A Retrospective Evaluation of Compliance in Various Surgical Departments with Respect to Surgical Antibiotic Prophylaxis in a Tertiary Care Hospital.

 

Dr. Niveditha¹,  Dr. Srikanth²*,  Dr. Rathai Rajagopalan¹, Dr. Shivamurthy M.C.¹

¹Department of Pharmacology, M.S. Ramaiah Medical College, MSR Nagar, MSRIT Post, Bangalore, 560054, India

²Department of Pharmacology, Khaja Banda Nawaz Institute of Medical Sciences, Gulbarga, 585104, India

*Corresponding Author E-mail:- pharmacsrikanth@gmail.com

Nosocomial infection is an infection that is not present or incubating when a patient is admitted  to a hospital. Infections acquired in the hospital account for major causes of morbidity, mortality, functional disability, emotional suffering and increases the total cost of treatment. The incidence varies between 5-10% in developed countries and 10-30% in developing countries. Every hospital is different and so are its infections, so every hospital needs to have an infection control committee which includes members of various disciplines and will be responsible for monitoring the occurrence of hospital infection and recommend corrective action. The infection control committee will have the responsibility of monitoring the occurrence of Hospital infection and recommending corrective action. It is made up of the representatives of various clinical and other disciplines. The study was undertaken with an objective to audit current practice against Hospital Infection Control Committee guidelines for antibiotic prophylaxis in four surgical specialties. The compliance to various recommendations was more than 75% in all the four departments, more steps need to be taken to increase the compliance to more than 95%. Having a policy helps in limiting the use of powerful antibiotics as initial treatment and saves it for the treatment of resistant organisms.

 

 

INTRODUCTION:

Nosocomial infections are defined as infections occurring in a hospital,  that happen after 48 hours of being admitted or within 30 days after discharge following in patient care¹. There are no reliable estimates of prevalence in India, but estimates vary from 10 to 30%, the least being about 3%  in the best of hospitals².

 

The infection causes the patient’s physical and mental sickness that makes the patient stay longer in the hospital without necessity³. Infections acquired in the hospital account for major causes of morbidity, mortality, functional disability, emotional suffering and increases the total cost of treatment. The most frequent nosocomial infections are infections of surgical wound, urinary tract infections and lower respiratory tract infections⁴.

 

Surgical site infections are the most common nosocomial infections in surgical patients, accounting for about 24% of the total number of nosocomial infections⁵. It’s rate has varied from a low of 2.5% to high of 41.9% ⁶.

 

Prevention of nosocomial infections is the responsibility of all individuals and services providing health care. It is the obligation of everyone to work co-operatively to reduce the risk of infection for patients and staff. Infection control programs are effective, if they are comprehensive and include activities such as surveillance, outbreak investigation, develop written policies for isolation of patients, prevention activities, staff training and monitoring of antibiotic utilization.

 

An “Infection Control Committee” provides a forum for all such activities. The infection control committee will have the responsibility of monitoring the occurrence of Hospital infection and recommending corrective action. It is made up of the representatives of various clinical and other disciplines.

 

The hospital antimicrobial guidelines were developed to provide a practical and uniform approach to the use of antibiotics by all the surgeons in the hospital. The main objective is to promote the rational use of antibiotics to prevent the emergence of drug resistant organisms and conserve the antibiotic molecules.

 

While formulating these guidelines, following things were taken into consideration:

1.        Evidence based medicine

2.        Literature references

3.        Recommendation from various departments

4.        Local microbiology patterns & trends of resistance

5.        Best practices

 

The study was undertaken with the following objectives.

1) To audit current practice against Hospital Infection Control Committee (HICC) guidelines for antibiotic prophylaxis in four surgical specialties

2) To identify if antibiotic prophylaxis given for the procedure was appropriate & in accordance with HICC guidelines

3) Brand evaluation among  various surgical specialties             

 

MATERIAL AND METHODS:

This retrospective study was conducted in a tertiary care hospital between January 2010 to June 2010, in four surgical departments      

·         Obstetrics and Gynecology(OBG)

·         Orthopedics(ORTHO)

·         Surgery

·         Urology

 

The following information was collected from Anesthetic records, Patient-notes, Drug charts, Nurses notes.

1) Type of surgical procedure

2) Details of the prophylactic antibiotic used with respect to

·         Dose

·         Route

·         Time of administration

·         Duration

 

This information was compared with recommendations of HICC policy. Recommendations have been made based on the quality of product and  experience of the clinicians. Brands used were compared with the list of recommended brand names.

