiguity in the literature with some papers advocating antibiotics in clean procedures [24,25] and others not [26,27]. However, SIGN recommends none in clean procedures. AP should be timed to provide maximal effect i.e. first surgical incision and for the entire duration of the surgery [9]. AP timing is optimal when administered intravenously no less than 30 min before the first surgical incision according to Scottish Intercollegiate Guidelines Network (SIGN) [11]. For procedures less than 4 h, a single antibiotic dose is considered to be sufficient [11,12]. The antibiotic must cover the expected pathogens, including anaerobes, E. coli and other enterobacteriacae [11]. Palmer et al. 1993 found coamoxiclav to be effective [28] and this antibiotic has been recommended as first line for clean contaminated surgery [11]. No
antibiotics are recommended for uncomplicated clean surgery [11,12]. Ho et al. 2011 emphasized the importance of appropriate antibiotic choice in elective colorectal surgery as she found a statistically significant increase in SSI when nonstandard regimens were administered (odds ratio 2.069; 95% confidence interval 1.078e1.868) [29]. The concurrent questionnaire similarly echoed our audit result by showing that all doctors demonstrated poor awareness of AP use. Particularly, 77% of doctors would prescribe a single dose of co amoxiclav for inguinal hernia repair procedures inappropriately. Only 44% of doctors prescribed co amoxiclav for colonic resections. The local protocol states that AP should be given before of anaethesia. However, in practice there was inconsistency with AP timing. A Swiss questionnaire found that for clean and clean contaminated surgeries, only 50% of responders would give AP within 30 min before incision [21]. Similarly, a van Kasteren's study focussing on a wider range of surgical procedures including gynaecological and vascular surgery, found that 50% of timings were concordant with the guidelines [14]. In a Kobayashi study, 95% of respondents administered AP within 1 h before incision but this was continued for at least 24 h in 90% of participating hospitals [30]. Interestingly, Hawn et al. (2013) found that there was no significant increase in SSI rates if AP was to be administered within 60 min prior to incision or after incision [31]. Regular audit of SSI amongst general surgical teams is not compulsory nationwide. This possibly explains why there is generally low knowledge of SSI rates. Pinkney et al. (2013) felt that SSI rates both in practice and literature may be higher than originally thought [32]. Prtak and Ridgway recommend surveillance of SSI and rates should be presented at Multi-Disciplinary Team meetings to stimulate discussion on possible initiatives to improve these rates [33]. Our re-audit showed a 2-fold improvement in adherence to protocol. Resources were more appropriately allocated with a decrease in AP in clean surgeries and this is regarded as the major success of this study. Although, there was improved adherence to AP use for clean contaminated surgeries, there was still a wide range of alternative APs regimens still being prescribed. Our Traffic Light Poster improved adherence to AP prophylaxis but we did not achieve 100% compliance. Awareness of AP protocols may also be enhanced by delivering the protocol electronically, pre-
Table 2 Questionnaire survey showing the percentage of correct responses for each question. Question
Correct response according to guidelines
% who answered correctly
Time to give first antibiotics prophylaxis dose Time to give second antibiotics prophylaxis dose in long procedures Number of post operative antibiotics prophylaxis dose in uncomplicated major abdominal surgery What antibiotics prophylaxis to give in clean proceduresa What antibiotics prophylaxis to give in clean contaminated proceduresb What is the expected incidence of post operative wound infection in clean wound What is the expected incidence of post operative wound infection in clean contaminated wound
Before Induction After 4 h None None Co Amoxiclav <5% <15%
73% 33% 56% 30% 45% 22% 36%
a b
Inguinal hernia repair and laparoscopic cholecystectomy. Bowel resection.
