Responsible antibiotic use in healthcare has been debated since superbug outbreaks, but other issues have pushed it to the forefront of infection control conversation. Most of the conversation has been focused on the family practice side of medicine, so Surgical Products connected with the experts to see what it means for surgical teams.
One was Association for Professionals in Infection Control and Epidemiology’s (APIC) communication committee member Kelley Boston, MPH, CIC, executive director of regulatory and accreditation compliance, infection prevention and management associates, and division director of infection prevention for Methodist Healthcare System.
The other was Society for Healthcare Epidemilogy of America (SHEA) Research Committee Member Dr. Deborah Stephanie Yokoe, MPH, hospital epidemiologist and medical director of the infection control department and member of the Infectious Diseases Division at Brigham and Women’s Hospital and Dana-Farber Cancer Institute in Boston, shared their thoughts.
How does antibiotic misuse affect surgical teams and the potential for SSIs?
Boston: Surgical antimicrobial prophylaxis is given to help reduce the risk of post-operative infection. It is recommended for all procedures that are dirty, contaminated or clean-contaminated, and may be recommended for clean procedures as well. For most procedures prophylactic antibiotics are recommended to be discontinued 24 hours after the procedure to reduce the risk of development of drug-resistance. There are excellent evidence based resources available developed by jointly by the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of America (SHEA)
When we use antibiotics for too long, or use the wrong drug, we can also drive drug resistance in colonizing organisms and put our patients at risk for other serious complications, such as Clostridium difficile infection.
Yokoe: There are two major ways that antibiotic misuse by surgical teams can impact patients’ risks for developing SSIs. The first is by not administering the right antibiotic at the right time for SSI prophylaxis. There is strong scientific evidence that antimicrobial prophylaxis can reduce the risk of infection for a wide variety of surgical procedures. There is also evidence that administering those antibiotics at the right time (for most antibiotics, this means starting the antibiotic within an hour prior to the initial surgical incision) impacts SSI risk. There are very useful guidelines available that provide detailed recommendations about the choice and timing of antimicrobial prophylaxis agents, including this guidelines which was the product of a collaboration between the American Society for Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare Epidemiologist of America (SHEA).
The second way that surgical teams can impact the type of organisms that cause SSIs is by unnecessarily extending the duration of antimicrobial prophylaxis. There is very little data that shows any benefit to extending the duration of antimicrobial prophylaxis for clean or clean-contaminated procedures beyond the time of incision closure. This holds true even for patients with drains or tubes that are left in place at the end of the procedure. The downside of extending antimicrobial prophylaxis is that this increases the risk for patients subsequently developing SSIs associated with organisms that are resistant to the antibiotics used for prophylaxis. These infections can be more difficult to treat because there are fewer effective antibiotics to choose from. Unnecessary exposure to antibiotics also increases the risk for other complications, including Clostridium difficile infections.
There is strong scientific evidence that antimicrobial prophylaxis can reduce the risk of infection for a wide variety of surgical procedures. There is also evidence that administering those antibiotics at the right time… impacts SSI risk.
What impact do surgical teams have on preventing superbugs through strategically used antibiotics?
Boston: Timing of antibiotics is critical to using them safely and effectively. Most antibiotics have to be given before the procedure and they may have to be readministered several times depending on the duration of the procedure. Good communication between the surgeons, anesthesiologists, pharmacists and the rest of the peri-operative team can help make sure that we are giving the right patients the right antibiotics at the right times
Communication on surgical scheduling and any delays in start times can help your team in the pre-op areas get the medications on board in the right window of time, so that you are ready to go once they are in the operating room.
Yokoe: As I discussed above, using prophylactic antibiotics for longer than necessary encourages the growth of organisms that are resistant to the antibiotic being used. This increases that patient’s risk for subsequently developing an infection due to a resistant organism. The same is true for using antibiotics that have a broader spectrum of activity than needed for specific infections. For example, clinical cultures may indicate that an SSI is due to a gram-negative organism that is susceptible to ceftriaxone but the patient is treated with a carbapanem antibiotic. The cabapenem is effective but has a broader spectrum of activity than needed for this infection and has the downside of increasing the risk for emergence of carbapenem-resistant organisms.
Are there any common practices surgical teams have that put patients at increased risk of superbug infections?
Boston: We need to make it easy for physicians to make the right antibiotic choices through ready access to guidelines and tools that make them easy to implement. We also need strong communication in our peri-operative teams so that we are able to be flexible and make changes quickly and safely when situations change.
Many organizations are implementing pre-admission programs to help drive better outcomes. These programs often include pre-admission screening for Staphylococcus aureus and MRSA colonization, so that prophylactic antibiotics can be adjusted and patient and family education on what is expected after surgery.
Others are taking a closer look at pre-operative skin prep beyond hair removal and skin antisepsis in the OR. Many organizations have added recommendations for patient bathing with an antiseptic soap the day prior to surgery, with additional skin cleaning when they arrive.
And then there’s the infection prevention basics – hand antisepsis, maintenance of the sterile field, surgical attire and environmental cleanliness. If we reduce the risk points for acquiring the infection in our ORs, we also reduce the risk of spreading MDROs to a patient who did not come in with one.
Yokoe: I think that there are several ways that surgical teams can practice antimicrobial stewardship and decrease the risk for “superbug” infections. Here are a few suggestions.
- When antibiotics are being used for perioperative antimicrobial prophylaxis, limit the duration of antibiotic administration. In the majority of instances, this means stopping the antibiotic at the end of the procedure.
- Use the excellent available guidelines and use antibiograms from your local healthcare facility’s microbiology laboratories to develop local antimicrobial prophylaxis guidelines.
- When treating surgical infections, make use of your patient’s clinical microbiology results to tailor the choice of antibiotics.
- Make use of your colleagues with infection prevention and healthcare epidemiology expertise to identify and implement evidence-based strategies for SSI prevention.
- Make use of clinicians with infectious diseases expertise to help you to make decisions about appropriate antibiotic choices to treat SSIs.