 

RESULTS:

A total of 2020 cases were evaluated during 6 months, total number of cases arranged according to surgical departments is shown in figure 1.

 

Figure 1:Number of cases( total=2020)

 

The gender distribution ( in percentage) of patients according to month wise is shown in figure 2.

 

Figure 2:Gender distribution of the patients

 

The compliance of various departments with respect to choice of antibiotic is shown in table 1. Highest % of compliance was found in orthopedics department and least in urology department.

 

Table 1:Compliance with respect to choice of antibiotic(%)

DEPARTMENT           JAN             FEB            MAR               APR                    MAY                     JUN                                          Average

OBG                               87                81                89                    87                        89                          77                                               84 ORTHOPEDICS            83                100              91                    95                        86                          77                                               89 GENERAL                     62                84                76                    91                        85                          83                                               80 SURGERY UROLOGY                    62                68                76                    80                        86                          79                                               75

The compliance of various departments with respect to time of administration  is shown in table 2. Highest % of compliance was found in OBG department and least in surgery department.

 

Table 2:Compliance with respect to time of  administration(%)

MONTH        OBG       ORTHO       SURGERY    UROLOGY

JANUARY     80            77                72                  76 FEBRUARY   92            86                64                  76 MARCH         87            95                89                  84 APRIL            92            78                90                 80 MAY              100          94                76                 66 JUNE              90           92                72                 76 AVERAGE      90           87                77                 76

 

The compliance of various departments with respect time brand usage is shown in table 2. Highest % of compliance was found in OBG department and least in urology department.

 

Table 3:Compliance with respect to brand usage(%)

MONTH      OBG     ORTHO     SURGERY     UROLOGY

JANUARY    82           76             70                  60 FEBRUARY 100         100            86                  80 MARCH       100          90             78                  71 APRIL          97           86             89                  92 MAY            100         88             80                  86 JUNE            95          84             86                  88 AVERAGE    95          87             81                 79

 

Table 4 shows the brands recommended by the infection control committee, and other brands used which were not recommended.

 

Table 4:Brands recommended and other  brands used

Antibiotic            Brands                                      Other                                       molecule              recommended                brands used

Ceftriaxone              C-tri, oframax,              Monocef

Cefazoline                Reflin,

Gentamicin              Gentamycin

Cefuroxime              Ceftum,Zocef                Forcef

Metronidazole          Metrogyl, flagyl           Tiniba Orni-o

Ciprofloxacin           Ciplox, cifran

Amikacin                                 Mikacin

Ceftizoxime             T-zox

Levofloxacin           levoday

Cefaperazone+         Kefbactum zostum         C-bact

sulbactum,                                          

Amoxicillin +

 

DISCUSSION:

Hospital-acquired infections have increased worldwide, contributing considerably to morbidity of the hospitalized patients⁷. This can prolong the hospital stay, which can add significantly to the economic burden to manage the underlying disease. The present study was conducted in four surgical departments to know the compliance to various recommendations of the HICC.

 

The compliance to various recommendations was more than 75% which is acceptable and more reforms are being done to increase the compliance to more than 95%. The hospital antimicrobial guidelines are set in place in order to optimize the use of antibiotics and minimize the chances of further antibiotic resistance.

 

The hospital must develop its own infection control committee because every hospital is different, so are its problems and every hospital’s personnel are different. Hospitals having such committees have demonstrated a 33% reduction in hospital infections compared to hospitals without any programme⁸.

 

One hospital having an effective programme calculated yearly cost saving in excess of 2 million dollars. Thus substantial gains are to be expected for both doctors and administrators by supporting infection control programmes⁹. In Cleveland, Ohio, The Six sigma methodology was used to improve adherence to the antibiotic policy. Percentage of patients receiving antimicrobial prophylaxis within 60mins of incision improved from a baseline of 38% to 86% ¹⁰.

 

Antibiotic susceptibility tests are done on a  regular basis and the common resistance patterns of the bacterial isolates are reported and discussed in the HICC meetings and the antibiotic policy is reviewed accordingly. Antibiotic policy is prepared in consultation with respective clinical departments. This is more so important in view of emerging resistance, the recent example being the Metallo-beta-lactamase-1 (NDM-1)¹¹.