Please cite this article in press as: M. Cameron, et al., Antibiotic prophylaxis audit and questionnaire study: Traffic Light Poster improves adherence to protocol in gastrointestinal surgery, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.05.008
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printing aspects of the guideline on prescription charts and to provide surgeons with evidence of content of guideline and to assess acceptance of protocol amongst surgeons before implementation. It is also a suggestion that the surgeon check AP selection during the ‘Before Induction’ period of the WHO Checklist [34] as this may improve the timing of administration of AP in our hospitals. When AP selection contradicts the protocol guideline, staff can raise concerns regarding the deviation from the guideline. Anaethetists play a vital role in improving adherence to protocol and should especially be kept up to date with guidelines and feel able to question any deviation from recommendations. 7. Conclusion In conclusion, SSIs are costly complications, which can result in increased morbidity and mortality. AP is a critical measure aimed at reducing the risk of SSI in gastrointestinal surgery. SIGN have produced AP guidelines, which form the basis of many local hospital protocols [11]. Our initial audit showed poor awareness to these guidelines and it appears that most surgeons and anaesthetists follow their own protocol based on previous experience. This is particularly true in clean procedures where there is inappropriate use of AP when not recommended. Our ‘Traffic Light’ poster markedly improved the adherence to protocol by acting as a vivid visual source of information when the surgical team were in doubt. We recommend that continual education on the appropriate AP administration protocols via a poster and engagement of both senior clinicians and juniors in this process. Declaration of competing interest All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. Appendix ASupplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.ijsu.2015.05.008. References [1] J.S. Burke, Infection control e a problem for patient safety, N. Engl. J. Med. 348 (2003) 651e656. [2] A.J. Mangram, T.C. Horan, M.L. Pearson, et al., Guideline for prevention of surgical site infection, Infect. Control Hosp. Epidemiol. 20 (2004) 247e264. [3] D. Bratzler, P. Houck, Antimicrobial prophylaxis for surgery: an Advisory Statement from the national surgical infection prevention project, Clin. Infect. Dis. 38 (2004) 1706e1715. [4] J.S. Solomkin, Antibiotic prophylaxis in surgery, in: J. Cohen, W.G. Powderly (Eds.), Infectious Diseases, second ed., Mosby, USA, 2004. [5] R.L. Nichols, Preventing surgical site infection, Clin. Med. Res. 2 (2004) 115e118. [6] J. Reilly, S. Stewart, G. Allardice, et al., NHS Scotland National HAI Prevalence Survey, Final report, Heath Protection Scotland, Glasgow, 2007, www.scot.nhs. uk/hai/ss (accessed 20.11.13). [7] CDC. Surgical Site Infections: Resources for Patients and Healthcare Providers. Available on http://www.cdc.gov/ncidod/dhqp/dpac_ssi. (accessed 01.07.13). [8] H.C. Polk Jr., J.F. Lopez-Mayor, Postoperative wound infection: a prospective study of determinant factors and prevention, J. Surg. 66 (1969) 97e103.
[9] B. Setiawan, The role of prophylactic antibiotics in preventing perioperative infection, Indones. J. Intern Med. 43 (2011) 262e266. [10] G. Privitera, P. Scapellini, G. Ortisi, Prospective study of Clostridium Difficile intestinal colonization and disease following single dose antibiotic prophylaxis in surgery, J. Antimicrob. Chemother. 35 (1991) 208e210. [11] Scottish Intercollegiate Guidelines Network, Antibiotic Prophylaxis in Surgery. A National Clinical Guideline No.104, July 2008. www.sign.ac.uk/pdf/sign104. pdf (accessed 20.11.13). [12] National Clinical Guidelines Centre, Surgical Site Infection: Prevention and Treatment of Surgical Site Infection, October 2008. www.nice.org.uk/ nicemedia/pdf/cg74niceguideline.pdf (accessed 20.11.13). [13] C. Eskicioglu, A.R. Gagliardi, D.S. Fenech, Surgical Site Infection prevention: a survey to identify the gaps between evidence and practice in University of Toronto to teaching hospitals, Can. J. Surg. 55 (2012) 223e238. [14] M.E. Van Kasteren, B.J. Kullberg, A.S. De Boer, et al., Adherence to local hospital guidelines for Surgical antimicrobial prophylaxis: a multicentre audit in Dutch hospitals, J. Antimicrob. Chemother. 