Perioperative antibiotic prophylaxisPerioperative antibiotic prophylaxis subprojectsubproject

BARN 4th Workshop, 9-10 October 2013, WarsawBARN 4th Workshop, 9-10 October 2013, Warsaw

Hospital of Lithuanian University of Health Sciences Kauno Klinikos

Institute of Hygiene

dr.G.Gailiene

• AimAim: To evaluate the quality of perioperative antibiotic prophylaxis (the adherence to the local prophylaxis guidelines) in the countries of Baltic Sea region.

• ObjectivesObjectives:– Evaluation of existing local AB stewardship; – Estimation of patients, who received AB within 1 hr – 15 min

prior to incision; – Estimation of patients, who received AB based on the local

guidelines;– Estimation of patients, who received AB after 24 hr;– Antibiotics used for prophylaxis;

• Multicenter prospective observational study;

• Duration 2 weeks (10 working days);

• Pilot study was performed in November-December 2012 in General Surgery Department and Orthopedic Department of Hospital of Lithuanian University of Health Sciences Kauno Klinikos.

• Main study – March - June 2013 – in departments of:– Obstetric - Gynaecology, – Cardiosurgery;– General Surgery.

MethodsMethods

PartParticipants of subprojecticipants of subproject: :

• Greta Gailiene, Zilvinas Dambrauskas, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Lithuania;

• Uga Dumpis, Aija Vilde, Pauls Stradini University Hospital, Latvia;

• Piret Mitt, Tartu University Hospital, Estonia;

• Pille Martin, West - Tallinn Central Hospital, Estonia;

• Birgitta Lytsy, Uppsala University Hospital, Sweden.

General dataGeneral data Number of beds Hospital of

Lithuanian University of

Health Sciences Kauno Klinikos

(Lithuania)LTLT

Stradins University Hospital

(Latvia)LVLV

Tartu University Hospital

(Estonia) EEEE

West - Tallinn Central

Hospital

(Estonia)EE2EE2

Uppsala University Hospital

(Sweden)SESE

Hospital 1947 822 975 481 1100

ABDOMINAL department

90 75 66 44 -

OBSTETRIC-GYNAECOLOGY

department

60 22 17 55 -

CARDIOSURGERY department

40 46 30 - 25

ResultsResults

AB stewardshipAB stewardship

0 1 2 3 4 5 6

A re meas ures taken to improve c omplianc e?

A re data on c omplianc e fed bac k to the hos pitaladminis tration?

A re data on c omplianc e fed bac k to the s urgic aldepartments ?

A re a s uffic ient number of s urgic al proc eduresinc luded in an audit of P A P ?

Were one or more audits for c omplianc e with the P A Pprotoc ol performed?

Is the hos pital P A P protoc ol regularly updated?

Were the s urgic al proc edures evaluated ac c ording toappropriatenes s of P A P indic ation?

A re patient-s pec ific fac tors taken into c ons iderationwhen updating the P A P -protoc ol?

Is the P A P protoc ol updated + ac c ording to the loc alantimic robial s us c eptibility patterns ?

A B prophylax is guidelines define:

A B prophylax is guidelines s tatus :obligatory

A B prophylax is guidelines s tatus :rec ommendation

Does the A B team have one or more annual plenarymeetings ?

Is there a multidis c iplinary A B -team that c ons is ts ofprofes s ionals from relevant areas ?

Y es

No

•AB doses•AB prescription duration •route of AB administrationalternative AB

SE 2(LV,SE)

3 (LT,EE,EE2)

3(EE,EE2,SE), 2 (LV,LT)

3(EE,EE2,SE)

2 (LV,LT)

3(EE,SE,EE

2) 2(LV,LT) 2(EE,EE2) 3(LV,LT,SE)

3(EE,EE2,SE)

2(LV,LT)

2(EE,EE2);3(LV,LT,SE)

Obstetric – gynaecology Obstetric – gynaecology Types of surgery (N)Types of surgery (N)

Obstetric – gynaecology surgeryObstetric – gynaecology surgeryAB prophylaxis (%)AB prophylaxis (%)

100

0

95.45

0 0 0

98.48

0

55.56

5.56

61.11

05.56

0

22.22

0

18.75

75.068.75

0 0 0 4.35 09.1

40.9

85.71

0 0 0

27.2716.67

0

20

40

60

80

100

120

Patientreceived

AB within 1hr prior toincision

PatientreceivedAB within

15 - 30 minprior toincision

PatientreceivedAB based

on theGuidelines

(first ABdose)

PatientreceivedAB based

on theGuidelines(second AB

dose)

Second ABdose due toprolongedoperation

Second ABdose due toblood loss

(≥1,5 L)

Patientreceived

AB after 24hr

* Patientreceived

AB after 24hr based on

theGuidelines

L T

L V

E E

E E (2)

*LV - 38.9 % patients received AB more than 1 hr prior to incision;

