Antibioticaprofylaxe en verbetertraject

Inge C. Gyssens MD PhDHasselt University, Belgium&Radboud University Medical Center, Nijmegen, The Netherlands

(2) Hospital: Cochrane Systematic Review

• First review [2005; Issue 3: CD003543]• Included studies up to November 2003

• Revised review [2013; Issue 4: CD003543]• Included studies up to December 2006• Meta-analysis for ITS• EPOC Risk of Bias criteria.

Courtesy of Ian M GouldICG 2014

(2) Hospital: Cochrane Systematic Review

• What interventions?

Courtesy of Ian M GouldICG 2014

Barriers to intervention

• Non acceptance of the principle• “Therapeutic freedom of the prescriber”• Non acceptance of external interference• Fear of:

political consequences

legal consequences• Financial and logistic barriers

START WITH AN INVENTORY OF BARRIERS

Grimshaw JM et al. Health Technol Assess. 2004;8:1-72. Review:ICG 2014

Quality standard for antimicrobial prophylaxis in surgical procedures

1. Indication

2. Choice of drug

3. Duration

4. Timing

• Bratzler et al. Clinical practice guidelines for surgical prophylaxis. Am J Health-Syst Pharm. 2013; 70:195-283

• SIGN guideline Surgical prophylaxis rev. July 2008 http://www.sign.ac.uk/pdf/sign104.pdf

ICG 2014

INDICATIONResponsibility of the surgeon/committee

Indications for surgical prophylaxis: cost effectiveness

• Define outcome and expected baseline risk– Surgical site infection (SSI) rate

• Superficial• Deep• Organ/space

• What are the Odds ratios (OR)?• What is the number needed to treat to avoid the

adverse outcome = number to treat (NNT)

http://www.sign.ac.uk/pdf/sign104.pdf version July 2008 ICG 2014

What is the evidence? Surgical procedures for which prophylaxis is indicated

http://www.sign.ac.uk/pdf/sign104.pdf version July 2008

Clean operations; the risk of infection is low but the consequences are serious

• Cataract surgery OR 0.36, NNT 451

• Cardiac pacemaker OR 0.26, NNT 38

• Total hip arthroplasty OR 0.27, NNT 42

• …..

ICG 2014

Percentage of patients with clean procedures and antibiotic prophylaxis

Semarang Surabaya

Bambang Wibowo, Hari Parathon, Gyssens I, unpublished data

CHOICE OF PROPHYLACTIC DRUGResponsibility of the committee

Quality improvement of surgical prophylaxis in Dutch hospitals:evaluation of a multi-site intervention by time series analysis

Marjo E. van Kasteren, Judith Mannien, Bart-Jan Kullberg, Annette S. de Boer,Nico J. Nagelkerke, Marja Ridderhof , Jan C. Wille and Inge C. Gyssens

J Antimicrob Chemother 2005;56:1094-1102

0

10

20

30

40

50

60

70

80

90

-6 -5 -4 -3 -2 -1 1 2 3 4 5 6

months to intervention

% o

f ca

ses 1st gen cephalosporin

2nd gen cephalosporin

amoxi/clavulanic acid

miscellaneous

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intervention

Largest effect with the restrictive component of the intervention: the change of antibiotic

DURATIONResponsibility of the committee

Total consumption of antibiotics for surgical prophylaxis in 13 hospitals

0

20

40

60

80

100

120

140

160

1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10

time-period

DD

D/1

00

pro

ce

du

res intervention

Quality improvement of surgical prophylaxis in Dutch hospitals:evaluation of a multi-site intervention by time series analysis

Marjo E. van Kasteren, Judith Mannien, Bart-Jan Kullberg et al.

J Antimicrob Chemother 2005;56:1094-1102

ICG 2014

TIMING

Responsibility of the ansthesiologist/committee

Antibiotic Prophylaxis and the Risk of Surgical SiteInfections following Total Hip Arthroplasty: Timely

Administration Is the Most Important FactorM.E.E. van Kasteren, J. Manniën, A. Ott, B.J. Kullberg, A.S. de Boer, I.C. Gyssens.

Clin Infect Dis 2007;44(7):921-7

0

2

4

6

8

10

12

14

16

18

20

-200/-91 -90/-61 -60/-31 -30/-1 0-30 31+

time to incision in minutes

% S

SI

n=17 n=538 n=1141 n=95 n=33n=98

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Timing after intervention

-6.0 -5.0 -4.0 -3.0 -2.0 -1.0 1.0 2.0 3.0 4.0 5.0 6.00

20

40

60

80

100

within 30 min before incision

between 2 h-30 min before incision

more than 2 h before incision

after incision

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Conclusion

• Many interventions to improve prescribing of prophylaxis have been tried

• Success is contextual• Cultural, socioeconomic and regulatory factors

play a role• In general, involving the prescribers in crucial

decisions is most successful

ICG 2014