51 (2004) 1389e1396. [15] C.E. Tourmousoglou, E.C. Yiannakopoulou, V. Kalapothaki, et al., Adherence to guidelines for antibiotic prophylaxis in general surgery: a critical appraisal, J. Antimicrob. Chemother. 61 (2008) 214e218. [16] B. Potenza, M. Deligencia, B. Estigoy, et al., Lessons learned from the institution of surgical care improvement project at a teaching medical center, Am. J. Surg. 196 (2009) 881e888. [17] S. Imai-Kamata, K. Fushimi, Factors associated with adherence to prophylactic antibiotic therapy for elective general surgeries in Japan, Int. J. Qual. Health Care 23 (2011) 161e172. [18] M.D. Cabana, C.S. Rand, N.R. Powe, et al., Why don't physicians follow clinical practice guidelines? A framework for improvement, JAMA 282 (1999) 1458e1465. [19] M.A. Prado, M.P. Lima, I. Gomes, et al., The implementation of a surgical antibiotic prophylaxis program: the pivotal contribution of the hospital pharmacy, Am. J. Infect. Control 30 (2002) 49e56. [20] V.G. Alexiou, V. Ierodiakonou, G. Peppas, et al., Antimicrobial prophylaxis in surgery: an international survey, Surg. Infect. 11 (2010) 343e348. [21] M. Diana, M. Hubner, M.C. Eisenring, et al., Measures to prevent surgical site infections: what surgeons (should) do? World J. Surg. 35 (2011) 280e288. [22] American Society of Health- System Pharmacists, ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. ASHP Commission on Therapeutics, Clin. Pharm. 11 (6) (1992 Jun) 483e513. www.ncbi.nlm.nih.gov/pubmed/ 1600684 (accessed 03.04.13). [23] A.M. Aiken, J.B. Haddow, N.R. Symons, et al., Use of Antibiotic Prophylaxis in elective inguinal hernia repair in adults in London and south east England: a cross sectional survey, Hernia 17 (2013) 657e664. [24] C.J. Ranaboldo, S.E. Karran, I.S. Bailey, et al., Antimicrobial prophylaxis in ‘clean’ surgery; inguinal hernia repair, J. Antimicrob. Chemother. 31 (1993) 35e41. [25] A. Rios, J. Rodriguez, V. Munitiz, et al., Antibiotic prophylaxis in incisional hernia repair using prosthesis, Hernia 5 (2001) 148e152. [26] T.J. Aufenacker, M.J. Koelemay, D.J. Gouma, et al., Systematic review and metaanalysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia, Br. J. Surg. 93 (2006) 5e10. [27] F.J. Sanchez- Manuel, J.L. Seco- Gil, Antibiotic prophylaxis for hernia repair (review), Cochrane Collab. (October 2004). www.onlinelibrary.wiley.com/doi/ 10.1002/14651858.CD003769.pub2/pdf (accessed 20.11.13). Q4 [28] B.V. Palmer, K.R. Mannur, W.B. Ross, An observer blind trial of co - amoxiclav versus cefuroxime plus metronidazole in the prevention of postoperative wound infection after general surgery, J. Hosp. Infect. 26 (1993) 287e292. [29] V. Ho, P. Barie, S. Stein, et al., Antibiotic regimen and the timing of prophylaxis are important for reducing surgical site infection after elective abdominal colorectal surgery, J. Surg. Infect. 12 (2011) 255e260. [30] M. Kobayashi, Y. Takesue, Y. Kitagawa, et al., Antimicrobial prophylaxis and Colon preparation for colorectal surgery: results of a questionnaire survey of 721 certified institutions in japan, Surg. Today 41 (2011) 1363e1369. [31] M.T. Hawn, J.S. Richman, C.C. Vick, et al., Timing of surgical antibiotic prophylaxis and the risk of surgical site infection, JAMA Surg. 148 (2013) 649e657. [32] T.D. Pinkney, M.C. Calvert, D.C. Barkett, et al., Impact of wound edge protects devices on surgical site infection after laparotomy: multicentre randomised controlled trial (ROSSINI TRIAL), BMJ 347 (2013) f4305. [33] L. Prtak, E. Ridgway, Prophylactic antibiotics in surgery, J. Surg. 27 (2009) 431e434. [34] World Alliance for Patient Safety, WHO Surgical Safety Checklist and Implementation Manual, 2008. www.who.int/patientsafety/safesurgery/ss_ checklist/en/ (accessed 02.07.13).