** EE - 1 (4.3%) patient received AB 8 min after incision; 30.4% patients did not received AB before operations (PAP is indicated only for hysterectomy, but 4 (out of 10) patients with ovarian surgery received PAP);

*** EE (2) 45.4 % patients received AB more than 1 hr prior to incision, 4.5% patients did not received AB.

AB used for prophylaxis before Obstetric-AB used for prophylaxis before Obstetric- g gynaecology surgery (%)ynaecology surgery (%)

0

10

20

30

40

50

60

70

80

90

100

LT

LV

EE

EE2

CardiosurgeryCardiosurgeryTypes of surgery (N)Types of surgery (N)

CardiosurgeryCardiosurgery

AB prophylaxis (%)AB prophylaxis (%)

* LV - 52.2 % patients received AB more than 1 hr prior to incision

32.0

0.0

24.0

0.0

21.4

78.6

0.0 0.0

64.29

35.71

100.0

28.57 25.0

47.83

0.0

47.83

93.75

0.0

100.0

68.0

100.0 100.0

0

20

40

60

80

100

120

P atientrec eived A Bwithin 1 hr

prior toinc is ion

P atientrec eived A B

within 15 - 30min prior to

inc is ion

P atientrec eived A B

bas ed on theG uidelines

(firs t A B dos e)

P atientrec eived A B

bas ed on theG uidelines

(s ec ond A Bdos e)

P atientrec eived A B

after 24 hr

*P atientrec eived A B

after 24 hrbas ed on the

G uidelines

L T

E E

S E

L V

AB used for prophylaxis before Cardiosurgery (%)AB used for prophylaxis before Cardiosurgery (%)

0102030405060708090

100

LT

LV

EE

SE

Abdominal surgeryAbdominal surgery Types of surgery (N)Types of surgery (N)

Abdominal surgeryAbdominal surgery

AB prophylaxis (%)AB prophylaxis (%) 100.0

0.0

100.0

0.012.90

0.013.04

86.67 82.61

100.0

56.52

0.04.2

41.6

100.0 100.0

0.0 0.012.90

77.4267.74

0.0

81.25

0.00.0

20.0

40.0

60.0

80.0

100.0

120.0

Patie ntre c e ive d A Bw ithin 1 hr

pr ior toinc is ion

Patie ntre c e ive d A B

w ithin 15 -30 m in pr ior

to inc is ion

Patie ntre c e ive d A B

bas e d onthe

Guide line s(firs t A B

dos e )

Patie ntre c e ive d A B

bas e d onthe

Guide line s(s e c ond A B

dos e )

Patie ntre c e ive d A B

afte r 24 hr

*Patie ntre c e ive d A B

afte r 24 hrbas e d on

theGuide line s

L T

E E

E E (2)

L V

*EE - 1 (2.2%) patient received AB after incision;

** EE (2) - 12.5% patients received first dose of AB on time of incision or after incision; 41.6 % patients did not received AB before operations;

*** LV - 9.7 % patients received AB after incision.

0

10

20

30

40

50

60

70

80

90

LTLVEEEE2

AB used for prophylaxis before Abdominal surgery (%)AB used for prophylaxis before Abdominal surgery (%)

AB appointment before surgery (%)AB appointment before surgery (%)

Surgery LTLT LVLV EEEE EE2EE2 SESE

Obstetric-gynaecology

Anesthesiologist+Surgeon – 100%

Surgeon – 100%

AnesthesioloAnesthesiologist– 100% gist– 100%

Surgeon – 100%

-

Cardiosurgery Anesthesiologist - 96%

Surgeon – 4 %

Anesthesiologist–

100%

AnesthesioloAnesthesiologist– 100% gist– 100%

- Anesthesiologist – 100%

Abdominal Anesthesiologist+Surgeon – 100%

Anesthesiologist+Surg

eon – 100%

AnesthesioloAnesthesiologist– 100% gist– 100%

Anesthesiologist– 84.6%

Surgeon – 15.4%

-

ResumeResume::• Multidisciplinary AB-team has only one hospital (20.0%).

• PAP protocol updated according to the local antimicrobial susceptibility patterns in 3 hospitals (60.0%).

• One or more audits for compliance with the PAP protocol are performed in 2 hospitals (40.0%).

• Antibiotic timing (1 h or 15 - 30min.) and appointment (surgeon or anesthesiologist, or both) before operation depends on the type of surgery, i.e. depends on ward, but not on hospital (except Tartu university hospital).

• Patients received AB more than 1 hr prior incision in 2 hospitals, in 3 hospitals - AB after incision.

• 4.35 – 98.5 % of patient received AB after 24 hr in all (5) hospitals, based on the Guidelines – in 2 hospitals.

• 1st and 2nd gen cephalosporins or combinations with other antibiotics were used most common for prophylaxis.

RecommendationsRecommendations

• Repeat study;

• Expand:– number of participating:

• persons• departments• countries

– duration of study– protocol (AB name, dose, precise injection or

oral administration time)

Thank you for attentionThank you for attention