Surgical antimicrobial prophylaxis : challenges in translating evidence to practice

Abstract EN

Surgical-site infections (ssis) are one of the most common healthcare-associated infections, accounting for 31% of all healthcareassociated infections worldwide.1 It is estimated that 2–5% of patients undergoing surgery develop SSIs, with a higher percentage estimated in resourcelimited healthcare settings.2 The impact of SSIs on healthcare delivery systems is very severe, resulting in prolonged hospitalisation, complex medical treatments, increased readmissions and outpatient visits as well as increased direct and indirect medical costs.3,4 In addition, these factors result in significant morbidity and mortality.3,4 Previous research indicates that approximately 60–80% of SSIs are preventable through the implementation of evidence-based practices such as surgical antimicrobial prophylaxis (SAP) guidelines.5 The key to preventing SSIs lies in the understanding and careful implementation of SAP guidelines.

Choosing the right antibiotic for each case is of particular importance, as the right antibiotic will produce adequate serum and tissue drug levels and exceed the minimal inhibitory concentration for any organisms that are likely to be encountered during the operation.

Optimal timing of the antibiotic prophylaxis administration is considered to be 30–60 minutes before the first incision is made, except for certain antibiotics (e.g.

vancomycin and ciprofloxacin) which are administered 120 minutes beforehand.6 Bratzler et al.

have confirmed that a single dose of an antimicrobial agent is sufficient for most surgical operations.6 Although the principles of antimicrobial prophylaxis in surgery are clearly established and several guidelines have been published, the implementation of these guidelines remains problematic and controversial among surgeons.7 The overprescription and inappropriate timing and duration of antimicrobials remains a significant issue in th practice of surgical prophylaxis.

In addition, the incidence of SSIs has increased and new antimicrobialresistant bacteria have emerged due to poor adherence to SAP guidelines.8,9 The aforementioned challenges have been widely addressed in many developed countries,10 although very little attention has been given to this issue in developing countries and the Middle Eastern region.

In the November 2015 issue of SQUMJ, Telfah et al.

published a report on the impact of a multidisciplinary quality improvement project on the adherence to SAP guidelines in the treatment of surgical oncology patients.10 A clinical pharmacist was noted to play a key role in updating the SAP guidelines and providing the surgeons with required prophylaxis education.

Telfah et al.

concluded that there was significant improvement in the adherence to SAP guidelines following the implementation of the multidisciplinary quality improvement project.10 This approach demonstrates the important role of both clinical pharmacists and surgeons in engaging with and improving adherence to SAP guidelines.7,11 A review of studies evaluating guideline implementation strategies found only modest-to-moderate effects and noted that healthcare organisations’ resources for guideline implementation were usually insufficient to allow much more than the dissemination of educational materials or lunchtime educational meetings, interventions whose effects were usually only short-lived.12 Barlow et al.

found that education and audit-based interventions used before the implementation of guidelines resulted in a significant increase in appropriate antibiotic prescriptions after the introduction of a multifaceted education programme.13 Audit feedback systems to improve the quality of care have also been shown to be feasible and effective in hospital settings in low-income countries.14 Consequently, successful guideline implementation .