Please cite this article in press as: M. Cameron, et al., Antibiotic prophylaxis audit and questionnaire study: Traffic Light Poster improves adherence to protocol in gastrointestinal surgery, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.05.008
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IJSU1866_proof ■ 20 May 2015 ■ 1/4
International Journal of Surgery xxx (2015) 1e4
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Q6
Antibiotic prophylaxis audit and questionnaire study: Traffic Light Poster improves adherence to protocol in gastrointestinal surgery
Q5
Michaella Cameron a, *, Stacey Jones a, Olufunso Adedeji b a
Q1
b
Foundation Year Two Doctor, University Hospital Lewisham, London, United Kingdom University Hospital Birminghma, United Kingdom
h i g h l i g h t s
Q2
We present the results of a closed loop audit and questionnaire survey, which measured adherence to antibiotics prophylaxis in gastrointestinal surgery. There is poor compliance to antibiotic protocols in gastrointestinal survey, in part to general lack of awareness. A survey of current practice revealed only 30% of respondents would not give antibiotic as recommended. 45% would use appropriate antibiotics prophylaxis for clean contaminated wounds. An educational intervention in the form of a ‘Traffic Light Poster’ improved adherence two fold with improved rationalizing of antibiotics.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 February 2015 Received in revised form 24 April 2015 Accepted 6 May 2015 Available online xxx
Objective: To measure adherence to antibiotic prophylaxis (AP) protocol amongst surgeons and anesthetists and explore their understanding of AP prescribing in practice. Design: A prospective audit of AP in gastrointestinal surgery and re-audit after intervention. A questionnaire survey of practice. Results: 58 (38%- clean; 62%- clean contaminated) operations were audited and 73 (48%-clean; 51%-clean contaminated) operations were re-audited after intervention with “Traffic Light Poster” (TFP) .55 colleagues (32 consultants and 23 trainees) were recruited for questionnaire survey in three West Midlands hospitals. Audit and Re-Audits. Only 31% of procedures followed the protocol correctly in the initial audit and this increased to 73% in the re-audit. 73% of patients undergoing clean procedures received AP inappropriately in the initial audit but reduced significantly to 20% (p < 0.002) in the re-audit. In the initial audit, 62% of clean contaminated procedures did not receive the appropriate first line AP but this fell to 35% (p < 0.05) in the re-audit. Questionnaire Survey- Only 30% of respondents would not give AP in clean surgery as recommended. 45% would use appropriate AP for clean-contaminated wounds. 73% of respondents will give AP at induction, 20% 1 h pre op and 7% just before incision. Conclusion: There is poor compliance with AP protocols in gastrointestinal surgery in part due to general lack of awareness. An educational intervention in the form of a ‘Traffic Light Poster’ improved adherence to AP protocol two fold. There was improved rationalizing of AP. Clean procedures, in particular, had less inappropriate prescribing. © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Keywords: Antibiotics Prophylaxis Traffic light chart Audit cycle
1. Introduction Antibiotic prophylaxis (AP) is an important measure used to decrease surgical site infections (SSI) incidence and it reduces
* Corresponding author.
contaminated inoculations perioperatively [1e5]. SSIs are common cause of hospital acquired infections [6,7] and appropriate AP can reduce the incidence fourfold [8] without increasing the incidence of C. Diff colitis [9,10]. Scottish Intercollegiate Guidelines Network (SIGN) have designed evidence-based guidelines, which advocate the rationalization of AP [11] and the National Institute for Clinical Excellence (NICE) also produced a similar AP guideline [12]. Despite
http://dx.doi.org/10.1016/j.ijsu.2015.05.008 1743-9191/© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: M. Cameron, et al., Antibiotic prophylaxis audit and questionnaire study: Traffic Light Poster improves adherence to protocol in gastrointestinal surgery, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.05.008
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published evidence for AP, there is low adherence to hospital AP protocols [13e16]. There are multiple reasons for low adherence to hospital protocols and lack of awareness is a common one [14e17]. Cabana et al. (1999) [18] identified 4 main reasons for poor compliance wit: lack of awareness of the evidence for the suggested guidelines, lack of familiarity, lack of agreement with guidelines and inertia of previous practice which means there is resistance to change. Eskicioglu et al. (2012) explains that broad reaching initiatives are key to narrowing the gap between evidence and practice [12]. Effective dissemination of AP guidelines is necessary in order to improve adherence. Prado et al. (2002) implemented a prophylaxis guideline as well as an educational intervention and measured an improvement in adherence from 56.4% to 100% [19]. Imai- Kamata and Fushimi (2011) also advocated the use of education which improved previous suboptimal AP prescribing specifically in terms of drug selection [17]. Alexiou et al. (2010) surveyed AP usage and found that strategies can differ significantly not just locally but internationally and suggested that uniform practice based on evidence is needed to improve the general adherence to protocols [20]. However, this is difficult especially when surgeons are accustomed to following their own protocol, which has always ‘worked’ for them [14,21]. Pontenza et al. (2009) observed that surgeons' resistance to change is often due to misunderstandings of the planning process involved [16]. This paper assesses the adherence to AP protocol with the following aims: 1) To audit the adherence to AP protocols in a tertiary hospital in West Midlands, UK 2) A cross-sectional survey of surgical and anaesthetic teams in three West Midlands Hospitals in order to assess their understanding of AP. 3) To re-audit adherence to AP protocols after the introduction of an educational ‘Traffic Light” poster.
