Antibiotic prophylaxis: what's the fuss?

AORN Journal, Nov, 2005 by Suzanne C. Beyea

Nurses frequently ask, "What is all the fuss about perioperative antibiotics? Why does my facility track the timing of administration and the dose, frequency, and type of antibiotic?" Other nurses may say, "I understand that antibiotic administration is important, but there are just so many competing priorities." Since the 1960s, evidence has indicated that antimicrobials administered shortly before the skin is incised can prevent surgical site infections.

A number of guidelines have been published describing the selection, timing, and duration of antimicrobial therapies for surgical prophylaxis for various types of surgery. (1) Despite this knowledge and information, clinical departments often lack a system that ensures that this simple task can be completed with 100% accuracy. Some perioperative nurses feel that same day surgery nurses should take responsibility for ensuring the timely administration of antibiotics. In some organizations, anesthesia care providers are responsible for hanging and starting antibiotics, while other organizations address starting antibiotics during the time out just before the incision is made. In many organizations and situations, prophylactic antibiotics are not given at the right time or for the correct duration, or the wrong medication is selected for administration. Failing to correctly administer antimicrobial prophylaxis can lead to surgical site infections, patient injury, mortality, and increased health care costs. How can nurses plan for antibiotic prophylaxis, a role that is so important to patient safety?

RECENT EVIDENCE

The most recent evidence that opportunities exist to improve health care organizations' performance related to the use of antimicrobial prophylaxis is provided by an analysis of 34,133 Medicare inpatients. (1) Researchers conducted an analysis on a systematic, random sample of patients who had undergone

* coronary bypass grafting;

* other open-chest cardiac surgery, excluding transplantation;

* vascular surgery, Including aneurysm repair, thromboendarterectomy, and vein bypass operations;

* general abdominal colorectal surgery;

* hip and knee total knee arthroplasty, excluding revision surgery; and

* abdominal and vaginal hysterectomy from Jan 1 to Nov 30, 2001. (1(p174))

The analysis found that only 55.7% of patients who had indications for parenteral antimicrobial prophylaxis received antibiotics within one hour before surgical incision. (1) When these medications were administered, 92.6% of doses were administered in a manner consistent with published guidelines, but only 40.7% of doses were discontinued within 24 hours of surgery end time. (1)

Why is this level of performance unacceptable? Simply, the risk related to not providing the correct antimicrobials at the right time and for the recommended duration is that patients may be injured if a wound infection occurs. Research findings suggest that more than 2% of surgeries in the United States are complicated by a surgical site infection. (2) Surgical site infections can result in an increased rate of mortality, morbidity, and health care costs. Perioperative antibiotics can only be effective and prevent these complications when the right medication is given at the right time for the right length of time.

AVAILABLE RESOURCES

Resources about the importance of perioperative antibiotics and how to make system improvements to ensure quality performance and favorable patient outcomes are readily available to all practitioners and patients in print or electronic formats. A primary source of information on this topic is the National Guideline Clearinghouse. (3) This government resource collects and publishes clinical practice guidelines on a variety of topics. In the instance of antibiotic prophylaxis for surgery, guidelines exist that address gynecologic procedures, gastrointestinal endoscopy, open fractures, penetrating abdominal trauma, and general surgery. These guidelines represent just a few of those developed by surgical specialty organizations.

The Society of Thoracic Surgeons has developed and published guidelines for antibiotic prophylaxis in cardiac surgery. (4) These guidelines address issues specific to cardiac surgery, including the duration of use, the specific antimicrobials, and the timing of the first administered dose. A number of other professional organizations, including the American College of Obstetricians and Gynecologists, also have developed guidelines specific to their practice. (5) Such resources generally are available through the specific organization or through the National Guideline Clearinghouse.

Another valuable resource is the Centers for Disease Control and Prevention's web site at http://www.cdc.gov. This web site contains the Guideline for the Prevention of Surgical Site Infection, (6) which provides information regarding surgical procedures that require antibiotic prophylaxis and the most likely causative pathogens for surgical site infections. This guideline also summarizes the extensive evidence about how to reduce overall risks of surgical site infection.