 

The following principles are used in formulating a policy for antibiotic use-

1)     Review antimicrobial agents and select a basic formulary.

2)     Establish prophylactic, empirical, and therapeutic guidelines (antibiotic policy).

3)     Restrict the use of agents that have special limited indications, cause excessive toxicity, or are costly.

4)     Release restricted agents for use in predetermined circumstances or after approval.

5)     Ensure that the antibiotics on the formulary are the same as those being used for susceptibility testing by the antibiogram.

6)     Monitor patterns of antibiotic susceptibility and trends in antibiotic use, providing regular feedback to the medical staff.

7)     Audit the use of specific antibiotics (antibiotic audit).

8)     Conduct ongoing educational programs

9)     Regulate in-hospital promotional efforts of pharmaceutical companies.

 

The committee performs three principal functions. The first is to gather data, a good microbiology laboratory is essential to isolate organisms, to plot antibiotic resistance patterns and to indicate to clinicians trends and changes in hospital flora¹².

 

The second function is to carry out surveillance, surveillance is a powerful tool in infection control but is time consuming and expensive. Spot surveillance is sometimes a quicker and cheaper approach; for example how many people in an ICU examine patients without first washing hands or using an alcohol rub solution^13,14. The third function of the committee is to enforce good infection control practices. For this certain concepts must be ingrained¹⁵.

 

LIMITATIONS OF THE STUDY:

The limitation of the study is that it was a retrospective study and duration was only for 6 months. More prospective studies with longer duration, along with incidence of hospital acquired infection are needed to determine the effectiveness of infection control committee. Further work would involve re-auditing on a regular basis to assess changes in trends following the implementation of modified recommendations

 

CONCLUSION:

An antibiotic policy restricts the occurrence of resistance and controls the spread of infection in the hospital. Having a policy helps in limiting the use of powerful antibiotics as initial treatment and saves it for the treatment of resistant organisms.

.

ACKNOWLEDGEMENT:

We authors thank Hospital Infection Control Committee, M.S. Ramaiah Medical College, Bangalore.

 

REFERENCES:

1)     Garner JS et al. CDC definitions for nosocomial infections. Am J Infect Control. 16;1988:128-40.

2)     Dr. Nita Jarmarwala, Dr. Mayur Jarmarwala. Journal of the Bombay Ophthalmologists’ Association. 11(2);2001:51-52.

3)     Luksamijarulkul P et al. Nosocomial surgical site infection among Photharam hospital patients with surgery. J Med Assoc Thai. 89(1);2006:81-9.

4)     Ducel G et al. Prevention of hospital acquired infections - a practical guide, 2nd ed. Geneva: WHO; 2002.

5)     Haley RW. The scientific basis for using surveillance and risk factor data to reduce nosocomial infection rates. J Hosp infect. 30(suppl);1995:3-14.

6)     Lilani SP et al. Surgical site infection in clean and clean-contaminated cases. Ind J Med Microbiol. 23(4);2005:249-52.

7)     Panhotra BR et al. Extended-spectrum Beta-lactamase-producing K. pneumoniae hospital-acquired bacteraemia, risk factors and clinical outcome. Saudi Med J. 25;2004:1871-6.

8)     Join Commission on Accreditation of Healthcare Organisation, Standards : Infection Control. In JCAHO : Accreditation manual for hospitals. Chicago: Joint Commission Accreditation of Healthcare Organizations 1990.

9)     Ingelhart JK. The American health care system expenditure. N Engl J Med. 340;1999:70-6.

10)   Brain m parker et al. Six sigma methodology to improve adherence for antibiotic prophylaxis. Anesth Analg. 104;2007:140-6.

11)   Yong D et al. Characterization of a new metallo-beta-lactamase gene, bla(NDM-1), and a novel erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India. Antimicrob Agents Chemother.  53(12);2009:5046–5054.

12)   Emori TG, Gaynes RP. An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev. 6;1993:428-42.

13)   Pittet D et al. Effectiveness of a hospital wide programme to improve compliance with hand hygiene. Lancet. 356;2000:1307-12.

14)   Farr BM. Reasons for non-compliance with infection control guidelines. Infect Control Hosp Epidemiol, 21:411-16, (2000).

15)   Burke JP. Infection control - A problem of patient safety. N Engl J Med. 348;2003:651-5.

 

 

Received on 08.04.2013          Modified on 19.04.2013

Accepted on 16.05.2013         © RJPT All right reserved