2.3.2. Questionnaire The questionnaire survey comprised of 10 questions, which included multiple choice and free text questions (See Appendix 1, web only). Responses were analysed using Microsoft Excel software programme. 3. Intervention The data on AP administration obtained from the initial audit was presented at a surgical Mortality and Morbidity Meeting. A ‘Traffic Light’ Poster (See Appendix 2, web only) was produced and approved by the Microbiology Department. Data of the re-audited AP prescribing analysed and efficacy of the poster intervention was presented. 4. Results 4.1. Audit 38% (22/58) of the procedures were clean and 62% (36/58) were clean-contaminated. Inguinal hernia repair was the most common clean procedure and bowel resection was the most common clean contaminated procedure. In the initial audit, the hospital protocol for AP was followed for 31% (18/58) of patients. Table 1. Displays the adherence to AP protocol for clean and clean contaminated surgeries (Table 2). Q3 3 different AP regimens were used in the clean procedure. The most frequently prescribed antibiotic was co-amoxiclav. In the clean-contaminated procedures, 9 different AP regimens were used as an alternative to the recommended antibiotics. The most frequently prescribed alternative antibiotic combination was coamoxiclav and metronidazole. 4 (12.5%) patients who underwent clean-contaminated procedures did not receive antibiotics. 4.2. Re-audit
AP use was audited for 21 days between October 2011eJanuary 2012. Questionnaires were randomly distributed concurrently during initial audit. An intervention in the form of a ‘Traffic Light’ poster was displayed in seven theatres thereafter. A re-audit commenced after intervention in May 2012 for 28 days. Differences in frequency were compared using chi-square with Fisher's exact test with a two-tailed p value.
48% (35/73) of the procedures were clean and 51% (37/73) were clean contaminated (See Table 1). The hospital protocol for AP was followed 73% of cases. Inguinal hernia repair was the most common clean procedure and co-amoxiclav was the most common AP choice. Bowel resection was the most common clean contaminated procedure and co-amoxiclav and metronidazole was the most common alternative AP for this procedure. There were 8 different AP regimens used as an alternative to the recommended antibiotics. 2 (5.4%) patients who underwent clean-contaminated procedures did not receive AP. Most patients received antibiotics at induction (51%), contrary to guidelines, with the remaining patients mostly receiving AP just before first incision (40%) and 4% receiving AP 1 h pre op.
2.2. Participants
5. Questionnaire survey
Three West Midlands Hospitals were included in the study population. Consultant general surgeons and anesthetists and their trainees were randomly selected for questionnaire. All protocols across the three hospitals were based on SIGN guidelines [11]. Both audits were undertaken in one large teaching hospital.
In the three hospitals, 32 consultants and 23 trainees in surgery and anaesthetics completed the AP questionnaire. Their responses are seen below: The questionnaire survey mirrored the clinical practice observed in the initial audit. Most responders would give antibiotic prophylaxis at induction (73%) but 20% would give AP at 1-h pre op and 7% would give AP just before incision. When asked to provide specific circumstances warranting postoperative antibiotic prophylaxis, 5% stated that they were unsure of indication and 67% of responders gave appropriate situations (high infection risk in faecal contamination and specific co-morbidities like infective endocarditis), which would indicate postoperative antibiotics. Antibiotic choice for specific procedures revealed a variety of
2. Methods 2.1. Design
2.3. Data collection 2.3.1. Audit Antibiotic prescribed and time administered was recorded. Penicillin allergy status, MRSA status and duration of surgery were recorded. Data was cross-referenced with anaesthetic charts and hospital electronic records.
Please cite this article in press as: M. Cameron, et al., Antibiotic prophylaxis audit and questionnaire study: Traffic Light Poster improves adherence to protocol in gastrointestinal surgery, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.05.008
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Table 1 Shows Adherence to Hospital Protocol Before and After ‘Traffic Light’ Poster Intervention. Wound classification
Definition according to SIGN
Hospital protocol criterion
Initial audit n (%)
Re-audit n (%)
Fishers p
Clean
Operation in which no respiratory, alimentary tract or genitourinary tracts are entered Operation in which the respiratory, alimentary or genitourinary tracts are entered but without significant spillage
No AP
6/22 (27)
28/35 (80)
<0.0002
Co- amoxiclav
12/32 (38)
24/37(65)
<0.05
Clean contaminated
responses for both the clean and clean contaminated procedures. The majority of responders would give antibiotics inappropriately for inguinal hernia (77%). 44% of responders correctly chose coamoxiclav in colonic resections and 29% will combine this antibiotic with metronidazole. 42% of responders would use coamoxiclav alone for closure of duodenal ulcers, 57% would use co amoxiclav for non-perforated appendectomies while 55% opting to use this antibiotic for gastrectomies. Only 25% of responders would use co-amoxiclav alone in perforated diverticular and with 15 different antibiotic prophylaxis regimes being noted. Finally, there was a relatively low awareness of SSI rates in the literature for clean and clean-contaminated procedures. Most responders underestimated the SSI rate in clean procedures with many opting to quote a less than 2% risk. 36% of responders did not know the SSI rates for clean contaminated procedures or estimated a less than 5% risk. 6. Discussion There is a poor awareness of antibiotic prophylaxis amongst surgeons and anaesthetists. This audit showed a low adherence with recommended guidelines for both clean and clean contaminated procedures. AP is being prescribed for clean procedures similarly to clean contaminated procedures. 73% of the clean procedures audited received antibiotics incorrectly and the questionnaire further depicted the general attitude that procedures such as inguinal hernia repair should receive antibiotics. This practice is similar to other studies where surgeons give AP in clean surgery [22,23]. There is ambiguity in the literature with some papers advocating antibiotics in clean procedures [24,25] and others not [26,27]. However, SIGN recommends none in clean procedures. AP should be timed to provide maximal effect i.e. first surgical incision and for the entire duration of the surgery [9]. AP timing is optimal when administered intravenously no less than 30 min before the first surgical incision according to Scottish Intercollegiate Guidelines Network (SIGN) [11]. For procedures less than 4 h, a single antibiotic dose is considered to be sufficient [11,12]. The antibiotic must cover the expected pathogens, including anaerobes, E. coli and other enterobacteriacae [11]. Palmer et al. 1993 found coamoxiclav to be effective [28] and this antibiotic has been recommended as first line for clean contaminated surgery [11]. No
antibiotics are recommended for uncomplicated clean surgery [11,12]. Ho et al. 2011 emphasized the importance of appropriate antibiotic choice in elective colorectal surgery as she found a statistically significant increase in SSI when nonstandard regimens were administered (odds ratio 2.069; 95% confidence interval 1.078e1.868) [29]. The concurrent questionnaire similarly echoed our audit result by showing that all doctors demonstrated poor awareness of AP use. Particularly, 77% of doctors would prescribe a single dose of co amoxiclav for inguinal hernia repair procedures inappropriately. Only 44% of doctors prescribed co amoxiclav for colonic resections. The local protocol states that AP should be given before of anaethesia. However, in practice there was inconsistency with AP timing. A Swiss questionnaire found that for clean and clean contaminated surgeries, only 50% of responders would give AP within 30 min before incision [21]. Similarly, a van Kasteren's study focussing on a wider range of surgical procedures including gynaecological and vascular surgery, found that 50% of timings were concordant with the guidelines [14]. In a Kobayashi study, 95% of respondents administered AP within 1 h before incision but this was continued for at least 24 h in 90% of participating hospitals [30]. Interestingly, Hawn et al. (2013) found that there was no significant increase in SSI rates if AP was to be administered within 60 min prior to incision or after incision [31]. Regular audit of SSI amongst general surgical teams is not compulsory nationwide. This possibly explains why there is generally low knowledge of SSI rates. Pinkney et al. (2013) felt that SSI rates both in practice and literature may be higher than originally thought [32]. Prtak and Ridgway recommend surveillance of SSI and rates should be presented at Multi-Disciplinary Team meetings to stimulate discussion on possible initiatives to improve these rates [33]. Our re-audit showed a 2-fold improvement in adherence to protocol. Resources were more appropriately allocated with a decrease in AP in clean surgeries and this is regarded as the major success of this study. Although, there was improved adherence to AP use for clean contaminated surgeries, there was still a wide range of alternative APs regimens still being prescribed. Our Traffic Light Poster improved adherence to AP prophylaxis but we did not achieve 100% compliance. Awareness of AP protocols may also be enhanced by delivering the protocol electronically, pre-
Table 2 Questionnaire survey showing the percentage of correct responses for each question. Question
Correct response according to guidelines
% who answered correctly
Time to give first antibiotics prophylaxis dose Time to give second antibiotics prophylaxis dose in long procedures Number of post operative antibiotics prophylaxis dose in uncomplicated major abdominal surgery What antibiotics prophylaxis to give in clean proceduresa What antibiotics prophylaxis to give in clean contaminated proceduresb What is the expected incidence of post operative wound infection in clean wound What is the expected incidence of post operative wound infection in clean contaminated wound
Before Induction After 4 h None None Co Amoxiclav <5% <15%
73% 33% 56% 30% 45% 22% 36%
a b
Inguinal hernia repair and laparoscopic cholecystectomy. Bowel resection.
Please cite this article in press as: M. Cameron, et al., Antibiotic prophylaxis audit and questionnaire study: Traffic Light Poster improves adherence to protocol in gastrointestinal surgery, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.05.008
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printing aspects of the guideline on prescription charts and to provide surgeons with evidence of content of guideline and to assess acceptance of protocol amongst surgeons before implementation. It is also a suggestion that the surgeon check AP selection during the ‘Before Induction’ period of the WHO Checklist [34] as this may improve the timing of administration of AP in our hospitals. When AP selection contradicts the protocol guideline, staff can raise concerns regarding the deviation from the guideline. Anaethetists play a vital role in improving adherence to protocol and should especially be kept up to date with guidelines and feel able to question any deviation from recommendations. 7. Conclusion In conclusion, SSIs are costly complications, which can result in increased morbidity and mortality. AP is a critical measure aimed at reducing the risk of SSI in gastrointestinal surgery. SIGN have produced AP guidelines, which form the basis of many local hospital protocols [11]. Our initial audit showed poor awareness to these guidelines and it appears that most surgeons and anaesthetists follow their own protocol based on previous experience. This is particularly true in clean procedures where there is inappropriate use of AP when not recommended. Our ‘Traffic Light’ poster markedly improved the adherence to protocol by acting as a vivid visual source of information when the surgical team were in doubt. We recommend that continual education on the appropriate AP administration protocols via a poster and engagement of both senior clinicians and juniors in this process. Declaration of competing interest All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. Appendix ASupplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.ijsu.2015.05.008. References [1] J.S. Burke, Infection control e a problem for patient safety, N. Engl. J. Med. 348 (2003) 651e656. [2] A.J. Mangram, T.C. Horan, M.L. Pearson, et al., Guideline for prevention of surgical site infection, Infect. Control Hosp. Epidemiol. 20 (2004) 247e264. [3] D. Bratzler, P. Houck, Antimicrobial prophylaxis for surgery: an Advisory Statement from the national surgical infection prevention project, Clin. Infect. Dis. 38 (2004) 1706e1715. [4] J.S. Solomkin, Antibiotic prophylaxis in surgery, in: J. Cohen, W.G. Powderly (Eds.), Infectious Diseases, second ed., Mosby, USA, 2004. [5] R.L. Nichols, Preventing surgical site infection, Clin. Med. Res. 2 (2004) 115e118. [6] J. Reilly, S. Stewart, G. Allardice, et al., NHS Scotland National HAI Prevalence Survey, Final report, Heath Protection Scotland, Glasgow, 2007, www.scot.nhs. uk/hai/ss (accessed 20.11.13). [7] CDC. Surgical Site Infections: Resources for Patients and Healthcare Providers. Available on http://www.cdc.gov/ncidod/dhqp/dpac_ssi. (accessed 01.07.13). [8] H.C. Polk Jr., J.F. Lopez-Mayor, Postoperative wound infection: a prospective study of determinant factors and prevention, J. Surg. 66 (1969) 97e103.
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